Publications by authors named "Mark S Litwin"

264 Publications

Improving Shared Decision Making in Latino Men With Prostate Cancer: A Thematic Analysis.

MDM Policy Pract 2021 Jan-Jun;6(1):23814683211014180. Epub 2021 May 27.

Department of Marketing, Shidler College of Business, University of Hawai'i, Honolulu, Hawai'i.

Multiple studies have shown that digitally mediated decision aids help prepare patients for medical decision making with their providers. However, few studies have investigated whether decision-support preferences differ between non-English-speaking and English-speaking Latino men with limited literacy. To identify and compare health information seeking patterns, preferences for information presentation, and interest in digital decision aids in a sample of Southern Californian underserved Latino men with newly diagnosed prostate cancer at a county hospital. We conducted semistructured, in-depth telephone interviews with 12 Spanish-speaking and 8 English-speaking Latino men using a purposive sampling technique. Following transcription of taped interviews, Spanish interviews were translated. Using a coding protocol developed by the team, two bilingual members jointly analyzed the transcripts for emerging themes. Coder agreement exceeded 80%. Differences were resolved through discussion. Thematic differences between groups with different preferred languages emerged. Most respondents engaged in online health information seeking using cellphones, perceived a paternalistic patient-provider relationship, and expressed willingness to use hypothetical digital decision aids if recommended by their provider. English speakers reported higher digital technology proficiency for health-related searches. They also more frequently indicated family involvement in digital search related to their condition and preferred self-guided, web-based decision aids. In comparison, Spanish speakers reported lower digital technology proficiency and preferred family-involved, coach-guided, paper and visual decision aids. English speakers reported substantially higher levels of formal education. Preferences regarding the use of digital technology to inform prostate cancer treatment decision making among underserved Latino men varied depending on preferred primary language. Effective preparation of underserved Latino men for shared decision making requires consideration of alternative approaches depending on level of education attainment and preferred primary language.
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http://dx.doi.org/10.1177/23814683211014180DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8165846PMC
May 2021

Establishing a global quality of care benchmark report.

Health Informatics J 2021 Apr-Jun;27(2):14604582211015704

Cancer Council Victoria, Australia.

Background: The Movember funded TrueNTH Global Registry (TNGR) aims to improve care by collecting and analysing a consistent dataset to identify variation in disease management, benchmark care delivery in accordance with best practice guidelines and provide this information to those in a position to enact change. We discuss considerations of designing and implementing a quality of care report for TNGR.

Methods: Eleven working group sessions were held prior to and as reports were being built with representation from clinicians, data managers and investigators contributing to TNGR. The aim of the meetings was to understand current data display approaches, share literature review findings and ideas for innovative approaches. Preferred displays were evaluated with two surveys (survey 1: 5 clinicians and 5 non-clinicians, 83% response rate; survey 2: 17 clinicians and 18 non-clinicians, 93% response rate).

Results: Consensus on dashboard design and three data-display preferences were achieved. The dashboard comprised two performance summary charts; one summarising site's relative quality indicator (QI) performance and another to summarise data quality. Binary outcome QIs were presented as funnel plots. Patient-reported outcome measures of function score and the extent to which men were bothered by their symptoms were presented in bubble plots. Time series graphs were seen as providing important information to supplement funnel and bubble plots. R Markdown was selected as the software program principally because of its excellent analytic and graph display capacity, open source licensing model and the large global community sharing program code enhancements.

Conclusions: International collaboration in creating and maintaining clinical quality registries has allowed benchmarking of process and outcome measures on a large scale. A registry report system was developed with stakeholder engagement to produce dynamic reports that provide user-specific feedback to 132 participating sites across 13 countries.
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http://dx.doi.org/10.1177/14604582211015704DOI Listing
June 2021

Initial Clinical Needs Among Transgender and Non-binary Individuals in a Large, Urban Gender Health Program.

J Gen Intern Med 2021 Apr 26. Epub 2021 Apr 26.

Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.

Background: Transgender and gender-diverse individuals are particularly vulnerable to healthcare discrimination and related health sequelae.

Objective: To demonstrate diversity in demographics and explore variance in needs at the time of intake among patients seeking care at a large, urban gender health program.

Design: We present summary statistics of patient demographics, medical histories, and gender-affirming care needs stratified by gender identity and sexual orientation.

Participants: We reviewed all intake interviews with individuals seeking care in our gender health program from 2017 to 2020.

Main Measures: Clients reported all the types of care in which they were interested at the time of intake as their "reason for call" (i.e., establish primary care, hormone management, surgical services, fertility services, behavioral health, or other health concerns).

Key Results: Of 836 patients analyzed, 350 identified as trans women, 263 as trans men, and 223 as non-binary. The most prevalent sexual identity was straight among trans women (34%) and trans men (38%), whereas most (69%) non-binary individuals identified as pansexual or queer; only 3% of non-binary individuals identified as straight. Over half of patients reported primary care, hormone management, or surgical services as the primary reason for contacting our program. Straight, transgender women were more likely to report surgical services as their primary reason for contacting our program, whereas gay transgender men were more likely to report primary care as their reason.

Conclusions: Individuals contacting our gender health program to establish care were diverse in sexual orientation and gender-affirming care needs. Care needs varied with both gender identity and sexual orientation, but primary care, hormone management, and surgical services were high priorities across groups. Providers of gender-affirming care should inquire about sexual orientation and detailed treatment priorities, as trans and gender-diverse populations are not uniform in their treatment needs or goals.
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http://dx.doi.org/10.1007/s11606-021-06791-9DOI Listing
April 2021

Moving urologic disparities research from evidence synthesis to translational research: a dynamic, multidisciplinary approach to tackling inequalities in urology.

Urology 2021 Apr 24. Epub 2021 Apr 24.

Department of Urology, University of California Los Angeles, Los Angeles, CA; UCLA Fielding School of Public Health; UCLA School of Nursing. Electronic address:

Disparities in urology are well-documented but less is known about the role of translational research within existing interventional models to address inequalities. In this narrative review, we utilize an accepted framework of the process of translational research in mitigating disparities to investigate current translational and interventional urologic programs that bridge the gap. Three established, disparity-focused urologic interventional programs were identified and are highlighted in depth. Finally, we extrapolate from these findings to provide 10 policy relevant implications to help move urologic disparities research from evidence synthesis to translational research.
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http://dx.doi.org/10.1016/j.urology.2021.04.018DOI Listing
April 2021

The Impact of Frailty on Outcomes of Sling Surgery with and without Prolapse Repair.

