Vol. 191, No. 4S, Supplement, Friday, May 16, 2014 THE JOURNAL OF UROLOGY� e15

General & Epidemiological Trends &Socioeconomics: Evidence-based Medicine &

Outcomes I

Podium

Friday, May 16, 2014 1:00 PM-3:00 PM

PD2-01INFECTION-RELATED HOSPITALIZATIONS AFTER PROSTATEBIOPSY IN A STATE-WIDE QUALITY IMPROVEMENTCOLLABORATIVE

Paul R. Womble, MD*, Maxwell W. Dixon, BS, Susan M. Linsell, MHSA,Zaojun Ye, MS, James E. Montie, MD, Ann Arbor, MI;Brian R. Lane, MD, PhD, Grand Rapids, MI; David C. Miller, MD, MPH,Ann Arbor, MI; Fank N. Burks, MD, Royal Oaks, MI

INTRODUCTION AND OBJECTIVES: While transrectal pros-tate biopsy is the cornerstone of prostate cancer diagnosis, seriouspost-biopsy infectious complications are reported to be increasing. Abetter understanding of the true prevalence and microbiology of theseevents is needed to guide quality improvement in this area and ulti-mately better early detection practices.

METHODS: Using data from the Michigan Urological SurgeryImprovement Collaborative (MUSIC) registry, we identified all menwho underwent transrectal prostate biopsy at 21 practices in Michiganfrom March 2012 through June 2013. Trained data abstractorsrecorded pertinent data, including prophylactic antibiotics and allbiopsy-related hospitalizations within 30 days of the procedures. For asubset of patients, claims data and follow-up telephone calls wereutilized for validation. All men admitted for an infectious complicationwere identified and their culture data obtained. We then compared thefrequency of infection-related hospitalization rates across practicesand according to antibiotic prophylaxis in concordance with AUA bestpractice recommendations.

RESULTS: The overall 30-day hospital admission rate followingprostate biopsy was 0.97%, ranging from 0% to 4.2% across 21 MUSICpractices (Figure). Ninety-five percent of admissions were for infectiouscomplications; the majority of cultures identified fluoroquinolone-resis-tant organisms. AUA concordant antibiotics were administered in 96.3%of biopsies. Patients receiving noncompliant antibiotic regimens weresignificantly more likely to be hospitalized for infectious complications(3.8% vs. 0.89%, p ¼ 0.0026).

CONCLUSIONS: Infection-related hospitalizations occur inapproximately 1% of men undergoing prostate biopsy in Michigan. Ourfindings suggest that many of these events could be avoided byimplementing new protocols (e.g., culture-specific or augmented anti-biotic prophylaxis) that both adhere with AUA best practice recom-mendations and address fluoroquinolone resistance.

Source of Funding: Blue Cross Blue Shield of Michigan

PD2-02QUALITY IMPROVEMENT OPPORTUNITIES IN PROSTATECTOMYCARE IN A REGIONAL HOSPITAL-BASED UROLOGIC QUALITYCOLLABORATIVE

John L. Gore*, Michael Porter, John Corman, Seattle, WA;Douglas Sutherland, Tacoma, WA; Zeila Schmidt, David Flum,Seattle, WA

INTRODUCTION AND OBJECTIVES: Prostate cancer careis susceptible to regional variation in selection for treatment and out-comes after primary therapy. Recent national recommendations havehighlighted the harms of prostate cancer treatment including urinaryincontinence and erectile dysfunction. We prospectively evaluatedradical prostatectomy (RP) outcomes at participating Washington-statehospitals to identify quality improvement opportunities in RP care.

METHODS: We convened a clinician advisory group of localurologists engaged in prostate cancer care to develop a chartabstraction tool that captures potential quality concerns in RP care. Theabstraction tool was implemented at nine regional hospitals with dataconsolidated for review quarterly. The research team and clinicianadvisory group were blinded to the hospital identities in hospital-specificfeedback reports. Data were analyzed as aggregate rates and hospital-specific rates without risk adjustment using descriptive statistics.

