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Problem: In the U.S., sudden unexpected infant deaths due to accidental suffocation and strangulation in bed are increasing. Though breastfeeding is a protective factor against sudden unexpected infant death, motivations to breastfeed often couple with unsafe infant sleep practices. Racial/ethnic disparities are present in sudden unexpected infant death, accidental suffocation and strangulation in bed, and breastfeeding., Background: Promoting infant safe sleep and breastfeeding through community-level initiatives could address disparities in related outcomes., Aim: Investigate the relationship between community-level strategies and associated state-level outcomes for infant safe sleep and breastfeeding., Methods: We employed an intervention mixed methods framework and exploratory sequential design. The qualitative component entailed a hermeneutical phenomenological framework to analyze key informant interview data from seven U.S. community-level providers participating in a practice improvement initiative. The quantitative component entailed descriptively analyzing infant safe sleep and breastfeeding indicators from the 2019 Pregnancy Risk Assessment Monitoring System and Ohio Pregnancy Assessment Survey. Qualitative and quantitative data were linked through embedded integration., Findings: We identified two mixed insights: gaps in promotion and outcomes, and persistent disparities between infant safe sleep and breastfeeding promotion and outcomes., Discussion: Our findings indicate conversational approaches could improve infant safe sleep and breastfeeding promotion, outcomes, and relative disparities. We find that community collaboration is needed to address organizational capacity limitations in promoting infant safe sleep and breastfeeding., Conclusion: Community-level organizations and providers should consider tailoring program offerings and care delivery to include conversational approaches and community collaboration to promote infant safe sleep and breastfeeding and decrease relative disparities in outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Estimation of life expectancy (LE) is important for the relative benefit of prostate specific antigen (PSA) screening. Limited data exists regarding screening for Black men with extended LE. The aim of the current study was to assess temporal trends in screening in United States (US) Black men with limited vs. extended LE, using a nationally representative dataset., Materials and Methods: Using the National Health Institution Survey (NHIS) 2000 to 2018, men aged ≥40 without prior history of prostate cancer (PCa) who underwent PSA screening in the last 12 months were stratified into limited LE (ie, LE <15 years) and extended LE (ie, LE≥15 years) using the validated Schonberg index. LE-stratified temporal trends in PSA screening were analyzed for all men, and then in Black men. Weighted multivariable analyses and dominance analyses identified the predictors of PSA screening., Results: PSA screening declined over the study period both for all eligible men with limited and extended LE, particularly between NHIS 2008 and 2013 (27.9%-20.7% in the extended). Screening increased significantly in Black men with extended LE (17.6% in 2010-25.7% in 2018). However, LE was not an independent predictor of screening in the Black cohort. Prior recipient of colonoscopy (55%-57%) and visit to health care provider (24%-32%) were the most important determinants for screening., Conclusion: For US men with extended LE, only 1 in 4 receive PSA screening, with a decline over the study-period. Screening rates increased for Black men. However, these changes were not driven by LE consideration itself, but participation in other screenings and access to a provider., Competing Interests: Disclosure None of the authors have any relevant disclosures, and none of the authors have any financial or non-financial interests that may be relevant to the submitted work., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To assess the incidence, cumulative healthcare burden, and financial impact of inpatient admissions for radiation cystitis (RC), while exploring practice differences in RC management between teaching and nonteaching hospitals., Methods: We focused on 19,613 patients with a diagnosis of RC within the National Inpatient Sample (NIS) from 2008 to 2014. ICD-9 diagnosis and procedure codes were used. Complex-survey procedures were used to study the descriptive characteristics of RC patients and the procedures received during admission, stratified by hospital teaching status. Inflation-adjusted cost and cumulative annual cost were calculated for the study period. Multivariable logistic regression was used to study the impact of teaching status on the high total cost of admission., Results: Median age was 76 (interquartile range 67-82) years. Most of the patients were males (73%; P < .001). 