J Urol 2021 Aug 1;206(2):382-389. Epub 2021 Apr 1.

Cedars Sinai Medical Center, Los Angeles, California.

Purpose: Frailty has emerged as a significant predictor of morbidity in urological surgery, but its impact on outcomes of sling surgery for stress incontinence remains unclear. The purpose of this study is to describe the prevalence of frailty among women undergoing sling surgery and determine the association of frailty with 30-day postoperative outcomes.

Materials And Methods: We analyzed data from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP®) in 2013-2016 to identify patients undergoing sling placement using Current Procedural Terminology, 10th edition, code 57288. Patients were categorized into 2 groups based on whether they underwent isolated sling placement or had a sling with concomitant prolapse surgery. Frailty was assessed using the 5-factor Modified Frailty Index (mFI-5) developed for use with the NSQIP data set. Patients were considered frail if 2 or more factors from the mFI-5 were present. Outcomes and complications within 30 days were captured from the NSQIP data and logistic regression models used to adjust for age, race/ethnicity, body mass index and frailty.

Results: We identified 25,887 women who underwent sling placement, 15,087 of whom underwent isolated sling placement (Group 1) and 10,800 of whom underwent sling with concomitant prolapse repair surgery (Group 2). Frailty was present in 9.3% of patients in Group 1 and 10.2% of patients in Group 2 (p=0.0122). Among those who underwent isolated sling placement, frailty was associated with increased length of hospital stay (OR 1.2, 95% CI 1.1-1.4, p=0.0008) and 30-day hospital readmission (OR 1.7, 95% CI 1.1-2.5, p=0.0093). Older patients undergoing isolated sling placement were more likely to have longer operation time (OR 1.2, 95% CI 1.1-1.3, p <0.0001) and hospital length of stay (OR 1.3, 95% CI 1.2-1.4, p <0.0001). Frailty was also associated with increased 30-day hospital readmission in patients who underwent sling with concomitant prolapse repair (OR 1.8, 95% CI 1.3-2.6, p=0.0003), while age was not (OR 0.9, 95% CI 0.7-1.1, p=0.29).

Conclusions: We found that frailty was present in relatively few patients undergoing sling surgery. Adverse postoperative outcomes and complications were low overall. Increased age and frailty were both associated with longer length of stay. Frailty, but not age, was significantly associated with increased likelihood of hospital readmission within 30 days following surgery. Our findings provide insight into the preoperative characteristics of women undergoing sling surgery in a large national sample, suggesting the need for preoperative identification of the frail patient.
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http://dx.doi.org/10.1097/JU.0000000000001769DOI Listing
August 2021

Cost-Effectiveness Analysis of Pembrolizumab for Bacillus Calmette-Guérin-Unresponsive Carcinoma In Situ of the Bladder.

J Urol 2021 May 21;205(5):1326-1335. Epub 2020 Dec 21.

Department of Urology, Mayo Clinic, Rochester, Minnesota.

Purpose: Patients with bacillus Calmette-Guérin-unresponsive carcinoma in situ are treated with radical cystectomy or salvage intravesical chemotherapy. Recently, pembrolizumab was approved for bacillus Calmette-Guérin-unresponsive carcinoma in situ.

Materials And Methods: We used a decision-analytic Markov model to compare pembrolizumab, salvage intravesical chemotherapy (with gemcitabine-docetaxel induction+monthly maintenance) and radical cystectomy for patients with bacillus Calmette-Guérin-unresponsive carcinoma in situ who are radical cystectomy candidates (index patient 1) or are unwilling/unable to undergo radical cystectomy (index patient 2). The model used a U.S. Medicare perspective with a 5-year time horizon. One-way and probabilistic sensitivity analyses were performed. Incremental cost-effectiveness ratios were compared using a willingness to pay threshold of $100,000/quality-adjusted life year.

Results: For index patient 1, pembrolizumab was not cost-effective relative to radical cystectomy (incremental cost-effectiveness ratios $1,403,008/quality-adjusted life year) or salvage intravesical chemotherapy (incremental cost-effectiveness ratios $2,011,923/quality-adjusted life year). One-way sensitivity analysis revealed that pembrolizumab only became cost-effective relative to radical cystectomy with a >93% price reduction. Relative to radical cystectomy, salvage intravesical chemotherapy was cost-effective for time horizons <5 years and nearly cost-effective at 5 years (incremental cost-effectiveness ratios $118,324/quality-adjusted life year). One-way sensitivity analysis revealed that salvage intravesical chemotherapy became cost-effective relative to radical cystectomy if risk of recurrence or metastasis at 2 years was less than 55% or 5.9%, respectively. For index patient 2, pembrolizumab required >90% price reduction to be cost-effective (incremental cost-effectiveness ratios $1,073,240/quality-adjusted life year). Pembrolizumab was cost-effective in 0% of 100,000 microsimulations in probabilistic sensitivity analyses for both index patients.

Conclusions: At its current price, pembrolizumab is not cost-effective for bacillus Calmette-Guérin-unresponsive carcinoma in situ relative to radical cystectomy or salvage intravesical chemotherapy. Although gemcitabine-docetaxel is not cost-effective relative to radical cystectomy at 5 years, further studies may validate its cost-effectiveness if recurrence and metastasis thresholds are met.
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http://dx.doi.org/10.1097/JU.0000000000001515DOI Listing
May 2021

Primary Robot-assisted Retroperitoneal Lymph Node Dissection for Men with Nonseminomatous Germ Cell Tumor: Experience from a Multi-institutional Cohort.

Eur Urol Focus 2020 Jul 15. Epub 2020 Jul 15.

NYU Langone Health, New York, NY, USA.

Background: Primary robot-assisted retroperitoneal lymph node dissection (RA-RPLND) for men with nonseminomatous germ cell tumor (NSGCT) is an alternative to open RPLND for stage I and select stage II patients.

Objective: To report the complication rates and oncologic outcomes from a multi-institutional series, and to estimate reduction in chemotherapy by using upfront minimally invasive surgery.

Design, Setting, And Participants: A retrospective chart review of men undergoing primary robot-assisted RPLND between 2014 and 2019 in five institutions by eight urologists experienced in testis cancer and robotic surgery.

Outcome Measurements And Statistical Analysis: Variables such as demographic and clinicopathologic information, operative parameters and complication rates, oncologic outcomes, sexual recovery, and hospital length of stay were collected. Descriptive statistics are presented.