RESULTS: We abstracted data on 461 patients undergoing RPat 9 area hospitals from 2011-2013. The majority were robot-assistedminimally invasive RPs (344/461, 74%), Participating hospitals report asmany as 97% or as few as 12% robot-assisted procedures. 26.3% ofcases were pathologic non-organ-confined prostate cancer (pT3 orhigher); pathologic stage was not further classified beyond "T2" or "T3" in31% of RPs. Surgical margins were positive in 18% of cases overall;hospital-specificpositivemargin rates ranged from12-25%amongorgan-confined cases and 0-75% among stage pT3 or higher prostate cancer.Lymphadenectomy was performed in 53-100% of RPs by hospital forintermediate and high-risk cancer cases. Length of stay exceeded threedays post-prostatectomy in more than 10% of cases at 4 hospitalsincluding one hospital where 36%of cases had prolonged lengths of stay.

CONCLUSIONS: We identified several quality improvementopportunities that may improve health outcomes among men undergoingRP for prostate cancer. Positive margin rates were excessive at somehospitals andmay represent uncertainty in the surgical approach to higherrisk cases. Variation in lengths of stay may represent provider variation inpost-prostatectomy clinical care algorithms. Survey of provider practicesmay inform development of quality improvement initiatives such as clinicalpathways that may address the variations in RP care identified.

Source of Funding: This work was supported by funding fromthe National Cancer Institute, the Agency of HealthcareResearch and Quality, and the Life Sciences Discovery Fund.

PD2-03IDENTIFICATION OF QUALITY IMPROVEMENT OPPORTUNITIESIN KIDNEY CANCER SURGERY THROUGH A REGIONALHOSPITAL-BASED UROLOGIC QUALITY COLLABORATIVE

John L. Gore*, Michael Porter, Danlel Lin, Jonathan Harper,Zeila Schmidt, David Flum, Seattle, WA

INTRODUCTION AND OBJECTIVES: Patient selection forradical (RN) and partial nephrectomy (PN) for suspicion of kidneycancer may depend more on provider factors than patient characteris-tics or cancer severity. National cancer registry data suggests thatpatients with small renal tumors have better overall survival whenmanaged with PN rather than RN. We prospectively evaluated periop-erative processes of care for patients undergoing kidney cancer surgeryat Washington State hospitals participating in a surgical collaborative toidentify quality improvement opportunities in kidney cancer care.

METHODS: We developed a chart abstraction tool that cap-tures potential quality concerns in kidney cancer surgical care. Theabstraction tool was implemented at nine regional hospitals with data

e16 THE JOURNAL OF UROLOGY� Vol. 191, No. 4S, Supplement, Friday, May 16, 2014

consolidated for review quarterly. A sampling of PN and RN cases wasabstracted. Hospital-specific feedback reports were blinded to thehospital identities; data were analyzed as aggregate rates and hospital-specific rates using descriptive statistics. Presented results were notrisk-adjusted.

RESULTS: We identified 75 patients undergoing RN or PN at9 area hospitals from 2011-2013. Staging evaluations were uncommon(preoperative chest x-ray and chest CT in 41% and 20%, respectively).Thirteen percent of patients had a preoperative renal mass biopsy. Forrenal tumors � 4 cm, 16/32 (50%) underwent PN. Hospital-specificutilization of PN for small renal masses exhibited variation: in 2 hospi-tals, 100% of tumors � 4 cm were treated with PN, while 1 hospitalperformed RN in all cases, and the remaining hospitals ranged from33%-67% utilization of PN. PN was less common for tumors 4-7 cm insize (4/26 cases [15%]). Venous thromboembolic events occurred in4% of kidney cancer surgeries.

CONCLUSIONS: We identified substantial variation in selectionof surgical technique and postoperative outcomes following PN and RNfor kidney cancer. Patients with small renal masses appear to havevariable access to PN, which could impact their long-term health out-comes. Better understanding of provider knowledge and attitudestoward management of small renal masses could inform qualityimprovement initiatives to address the variations in care identified.

Source of Funding: This work was supported by funding fromthe National Cancer Institute, the Agency of HealthcareResearch and Quality, and the Life Sciences Discovery Fund.

PD2-04SURGEON ADOPTION OF MINIMALLY INVASIVE RADICALPROSTATECTOMY

Christopher Anderson*, Coral Atoria, Karim Touijer, James Eastham,Elena Elkin, New York, NY

INTRODUCTION AND OBJECTIVES: Minimally invasiveradical prostatectomy (MIRP) is now the most common surgical treat-ment for prostate cancer, and many open surgeons have adopted theminimally invasive approach. Our objective was to describe the patternof MIRP adoption among surgeons, and assess whether open surgeonswho adopted MIRP had inferior outcomes to surgeons who exclusivelyperformed MIRP.