59,571 (61%) patients received at least one procedure, of which, 24,816 (25.5%) received more than one procedure. Median length of stay was 5days (interquartile range 2-9). Female patients and patients with a higher comorbidity score were more frequently treated at teaching hospitals. A higher proportion of patients received a procedure at a teaching hospital (64% vs 59%; P < .001). The inflation-adjusted cost was 9207 USD and was higher in teaching hospitals. The cumulative cost of inpatient treatment of RC was 63.5 million USD per year and 952.2 million USD over the study period., Conclusion: The incidence of RC-associated admissions is rising in the US. This disease is a major burden to US healthcare. The awareness of the inpatient economic burden and healthcare utilization associated with RC may have funding implications., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: There are not other Declarations of interest If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Multiple myeloma (MM) is one of the most diagnosed hematologic malignancies in the United States. Despite improvements in therapy, health disparities persist among patients with MM. Here, we aim to determine whether there are disparities in time to diagnosis (TTD) among MM patients with regard to income, race/ethnicity, and gender., Patients: Patients with a monoclonal protein detected in the serum and/or urine and a subsequent bone marrow biopsy confirmed diagnosis of MM were included in the study., Methods: We extracted data on patients with MM and assessed whether the predictor variables were associated with the primary outcome of TTD, which we define as the time between detection of a monoclonal protein in the serum or urine and bone marrow biopsy diagnosis of MM., Results: Compared to patients with commercial insurance, patients receiving Medicaid (HR: 0.408, 95% CI: 0.206-0.808; P = .010) and patients without insurance (HR: 0.428, 95% CI: 0.207-0.885; P = .022) were significantly more likely to have delayed TTD. TTD was also prolonged if the provider who ordered the testing for the detection of a monoclonal protein was not a hematologist (HR: 0.435, 95% CI: 0.284-0.668; P < .0001). No disparities were found with regard to race/ethnicity or gender., Conclusion: This study suggests there may be socioeconomic disparities in TTD among patients with MM. Interventions such as patient navigation may be useful to reduce TTD among socioeconomically disadvantaged patient populations. Further studies need to be conducted to elucidate reasons for delays., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Importance: Preference signals were to be implemented in over 15 specialties during the 2022-2023 residency match. Analyzing results from the implementation of signals during the American Urological Association (AUA) urology match may inform future behavior., Objective: To characterize applicant and program signal usage and results in the Society of Academic Urology and AUA databases with respect to interview invites and rank list creation., Design, Setting, and Participants: This cohort study involved all applicants and residencies in the 2021-2022 AUA match with data analysis conducted in April through July 2022., Exposures: Five signals indicating interest., Main Outcomes and Measures: Using verified match and survey data reported by applicants and programs, a logistic regression was performed on applicant factors associated with obtaining an interview-the main outcome (using inclusion on rank list as a proxy): age, gender, degree (MD or DO), dispersal of signal, US senior status, racial minority group status, Latino ethnicity, international medical graduate status, presence of a home program, AUA geographic section, and US Medical Licensing Examination Step 1 score. Applicant signal dispersal strategies were stratified by applicant and program competitiveness, as well as program behavior upon receipt of signal with respect to extending interviews and rank list ordering of applicants., Results: A total of 2659 signals were sent by 553 candidates (mean [SD] age, 27.4 [2.9] years; 179 female [32.4%], 243 racial minority candidates [61.2%]) submitting rank lists for 364 positions at 143 programs. Programs received a median (IQR) of 352 (295-411) applications and were signaled to a median of 16 (8-26) times each. In a logistic regression estimating interview status, geographic proximity (OR, 3.25; 95% CI, 2.05-5.15; P = .001) and signal status (OR, 6.04; 95% CI, 3.50-10.40; P < .001) were associated with receiving an interview. Using multiple imputation by chained equations to impute missing data and broadening the data set, male gender (OR, 0.64; 95% CI, 0.45-0.92; P = .04) and international medical graduate status (OR, 0.35; 95% CI, 0.15-0.81; P = .04) were negative variables, while MD degree (OR, 2.36; 95% CI, 1.27-4.36; P = .02) and US senior status (OR, 1.91; 95% CI, 1.13-3.23; P = .04) were positive variables., Conclusions and Relevance: This study of the usage and trends of the newly added preference signals reported the most common strategies for signal dispersal; in an analysis of factors involved in obtaining an interview, geographic similarity between applicant and program and preference signal usage were associated with successful applications.