Results And Limitations: Forty-nine patients were analyzed with a median follow-up of 15.0 mo (interquartile range 6.5-29.1 mo). Median operative time was 288 min, estimated blood loss was 100 ml, and lymph node yield was 32. Median length of stay was 1 d. There were nine postoperative complications, 44% (4/9) of which were Clavien grade 1. There were no Clavien grade IV complications. Twenty-one patients had metastatic NSGCT (42.8%), of whom nine (18.4%) received adjuvant chemotherapy. Four patients experienced recurrence (three out-of-field and one in-field recurrence). Limitations include the retrospective study design and various surgical techniques among surgeons.

Conclusions: Primary robot-assisted RPLND for NSGCT can be performed safely, with low complication rates and acceptable oncologic outcomes reducing the need for chemotherapy. For a population in which compliance with surveillance is typically challenging, robot-assisted RPLND may improve quality of care and outcomes for patients with NSGCT.

Patient Summary: In experienced centers, robot-assisted retroperitoneal lymph node dissection can be performed safely with similar oncologic outcomes to an open approach, while providing an option that may reduce the need for chemotherapy.
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http://dx.doi.org/10.1016/j.euf.2020.06.014DOI Listing
July 2020

Modifiable health behaviors among low-income, uninsured men with prostate cancer.

Urol Oncol 2020 09 2;38(9):735.e1-735.e8. Epub 2020 Jul 2.

Department of Urology, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, CA; Department of Health Policy & Management, UCLA Fielding School of Public Health; and UCLA School of Nursing, Los Angeles, CA. Electronic address:

Background: As life expectancy of men with prostate cancer (CaP)improves, the risks of chronic diseases and comorbid conditions become more relevant. Improving modifiable health behaviors now serves as a focus of guidelines to reduce all-cause morbidity and mortality from chronic disease among CaP survivors. Few studies have reported on these health behaviors in low-income, uninsured men with CaP METHODS: In addition to baseline demographic data, we collected four health behaviors in low-income men with CaP via telephone survey: physical activity, dietary intake of fruits and vegetables, weight management, and alcohol consumption. These behaviors were assessed for adherence to the American Cancer Society Prostate Cancer Survivorship Care Guidelines for health promotion.

Results: Of 236 participants, most self-identified as racial/ethnic minority (61% Hispanic, 16% Black). Most men demonstrated low (21%) or moderate (66%) adherence to guidelines, almost all of whom had poor adherence with recommendations for physical activity and fruit and vegetable intake. Multivariate analysis showed that non-white men were more likely to demonstrate low or moderate adherence.

Conclusions: Most men in this cohort of low-income, uninsured CaP survivors did not engage the healthy behaviors promulgated by the American Cancer Society. Future interventions in this population should focus on encouraging and facilitating healthier lifestyle choices in physical activity, diet, and weight management.
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http://dx.doi.org/10.1016/j.urolonc.2020.06.005DOI Listing
September 2020

Cost-Effectiveness of Maintenance bacillus Calmette-Guérin for Intermediate and High Risk Nonmuscle Invasive Bladder Cancer.

J Urol 2020 Sep 19;204(3):442-449. Epub 2020 Mar 19.

Department of Urology, Mayo Clinic, Rochester, Minnesota.

Purpose: While guidelines support the use of maintenance bacillus Calmette-Guérin for patients with intermediate and high risk nonmuscle invasive bladder cancer, in an era of bacillus Calmette-Guérin shortage we explored the cost-effectiveness of maintenance bacillus Calmette-Guérin.

Materials And Methods: A Markov model compared the cost-effectiveness of maintenance bacillus Calmette-Guérin to surveillance after induction bacillus Calmette-Guérin for intermediate/high risk nonmuscle invasive bladder cancer from a U.S. Medicare perspective. Five-year oncologic outcomes, toxicity rates and utility values were extracted from the literature. Univariable and multivariable sensitivity analyses were conducted. A willingness to pay threshold of $100,000 per quality adjusted life year was considered cost-effective.

Results: At 5 years mean costs per patient were $14,858 and $13,973 for maintenance bacillus Calmette-Guérin and surveillance, respectively, with quality adjusted life years of 4.046 for both, making surveillance the dominant strategy. On sensitivity analysis full dose and 1/3 dose maintenance bacillus Calmette-Guérin became cost-effective if the absolute reduction in 5-year progression was greater than 2.1% and greater than 0.76%, respectively. On further sensitivity analysis full dose and 1/3 dose maintenance bacillus Calmette-Guérin became cost-effective when maintenance bacillus Calmette-Guérin toxicity equaled surveillance toxicity. In multivariable sensitivity analyses using 100,000 Monte-Carlo microsimulations, full dose and 1/3 dose maintenance bacillus Calmette-Guérin was cost-effective in 17% and 39% of microsimulations, respectively.

Conclusions: Neither full dose nor 1/3 dose maintenance bacillus Calmette-Guérin appears cost-effective for the entire population of patients with intermediate/high risk nonmuscle invasive bladder cancer. These data support prioritizing maintenance bacillus Calmette-Guérin for the subset of patients with high risk nonmuscle invasive bladder cancer most likely to experience progression, in particular those who tolerated induction bacillus Calmette-Guérin well. Overall, our findings support the American Urological Association policy statement to allocate bacillus Calmette-Guérin for induction rather than maintenance therapy during times of bacillus Calmette-Guérin shortage.
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http://dx.doi.org/10.1097/JU.0000000000001023DOI Listing
September 2020

Underutilization of Androgen Deprivation Therapy with External Beam Radiotherapy in Men with High-grade Prostate Cancer.

Eur Urol Oncol 2021 Apr 2;4(2):327-330. Epub 2019 Feb 2.

Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA; Department of Urology, University of California, Los Angeles, Los Angeles, CA, USA. Electronic address:

Multiple randomized trials have shown a survival benefit to long durations of androgen deprivation therapy (ADT) in patients with Gleason grade group (GG) 4-5 (ie, Gleason score 8-10) prostate cancer (PCa) undergoing definitive external beam radiotherapy (EBRT). We conducted a population-based retrospective study utilizing the complete Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database from 2008 to 2011, extracting PCa patients of non-Hispanic white (NHW) and African-American (AA) race diagnosed with GG 4-5PCa who received EBRT with or without concomitant ADT. Of 961 patients receiving definitive EBRT, 225 (23.4%) received no ADT, 297 (30.9%) received 1-6mo of ADT, 313 (32.6) received 7-23mo of ADT, and 126 (13.1%) received ≥24mo of ADT. On multinomial logistic regression after inverse probability treatment weighting to balance for differences in other covariates, AA men still had significantly lower odds of receiving 1-6mo of ADT versus no ADT compared with NHW men (odds ratios 0.519 [95% confidence interval, 0.384-0.700]). In conclusion, long-duration ADT is underutilized, with nearly 90% of patients with GG 4-5PCa receiving <24mo of concomitant ADT, and AA men are less likely to receive ADT than NHW men. PATIENT SUMMARY: In this report, we examined the utilization of concomitant androgen deprivation therapy (ADT) among men with high-grade prostate cancer undergoing definitive external beam radiotherapy. We found that long-duration ADT was underutilized overall; moreover, African-American men were less likely to receive concomitant ADT than non-Hispanic white men.
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http://dx.doi.org/10.1016/j.euo.2019.01.006DOI Listing
April 2021

Predicting Short-term Outcomes After Radical Cystectomy Based on Frailty.