METHODS: In the population-based SEER-Medicare dataset,we identified all surgeons who performed MIRP or open radicalprostatectomy (ORP) for prostate cancer from 2002-2008. Minimallyinvasive surgeons were classified as converters if they had performedORP prior to their first MIRP, or de novo if they had not. We calculatedthe proportion of prostatectomies converters performed minimallyinvasively each year. In a cohort of men �66 years old who had MIRPfor prostate cancer from 2003-2008, we used logistic regression toestimate the impact of surgeon type (converter vs. de novo) on thereceipt of any secondary cancer treatment, and claims for inconti-nence, erectile dysfunction (ED) and bladder outlet obstruction (BOO)at �3 months postoperatively. All endpoints were assessed at 3 yearspostoperatively.

RESULTS: We identified 750 MIRP surgeons (450 convertersand 300 de novo) who performed 9,193 MIRPs. On average there were75 (SD 30) new converters and 50 (SD 23) new de novo surgeons eachyear. Converters performed 65% of all MIRPs and de novo surgeonsperformed 35%, although their average annual MIRP volume was similar(converter 5.3 (SD 6.8) vs. de novo 5.5 (SD 12.3)). In 2003 convertersperformed a median 50% (IQR 33.3%, 95.5%) of their cases minimallyinvasively which increased to 100% (IQR 83%, 100%) in 2008 (figure).

At 3 years after surgery, there were no differences in use of sec-ondary cancer treatments (OR 1.09 [95% CI 0.71-1.69]), and incon-tinence (OR 1.21 [95% CI 0.87-1.69]) or BOO (OR 1.01 [95% CI0.69-1.47]) between patients treated by converters and de novosurgeons, controlling for patient characteristics and surgeon MIRPvolume. However, patients treated by converters had a higher rate ofED (OR 1.48 [95% CI 1.11-1.98]).

CONCLUSIONS: Following the introduction of robotic technol-ogy, many open surgeons rapidly adopted MIRP. Converters may havehad a different intensity of MIRP training than de novo surgeons,translating to variations in their patients’ functional outcomes.

Source of Funding: None

PD2-05PREDICTORS OF 30-DAY READMISSION FOLLOWING PARTIALAND RADICAL NEPHRECTOMY FOR KIDNEY CANCER

Abram McBride*, Max McKibben, Josip Vukina, Jonathan Matthews,Raj Pruthi, Mathew Raynor, Eric Wallen, Michael Woods,Matthew Nielsen, Angela Smith, Chapel Hill, NC

INTRODUCTION AND OBJECTIVES: Readmissions arecommon among patients undergoing major abdominal surgery forcancer, leading to estimated Medicare costs of $17.4 billion annually.Surgical readmissions account for 22% of total readmissions, but littledata exist regarding urologic readmission rates for kidney cancer.Evaluating the SEER-Medicare database, readmissions followingnephrectomy approached 10% but no data were provided regardingsurgical approach. Our objective was therefore to evaluate predictorsof readmissions in a multi-institutional prospective database amongpatients undergoing laparoscopic and open radical and partialnephrectomy for kidney cancer.

METHODS: Using the American College of Surgeons-NationalSurgeon Quality Improvement Program (ACS-NSQIP) database, weperformed a review of patients undergoing nephrectomy for kidneycancer in 2011. ACS-NSQIP collects data on 135 variables, includingperi-operative data and readmissions on major surgical procedures atover 450 participating academic and private institutions. Overall read-mission rates were calculated and predictors of readmission wereidentified using multivariable logistic regression models.

RESULTS: Of 438 patients who underwent radical nephrec-tomy, 47% were performed via open approach with readmission rates ofopen or laparoscopic radical nephrectomy 8% and 3.9%, respectively.On multivariable analysis, surgical approach (open vs. lap), preopera-tive dialysis, and higher ASA score were significant predictors ofsubsequent readmission (see Table). Of 343 patients who underwentpartial nephrectomy, approximately half underwent open or laparo-scopic approach. Readmission rates among partial nephrectomypatients were similar between open and laparoscopic approaches(4.7% vs. 4.6%, respectively). On multivariable analysis, no significantcovariates were noted to predict 30-day readmissions in this population.

CONCLUSIONS: Readmission rates following partial nephrec-tomy (regardlessof approach) remain low.However, radical nephrectomydemonstrated higher readmission rates with an open approach, preop-erative dialysis, and higher ASA score identified as significant predictorsof readmission following radical nephrectomy.