Supporting social emotional development, beginning at birth, can improve lifelong health. The American Academy of Paediatrics recommends 12 well-child visits between birth and age 3 years. Each well-child visit provides a unique opportunity to interact with and support families to promote social emotional development of children. Eighteen US paediatric practices joined a learning community to use improvement science to test and implement evidence-informed strategies that nurture parent-child relationships and promote the social emotional development of young children.Quality improvement methods were used to integrate 11 strategies into well-child visits between birth and age 3 years and measure the improvements with a set of outcome, process and balancing measures. Participation among the 18 paediatric practices was high with 72% of teams attending monthly webinars and 97% of teams attending the three learning sessions. Over 12 months, the percentage of children receiving age-appropriate social emotional development screens at participating practices' well-child visits increased from a baseline median of 83% to 93%.Current paediatric practice in the USA focuses primarily on cognitive and physical development, and paediatric providers are less familiar with established practices to screen for social emotional development and promote the caregiver-child relationship. This project suggests that improvement methods show promise in increasing the number of children who receive age-appropriate social emotional development screens or assessments at well-child visits., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Ductal adenocarcinoma is considered a rare histological variant of prostate adenocarcinoma (PCa). Given the rarity of this subtype, optimal treatment strategies for men with nonmetastatic ductal PCa is largely unknown. We aimed to describe the impact of surgery, radiotherapy, systemic therapy, and observation on overall survival (OS) in men with nonmetastatic ductal PCa., Materials and Methods: We selected 1,656 cases of nonmetastatic ductal PCa, diagnosed between 2004 and 2015, within the National Cancer Database. Covariates included age, race, Charlson comorbidity score, clinical T stage, clinical lymph node stage, serum prostate specific antigen (PSA), income, hospital type, insurance status, year of diagnosis, and location of residence. Cox regression analysis tested the impact of treatment (surgery, radiotherapy, systemic therapy, and observation) on OS., Results: In men with nonmetastatic ductal PCa, median (interquartile range [IQR]) age and PSA were 67 (60-73) years and 6.2 (4.2-10.7) ng/ml, respectively. Advanced local stage (≥cT3a) was most frequently observed in patients initially treated with systemic therapy (34.8%), followed by those treated with radiotherapy (18.1%), surgery (7.1%) and observation (6.4%, P< 0.001). Serum PSA at presentation was highest in the systemic therapy cohort (median 16.0 ng/ml, IQR: 4.9-37.7), followed by the radiotherapy cohort (median 7.2 ng/ml, IQR: 4.1-12.2), observation cohort (median 7.0 ng/ml, IQR: 4.3-13.3) and surgery cohort (median 5.9 ng/ml, IQR: 4.3-9.2, P< 0.001). Multivariable analysis showed that in comparison to men treated surgically, OS was significantly lower for patients receiving radiotherapy (HR 2.2; 95% CI: 1.5-3.2), under observation (HR 4.6; 95% CI: 2.8-7.6) and receiving systemic therapy (HR 5.2; 95% CI: 3.0-9.1) as an initial course of treatment., Conclusions: While limited by its retrospective nature, our study shows that starting treatment with surgery is associated with more favorable long-term OS outcomes than radiotherapy, systemic therapy or observation., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To examine the utilization of adjuvant radiotherapy (aRT) in contemporary prostate cancer patients with adverse pathological features at radical prostatectomy (RP)., Methods: We identified 189,240 patients with adverse features at RP (positive margin, stage ≥pT3a, and/or pN1 disease), from 2004 to 2015, within the National Cancer Database, and validated our findings within Surveillance, Epidemiology, and End Results (SEER) program. We examined the utilization of patients with aRT with adverse features at RP and patients with very aggressive disease (at least 2 of the following: ≥pT3b, pathological Gleason 8-10, and pN1). Regression analysis examined the relationship of various predictors of utilization adjusting to confounders. Pseudo R 2 analysis examined the magnitude of influence that each variable had on the decision to use aRT., Results: Within the National Cancer Database cohort, only 11.7% of our patients received aRT. In patients with very aggressive disease, aRT utilization rate was 28.9%. Within the SEER cohort, 16.3% of patients with any adverse features at time of RP received aRT. In patients with very aggressive disease, only 30% of patients received aRT. Further, year of diagnosis, Gleason grade, pathologic stage, and positive