Urology 2019 11 12;133:25-33. Epub 2019 Jul 12.

Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA; UCLA Fielding School of Public Health, Los Angeles, CA; UCLA School of Nursing, Los Angeles, CA.

Objective: To evaluate the impact of frailty on adverse perioperative outcomes in patients treated with radical cystectomy for bladder cancer.

Material And Methods: We identified 9459 adults (age ≥18) in the Nationwide Readmission Database who underwent radical cystectomy in 2014 for bladder cancer. We defined patients' frailty status using Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator and compared in-hospital mortality, ICU-level complications, 30-day readmissions, nonhome discharge, length of hospitalization, and hospital-related costs between frail and nonfrail patients using χ tests. We used multivariate logistic regression to identify predictors of the primary outcomes of interest.

Results: Of 9459 patients undergoing radical cystectomy, 7.1% (n = 673) met criteria. Frail patients were more likely than nonfrail patients to have comorbid conditions (68.2% vs 59.7%; P= .005), in-hospital mortality (4.2% vs 1.5%; P= .04), ICU-level complications (52.9% vs 18.6%; P<.001), nonhome discharge (33.9% vs 11.6%; P <.001), longer length of stay (median 15 vs 7 days; P<.001), and higher median cost of the index admission ($39,665 vs $27,307). Frailty was the strongest independent predictor of ICU-level complications, nonhome discharge, increased length of stay, and hospital-related costs of any covariate.

Conclusion: Frail patients receiving radical cystectomy were more likely than nonfrail patients to have adverse perioperative outcomes and higher odds of in-hospital mortality, ICU-level complications, nonhome discharge, increased length of stay, and hospital-related costs. Preoperative consideration of frailty may be useful in clinical guidance and shared decision-making.
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http://dx.doi.org/10.1016/j.urology.2019.04.057DOI Listing
November 2019

Financial Margins for Prostate Cancer Surgery: Quantifying the Impact of Modifiable Cost Inputs in an Episode Based Reimbursement Model.

J Urol 2019 09 8;202(3):539-545. Epub 2019 Aug 8.

Department of Urology, David Geffen School of Medicine, UCLA, Los Angeles, California.

Purpose: The United States health care system is rapidly moving away from fee for service reimbursement in an effort to improve quality and contain costs. Episode based reimbursement is an increasingly relevant value based payment model of surgical care. We sought to quantify the impact of modifiable cost inputs on institutional financial margins in an episode based payment model for prostate cancer surgery.

Materials And Methods: A total of 157 consecutive patients underwent robotic radical prostatectomy in 2016 at a tertiary academic medical center. We compiled comprehensive episode costs and reimbursements from the most recent urology consultation for prostate cancer through 90 days postoperatively and benchmarked the episode price as a fixed reimbursement to the median reimbursement of the cohort. We identified 2 sources of modifiable costs with undefined empirical value, including preoperative prostate magnetic resonance imaging and perioperative functional recovery counseling visits, and then calculated the impact on financial margins (reimbursement minus cost) under an episode based payment.

Results: Although they comprised a small proportion of the total episode costs, varying the use of preoperative magnetic resonance imaging (33% vs 100% of cases) and functional recovery counseling visits (1 visit in 66% and 2 in 100%) reduced average expected episode financial margins up to 22.6% relative to the margin maximizing scenario in which no patient received these services.

Conclusions: Modifiable cost inputs have a substantial impact on potential operating margins for prostate cancer surgery under an episode based payment model. High cost health systems must develop the capability to analyze individual cost inputs and quantify the contribution to quality to inform value improvement efforts for multiple service lines.
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http://dx.doi.org/10.1097/JU.0000000000000283DOI Listing
September 2019

The resilience of men: quality of life after prostate cancer.

Authors:
Mark S Litwin

Nat Rev Urol 2019 Jun;16(6):334-335

Department of Urology, David Geffen School of Medicine at UCLA, Department of Health Policy & Management, UCLA Fielding School of Public Health and UCLA School of Nursing, Los Angeles, CA, USA.

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http://dx.doi.org/10.1038/s41585-019-0176-4DOI Listing
June 2019

Development of Technologic Solutions to Address Complex Local Requirements of an International Prostate Cancer Clinical Quality Registry.

JCO Clin Cancer Inform 2019 03;3:1-11

Monash University, Melbourne, Victoria, Australia.

Purpose: To detail the process for importing a defined data set into a centralized global registry via a secure file transfer platform and to understand the barriers to the establishment of a centralized global registry.

Results: A bespoke solution was developed to allow transmission of data from international local data centers to a centralized repository. Data elements included in the import template were drawn from existing International Consortium for Health Outcome Measurement variables and refined to ensure accurate benchmarking as well as feasibility in data completeness. The data set was organized in accordance with the prostate cancer care trajectory. Key considerations in developing the data transfer platform included import file format, process of input validation, and technical provisions. Given the diversity in the legislation and ethical requirements with respect to consent, data handling, and cross-border data transfer across geographic locations, we encouraged each local data center to consult with its legal advisors and research ethics committee early on in the process.

Discussion: A global collaboration, although highly valuable, posed many challenges because of inconsistent methods of data collection. User acceptance of a system is paramount to the success of establishing a metaregistry. Local information technology support and regular regression testing ensures quality and maintenance of the database.

Conclusion: We developed a Web-based system to facilitate the collection and secure storage of common data, which is scalable and secure. It is anticipated that through systematic recording of data, global standards of clinical practice and outcomes of care will see vast improvements.
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http://dx.doi.org/10.1200/CCI.18.00114DOI Listing
March 2019

Sexual well-being and diurnal cortisol after prostate cancer treatment.

J Health Psychol 2020 09 26;25(10-11):1796-1801. Epub 2018 Apr 26.

Rush University Medical Center, USA.

Sexual dysfunction and psychological distress are common after prostate cancer. Research has not examined the role of neuroendocrine markers of stress (e.g. cortisol). This study examines whether sexual functioning or sexual bother is associated with diurnal cortisol. Men treated for prostate cancer completed the University of California-Los Angeles Prostate Cancer Index and provided saliva samples four times daily for cortisol assessment. Higher sexual bother, but not sexual functioning, was associated with steeper cortisol slope. Better sexual functioning, and not sexual bother, was significantly associated with the cortisol awakening response. Assessment of stress and stress-reducing interventions might be warranted in sexual rehabilitation after prostate cancer.
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http://dx.doi.org/10.1177/1359105318772655DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309533PMC
September 2020

Health Changes in Low Income Men Transitioning from a State Funded Prostate Cancer Program to Comprehensive Insurance.

J Urol 2018 07 6;200(1):74-81. Epub 2018 Feb 6.

Department of Urology, Los Angeles, California; UCLA Fielding School of Public Health, Los Angeles, California.

Purpose: We evaluated the effect of transitioning from a prostate cancer specific treatment program to comprehensive insurance under the ACA (Patient Protection and Affordable Care Act) on the physical, mental and prostate cancer related health of poor, previously uninsured men.

Materials And Methods: We assessed general and prostate cancer specific health related quality of life using the RAND SF-12v2™ (12-Item Short Form Survey, version 2) and the UCLA PCI (Prostate Cancer Index) at 3 time points in 24 men who transitioned to comprehensive insurance as the insured group relative to 39 who remained in the prostate cancer program as the control group. We used mixed effects models controlling for treatment and patient factors to measure health differences between the groups during the transition period.

Results: Demographics, prostate cancer treatment patterns, and mental, physical and general health were similar before transition in the control and insured groups. After transition men who gained insurance coverage reported significantly worse physical health than men who remained in the prostate cancer program (p = 0.0038). After adjustment in the mixed effects model physical health remained worse in men who gained insurance (p = 0.0036). Mental health and prostate cancer related quality of life did not differ with time between the groups.

Conclusions: Compared to controls who remained in the state funded prostate cancer treatment program for poor, uninsured men, newly insured men reported worse physical health after transitioning to ACA coverage. Providers and policy makers may draw important lessons from understanding the mechanisms of this paradoxical worsening in physical health after gaining insurance. These results inform the development of disease specific models of care in the broader health insurance context.
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http://dx.doi.org/10.1016/j.juro.2018.01.084DOI Listing
July 2018

Electronic health record problem lists: accurate enough for risk adjustment?

Am J Manag Care 2018 01 1;24(1):e24-e29. Epub 2018 Jan 1.

Cedars-Sinai Medical Center, 8635 W 3rd St, Ste 1070W, Los Angeles, CA 90048. Email:

Objectives: To determine whether comorbidity information derived from electronic health record (EHR) problem lists is accurate.

Study Design: Retrospective cohort study of 1596 men diagnosed with prostate cancer between 1998 and 2004 at 2 Southern California Veterans Affairs Medical Centers with long-term follow-up.

Methods: We compared EHR problem list-based comorbidity assessment with manual review of EHR free-text notes in terms of sensitivity and specificity for identification of major comorbidities and Charlson Comorbidity Index (CCI) scores. We then compared EHR-based CCI scores with free-text-based CCI scores in prediction of long-term mortality.

Results: EHR problem list-based comorbidity assessment had poor sensitivity for detecting major comorbidities: myocardial infarction (8%), cerebrovascular disease (32%), diabetes (46%), chronic obstructive pulmonary disease (42%), peripheral vascular disease (31%), liver disease (1%), and congestive heart failure (23%). Specificity was above 94% for all comorbidities. Free-text-based CCI scores were predictive of long-term other-cause mortality, whereas EHR problem list-based scores were not.

Conclusions: Inaccuracies in EHR problem list-based comorbidity data can lead to incorrect determinations of case mix. Such data should be validated prior to application to risk adjustment.
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January 2018

Cohort profile: the TrueNTH Global Registry - an international registry to monitor and improve localised prostate cancer health outcomes.

BMJ Open 2017 Nov 28;7(11):e017006. Epub 2017 Nov 28.

Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, USA.

Purpose: Globally, prostate cancer treatment and outcomes for men vary according to where they live, their race and the care they receive. The TrueNTH Global Registry project was established as an international registry monitoring care provided to men with localised prostate cancer (CaP).

Participants: Sites with existing CaP databases in Movember fundraising countries were invited to participate in the international registry. In total, 25 Local Data Centres (LDCs) representing 113 participating sites across 13 countries have nominated to contribute to the project. It will collect a dataset based on the International Consortium for Health Outcome Measures (ICHOM) standardised dataset for localised CaP.

Findings To Date: A governance strategy has been developed to oversee registry operation, including transmission of reversibly anonymised data. LDCs are represented on the Project Steering Committee, reporting to an Executive Committee. A Project Coordination Centre and Data Coordination Centre (DCC) have been established. A project was undertaken to compare existing datasets, understand capacity at project commencement (baseline) to collect the ICHOM dataset and assist in determining the final data dictionary. 21/25 LDCs provided data dictionaries for review. Some ICHOM data fields were well collected (diagnosis, treatment start dates) and others poorly collected (complications, comorbidities). 17/94 (18%) ICHOM data fields were relegated to non-mandatory fields due to poor capture by most existing registries. Participating sites will transmit data through a web interface biannually to the DCC.

Future Plans: Recruitment to the TrueNTH Global Registry-PCOR project will commence in late 2017 with sites progressively contributing reversibly anonymised data following ethical review in local regions. Researchers will have capacity to source deidentified data after the establishment phase. Quality indicators are to be established through a modified Delphi approach in later 2017, and it is anticipated that reports on performance against quality indicators will be provided to LDCs.
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http://dx.doi.org/10.1136/bmjopen-2017-017006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5719323PMC
November 2017

Editorial Comment.

J Urol 2018 01 13;199(1):96. Epub 2017 Oct 13.

Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California.

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http://dx.doi.org/10.1016/j.juro.2017.07.112DOI Listing
January 2018

Trends in Aging-Related Services During Nephrectomy: Implications for Surgery in an Aging Population.

J Am Geriatr Soc 2017 Oct 11;65(10):2290-2296. Epub 2017 Aug 11.

Department of Urology, Weill Cornell School of Medicine, New York, New York.

Objectives: To characterize the extent to which geriatric and related healthcare services are provided to older adults undergoing surgery for kidney cancer, a potential growth area in geriatrics and oncology.

Design: Population-based observational study.

Setting: Surveillance, Epidemiology, and End Results cancer data linked with Medicare claims.

Participants: Adults aged 65 and older with kidney cancer treated surgically from 2000 to 2009 (N = 19,129).

Measurements: Receipt of geriatric consultation, medical comanagement during the surgical hospitalization, inpatient physical or occupational therapy (PT/OT), and postacute PT/OT during the surgical care episode. Multivariable, mixed-effects models were used to identify associated participant and hospital characteristics, examine trends over time, and characterize hospital-level variation.

Results: Geriatric consultation occurred rarely in the perioperative period (2.6%). Medical comanagement (15.8%), inpatient PT/OT (34.2%), and postacute PT/OT (15.6%) occurred more frequently. In our mixed-effects models, participant age and comorbidity burden appeared to be consistent determinants of use of services, although hospital-level variation was also noted (P < .001). Use of geriatric consultation increased modestly in the latter years of the study period (P < .05). In contrast, medical comanagement (183%), inpatient PT/OT (73%), and postacute PT/OT (71%) increased substantially over the study period (P < .001).

Conclusion: Although geriatric consultation remained sparse, use of medical comanagement and rehabilitation services has grown considerably for older adults undergoing surgery for kidney cancer. Efforts to reorganize cancer and surgery care should explore reasons for variation and the potential for these service elements to meet the health needs of an aging population.
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http://dx.doi.org/10.1111/jgs.15046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5641234PMC
October 2017

The Diagnosis and Treatment of Prostate Cancer: A Review.

JAMA 2017 Jun;317(24):2532-2542

Department of Urology, University of North Carolina, Chapel Hill.

Importance: Prostate cancer is the most common cancer diagnosis made in men with more than 160 000 new cases each year in the United States. Although it often has an indolent course, prostate cancer remains the third-leading cause of cancer death in men.

Observations: When prostate cancer is suspected, tissue biopsy remains the standard of care for diagnosis. However, the identification and characterization of the disease have become increasingly precise through improved risk stratification and advances in magnetic resonance and functional imaging, as well as from the emergence of biomarkers. Multiple management options now exist for men diagnosed with prostate cancer. Active surveillance (the serial monitoring for disease progression with the intent to cure) appears to be safe and has become the preferred approach for men with less-aggressive prostate cancer, particularly those with a prostate-specific antigen level of less than 10 ng/mL and Gleason score 3 + 3 tumors. Surgery and radiation continue to be curative treatments for localized disease but have adverse effects such as urinary symptoms and sexual dysfunction that can negatively affect quality of life. For metastatic disease, chemotherapy as initial treatment now appears to extend survival compared with androgen deprivation therapy alone. New vaccines, hormonal therapeutics, and bone-targeting agents have demonstrated efficacy in men with metastatic prostate cancer resistant to traditional hormonal therapy.

Conclusions And Relevance: Advances in the diagnosis and treatment of prostate cancer have improved the ability to stratify patients by risk and allowed clinicians to recommend therapy based on cancer prognosis and patient preference. Initial treatment with chemotherapy can improve survival compared with androgen deprivation therapy. Abiraterone, enzalutamide, and other agents can improve outcomes in men with metastatic prostate cancer resistant to traditional hormonal therapy.
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http://dx.doi.org/10.1001/jama.2017.7248DOI Listing
June 2017

External Beam Radiation Therapy or Brachytherapy With or Without Short-course Neoadjuvant Androgen Deprivation Therapy: Results of a Multicenter, Prospective Study of Quality of Life.

Int J Radiat Oncol Biol Phys 2017 06 22;98(2):304-317. Epub 2017 Feb 22.

Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri.

Purpose: The long-term effects of neoadjuvant androgen deprivation therapy (NADT) with radiation therapy on participant-reported health-related quality of life (HRQOL) have not been characterized in prospective multicenter studies. We evaluated HRQOL for 2 years among participants undergoing radiation therapy (RT) with or without NADT for newly diagnosed, early-stage prostate cancer.

Methods And Materials: We analyzed longitudinal cohort data from the Prostate Cancer Outcomes and Satisfaction with Treatment Quality Assessment Consortium to ascertain the HRQOL trajectory of men receiving NADT with external beam RT (EBRT) or brachytherapy. HRQOL was measured using the expanded prostate cancer index composite 26-item questionnaire at 2, 6, 12, and 24 months after the initiation of NADT. We used the χ or Fisher exact test to compare the shift in percentages between groups that did or did not receive NADT. Analyses were conducted at the 2-sided 5% significance level.

Results: For subjects receiving EBRT, questions regarding the ability to have an erection, ability to reach an orgasm, quality of erections, frequency of erections, ability to function sexually, and lack of energy were in a significantly worse dichotomized category for the patients receiving NADT. Comparing the baseline versus 24-month outcomes, 24%, 23%, and 30% of participants receiving EBRT plus NADT shifted to the worse dichotomized category for the ability to reach an orgasm, quality of erections, and ability to function sexually compared with 14%, 13%, and 16% in the EBRT group, respectively.

Conclusions: Compared with baseline, at 2 years, participants receiving NADT plus EBRT compared with EBRT alone had worse HRQOL, as measured by the ability to reach orgasm, quality of erections, and ability to function sexually. However, no difference was found in the ability to have an erection, frequency of erections, overall sexual function, hot flashes, breast tenderness/enlargement, depression, lack of energy, or change in body weight. The improved survival in intermediate- and high-risk patients receiving NADT and EBRT necessitates pretreatment counseling of the HRQOL effect of NADT and EBRT.
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http://dx.doi.org/10.1016/j.ijrobp.2017.02.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5493021PMC
June 2017

Patient Function and the Value of Surgical Care for Kidney Cancer.

J Urol 2017 05 13;197(5):1200-1207. Epub 2016 Dec 13.

Department of Urology, Weill Cornell School of Medicine, New York, New York.

Purpose: Frailty and functional status have emerged as significant predictors of morbidity and mortality for patients undergoing cancer surgery. To articulate the impact on value (ie quality per cost), we compared perioperative outcomes and expenditures according to patient function for older adults undergoing kidney cancer surgery.

Materials And Methods: Using linked SEER (Surveillance, Epidemiology and End Results)-Medicare data, we identified 19,129 elderly patients with kidney cancer treated with nonablative surgery from 2000 to 2009. We quantified patient function using function related indicators (claims indicative of dysfunction and disability) and measured 30-day morbidity, mortality, resource use and cost. Using multivariable, mixed effects models to adjust for patient and hospital characteristics, we estimated the relationship of patient functionality with both treatment outcomes and expenditures.

Results: Of 19,129 patients we identified 5,509 (28.8%) and 3,127 (16.4%) with a function related indicator count of 1 and 2 or greater, respectively. While surgical complications did not vary (OR 0.95, 95% CI 0.86-1.05), patients with 2 or more indicators more often experienced a medical event (OR 1.22, 95% CI 1.10-1.36) or a geriatric event (OR 1.55, 95% CI 1.33-1.81), or died within 30 days of surgery (OR 1.43, 95% CI 1.10-1.86) compared with patients with no baseline dysfunction. These patients utilized significantly more medical resources and amassed higher acute care expenditures (p <0.001).

Conclusions: During kidney cancer surgery, patients in poor functional health can face a more eventful medical recovery at elevated cost, indicating lower value care. Greater consideration of frailty and functional status during treatment planning and transitions may represent areas for value enhancement in kidney cancer and urology care.
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http://dx.doi.org/10.1016/j.juro.2016.12.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7433987PMC
May 2017

Health status and use of partial nephrectomy in older adults with early-stage kidney cancer.

Urol Oncol 2017 04 7;35(4):153.e7-153.e14. Epub 2016 Dec 7.

Department of Urology, Weill Cornell School of Medicine, New York, NY.

Introduction: The long-term benefits of nephron-sparing surgery for kidney cancer depend on patient health. Accordingly, we examined whether receipt of partial nephrectomy varied with baseline comorbidity or functionality among older adults with stage I kidney cancer.

Materials And Methods: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 2000 to 2009, we identified patients treated with partial or radical nephrectomy for stage I kidney cancer. We examined treatment trends according to baseline comorbidity, function, and relevant health conditions. We then estimated the probability of partial nephrectomy using multivariable, mixed-effects models adjusting for patient, surgeon, and hospital characteristics.

Results: Overall, 2,956 of 11,678 patients (25.3%) underwent treatment with partial nephrectomy. Receipt of partial nephrectomy was associated with younger age, male sex, higher socioeconomic position, smaller tumor size, and treatment by a high-volume provider, cancer center, or academic institution (P<0.001). During the study period, utilization increased significantly (P<0.001) but did not differ according to comorbidity or patient function. Adjusting for patient, surgeon, and hospital characteristics, the probability of partial nephrectomy by comorbidity and function categories remained within a narrow range from 19.6% to 22.8%. Only preexisting kidney disease appeared to be linked to partial nephrectomy usage (odds ratio = 1.49, 95% CI: 1.33-1.66).

Conclusion: With the exception of kidney disease, the increasing use of partial nephrectomy did not vary with respect to health status. As the potential benefits of partial nephrectomy differ according to a patient׳s underlying health, selection tools and algorithms that match treatment to patient comorbidity or function may be needed to optimize kidney cancer care in the United States.
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http://dx.doi.org/10.1016/j.urolonc.2016.11.007DOI Listing
April 2017

Relief of Urinary Symptom Burden after Primary Prostate Cancer Treatment.

J Urol 2017 02 2;197(2):376-384. Epub 2016 Sep 2.

Department of Urology, Emory University School of Medicine, Atlanta, Georgia.

Purpose: Harms of prostate cancer treatment on urinary health related quality of life have been thoroughly studied. In this study we evaluated not only the harms but also the potential benefits of prostate cancer treatment in relieving the pretreatment urinary symptom burden.

Materials And Methods: In American (1,021) and Spanish (539) multicenter prospective cohorts of men with localized prostate cancer we evaluated the effects of radical prostatectomy, external radiotherapy or brachytherapy in relieving pretreatment urinary symptoms and in inducing urinary symptoms de novo, measured by changes in urinary medication use and patient reported urinary bother.

Results: Urinary symptom burden improved in 23% and worsened in 28% of subjects after prostate cancer treatment in the American cohort. Urinary medication use rates before treatment and 2 years after treatment were 15% and 6% with radical prostatectomy, 22% and 26% with external radiotherapy, and 19% and 46% with brachytherapy, respectively. Pretreatment urinary medication use (OR 1.4, 95% CI 1.0-2.0, p = 0.04) and pretreatment moderate lower urinary tract symptoms (OR 2.8, 95% CI 2.2-3.6) predicted prostate cancer treatment associated relief of baseline urinary symptom burden. Subjects with pretreatment lower urinary tract symptoms who underwent radical prostatectomy experienced the greatest relief of pretreatment symptoms (OR 4.3, 95% CI 3.0-6.1), despite the development of deleterious de novo urinary incontinence in some men. The magnitude of pretreatment urinary symptom burden and beneficial effect of cancer treatment on those symptoms were verified in the Spanish cohort.

Conclusions: Men with pretreatment lower urinary tract symptoms may experience benefit rather than harm in overall urinary outcome from primary prostate cancer treatment. Practitioners should consider the full spectrum of urinary symptom burden evident before prostate cancer treatment in treatment decisions.
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http://dx.doi.org/10.1016/j.juro.2016.08.101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5501938PMC
February 2017

Patient function, long-term survival, and use of surgery in patients with kidney cancer.

Cancer 2016 Dec 12;122(24):3776-3784. Epub 2016 Aug 12.

Department of Urology, Weill Cornell School of Medicine, New York, New York.

Background: Beyond age and comorbidity, functionality can shape the long-term survival potential of patients with cancer. Accordingly, herein the authors compared mortality and receipt of cancer-directed surgery according to patient function among older adults with kidney cancer.

Methods: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 2000 through 2009, the authors studied 28,326 elderly subjects with primary kidney cancer. Patient function was quantified using function-related indicators, claims indicative of dysfunction and disability. Adjusting for patient and cancer characteristics, competing risk regression was used to assess the relationship between function-related indicator count and cause-specific mortality and then generalized estimating equations were used to quantify the probability of surgery.

Results: A total of 13,619 adult patients (48.1%) with at least 1 function-related indicator were identified. A higher indicator category was associated with older age, greater comorbidity, female sex, unmarried status, lower socioeconomic status, and higher stage of disease (P<.001). Compared with patients with an indicator count of 0, those with an indicator count of 1 (hazard ratio, 1.10; 95% confidence interval [95% CI], 1.04-1.16) and ≥2 (hazard ratio, 1.46; 95% CI, 1.39-1.53) were found to have higher other-cause mortality. Conversely, kidney cancer mortality varied minimally with patient function. Patients with ≥ 2 indicators received cancer-directed surgery less often than those without disability (odds ratio, 0.61; 95% CI, 0.56-0.66), although treatment probabilities remained high for patients with locoregional disease and low for those with metastatic cancer.

Conclusions: Among older adults with kidney cancer, functional health stands as a significant predictor of long-term survival. However, receipt of cancer-directed surgery appears largely determined by cancer stage. Patient function should be considered more heavily when determining treatment for older adults with kidney cancer. Cancer 2016;122:3776-3784. © 2016 American Cancer Society.
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http://dx.doi.org/10.1002/cncr.30275DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6156784PMC
December 2016

Association Between Number of Endoscopic Resections and Utilization of Bacillus Calmette-Guérin Therapy for Patients With High-Grade, Non-Muscle-Invasive Bladder Cancer.

Clin Genitourin Cancer 2017 02 25;15(1):e25-e31. Epub 2016 Jun 25.

Department of Urology, Health Services Research Group, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA. Electronic address:

Background: Bacillus Calmette-Guérin (BCG) is the reference standard treatment for patients with high-grade, non-muscle-invasive bladder cancer (NMIBC). We previously described noncompliance with guidelines for BCG use in patients with high-risk disease. In the current study, we sought to characterize how the number of endoscopic resections of bladder tumors affects BCG utilization using population-level data.

Patients And Methods: We queried a Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to evaluate claims records of 4776 patients diagnosed with high-grade NMIBC between 1992 and 2002 and followed until 2007, who survived for at least 2 years and who did not undergo definitive treatment with cystectomy, radiotherapy, or systemic chemotherapy. We stratified patients on the basis of the number of endoscopic resections of bladder tumors. We used chi-square analysis to compare number of resections to BCG utilization and multinomial logistic regression analysis to quantify BCG utilization by patient and tumor characteristics.

Results: Utilization of BCG increases with increasing endoscopic resections from 40% at diagnosis to 72% after 6 resections. The cumulative rate of at least an induction course of BCG plateaus after 3 resections. Lower BCG utilization was associated with advanced age (≥ 80 years), while increased utilization was associated with being married, higher disease stage (Tis and T1) and grade (undifferentiated), and increasing endoscopic resections.

Conclusion: A significant fraction of patients with NMIBC do not receive induction BCG despite its proven benefit in minimizing recurrences. Most patients receive BCG only after multiple endoscopic resections. Strategies focused on earlier adoption of BCG to prevent recurrences instead of reacting to recurrences may limit progression and improve survival.
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http://dx.doi.org/10.1016/j.clgc.2016.06.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5183565PMC
February 2017

Patient experience and quality of urologic cancer surgery in US hospitals.

Cancer 2016 08 2;122(16):2571-8. Epub 2016 Jun 2.

Department of Urology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California.

Background: Care interactions as perceived by patients and families are increasingly viewed as both an indicator and lever for high-value care. To promote patient-centeredness and motivate quality improvement, payers have begun tying reimbursement with related measures of patient experience. Accordingly, the authors sought to determine whether such data correlate with outcomes among patients undergoing surgery for genitourinary cancer.

Methods: The authors used the Nationwide Inpatient Sample and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data from 2009 through 2011. They identified hospital admissions for cancer-directed prostatectomy, nephrectomy, and cystectomy, and measured mortality, hospitalization length, discharge disposition, and complications. Mixed effects models were used to compare the likelihood of selected outcomes between the top and bottom tercile hospitals adjusting for patient and hospital characteristics.

Results: Among a sample of 46,988 encounters, the authors found small differences in patient age, race, income, comorbidity, cancer type, receipt of minimally invasive surgery, and procedure acuity according to HCAHPS tercile (P<.001). Hospital characteristics also varied with respect to ownership, teaching status, size, and location (P<.001). Compared with patients treated in low-performing hospitals, patients treated in high-performing hospitals less often faced prolonged hospitalization (odds ratio, 0.77; 95% confidence interval, 0.64-0.92) or nursing-sensitive complications (odds ratio, 0.85; 95% confidence interval, 0.72-0.99). No difference was found with regard to inpatient mortality, other complications, and discharge disposition (P>.05).

Conclusions: Using Nationwide Inpatient Sample and HCAHPS data, the authors found a limited association between patient experience and surgical outcomes. For urologic cancer surgery, patient experience may be optimally viewed as an independent quality domain rather than a mechanism with which to improve surgical outcomes. Cancer 2016;122:2571-8. © 2016 American Cancer Society.
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http://dx.doi.org/10.1002/cncr.30081DOI Listing
August 2016

Author Reply.

Urology 2016 07 11;93:75-6. Epub 2016 May 11.

Department of Urology, University of California, Los Angeles, CA.

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http://dx.doi.org/10.1016/j.urology.2016.02.060DOI Listing
July 2016

The Quality of Care Provided to Women with Urinary Incontinence in 2 Clinical Settings.

J Urol 2016 Oct 7;196(4):1196-200. Epub 2016 May 7.

Department of Medicine, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California; Veterans Administration Greater West Los Angeles Medical Center, Los Angeles, California.

Purpose: Our aim was to test the feasibility of a set of quality of care indicators for urinary incontinence and at the same time measure the care provided to women with urinary incontinence in 2 clinical settings.

Materials And Methods: This was a pilot test of a set of quality of care indicators. A total of 20 quality of care indicators were previously developed using the RAND Appropriateness Method. These quality of care indicators were used to measure care received for 137 women with a urinary incontinence diagnosis in a 120-physician hospital based multispecialty medical group. We also performed an abstraction of 146 patient records from primary care offices in Southern California. These charts were previously used as part of ACOVE (Assessing Care of Vulnerable Elders Project). As a post-hoc secondary analysis, the 2 populations were compared with respect to quality, as measured by compliance with the quality of care indicators.

Results: In the ACOVE population, 37.7% of patients with urinary incontinence underwent a pelvic examination vs 97.8% in the multispecialty medical group. Only 15.6% of cases in the multispecialty medical group and 14.2% in ACOVE (p = 0.86) had documentation that pelvic floor exercises were offered. Relatively few women with a body mass index of greater than 25 kg/m(2) were counseled about weight loss in either population (20.9% multispecialty medical group vs 26.1% ACOVE, p = 0.76). For women undergoing sling surgery, documentation of counseling about risks was lacking and only 9.3% of eligible cases (multispecialty medical group only) had documentation of the risks of mesh.

Conclusions: Quality of care indicators are a feasible means to measure the care provided to women with urinary incontinence. Care varied by population studied and yet deficiencies in care were prevalent in both patient populations studied.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5067158PMC
http://dx.doi.org/10.1016/j.juro.2016.05.005DOI Listing
October 2016
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