surgical margin were the variables that had the greatest influence on the decision to use aRT, and that positive surgical margin, type of institution at which care was received, and lymph node involvement were the most influential variables in patients with very aggressive disease., Conclusions: The current standard of care in the United States represents a significant underutilization of aRT in eligible patients with prostate cancer. Urgent efforts are necessary to address this quality-of-care concern., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: The American Joint Committee on Cancer recognizes 6 rare histological variants of prostate adenocarcinoma. We describe the contemporary presentation and overall survival of these rare variants., Materials and Methods: We examined 1,345,618 patients who were diagnosed with prostate adenocarcinoma between 2004 and 2015 within the National Cancer Database. We focused on the variants mucinous, ductal, signet ring cell, adenosquamous, sarcomatoid and neuroendocrine. Characteristics at presentation for each variant were compared with nonvariant prostate adenocarcinoma. Cox regression was used to study the impact of histological variant on overall mortality., Results: Few (0.38%) patients presented with rare variant prostate adenocarcinoma. All variants had higher clinical tumor stage at presentation than nonvariant (all p <0.001). Metastatic disease was most common with neuroendocrine (62.9%), followed by sarcomatoid (33.3%), adenosquamous (31.1%), signet ring cell (10.3%) and ductal (9.8%), compared to 4.2% in nonvariant (all p <0.001). Metastatic disease in mucinous (3.3%) was similar to nonvariant (p=0.2). Estimated 10-year overall survival was highest in mucinous (78.0%), followed by nonvariant (71.1%), signet ring cell (56.8%), ductal (56.3%), adenosquamous (20.5%), sarcomatoid (14.6%) and neuroendocrine (9.1%). At multivariable analysis, mortality was higher in ductal (HR 1.38, p <0.001), signet ring cell (HR 1.53, p <0.01), neuroendocrine (HR 5.72, p <0.001), sarcomatoid (HR 5.81, p <0.001) and adenosquamous (HR 9.34, p <0.001) as compared to nonvariant., Conclusions: Neuroendocrine, adenosquamous, sarcomatoid, signet ring cell and ductal variants more commonly present with metastases. All variants present with higher local stage than nonvariant. Neuroendocrine is associated with the worst and mucinous with the best overall survival.

Objective: Prior research has suggested that treatment-resistant psychosis (TRP) may be a categorically distinct subtype from treatment-responsive psychotic disorders. However, relatively few studies have investigated the cognitive profile of individuals with TRP. Moreover, no prior studies have investigated the effectiveness of using the NIH Toolbox Cognition Battery (NTCB) for assessing cognition among psychiatric inpatients despite its promising efficiency and practicality in such settings. The current study aimed to investigate the validity of the NTCB and the associated cognitive profile of inpatients with TRP. Methods: Participants (N = 38) were administered the NTCB and a neuropsychological test battery. The Positive and Negative Syndrome Scale and the Routine Assessment of Patient Progress measured psychosis symptomatology and daily functioning, respectively. Results: Results showed deficits relative to normative values in fluid cognitive abilities using the NTCB, as predicted. There was strong convergent validity and adequate divergent validity between the NTCB subtests and corresponding neuropsychological measures, though no NTCB subtest correlated with performance on the Wisconsin Card Sorting Task. NTCB performance correlated with positive and disorganized symptoms of psychosis as well as daily functioning. Conclusions: Taken together, the NTCB appears to be a relatively strong tool for cognitive screening among psychiatric inpatients and may be used to identify which patients might benefit from further neuropsychological evaluation.

Currently, surveillance guidelines following surgical resection of clinically localized renal cell carcinoma (RCC) are clear within the first 5 yr; however, these lack the same degree of objectivity following this cutoff. We sought to investigate the long-term risk of recurrence in surgically treated RCC in order to determine the utility of long-term surveillance. A post hoc analysis of patients within the Eastern Cooperative Oncology Group-American College of Radiology Imaging Network (ECOG-ACRIN) E2805 trial cohort was performed. The 36-mo cumulative incidence of recurrence was assessed at set intervals following surgery, in order to dynamically assess recurrence through the use of a conditional survival model. Of the 1943 patients included in the original cohort, 730 developed recurrence. The 36-mo cumulative incidences of recurrence were found to be 31%, 26%, 19%, 16%, 19%, and 20% for patients at 0, 12, 24, 36, 48, and 60 mo from surgery, respectively. At 0 mo from surgery, age, pathological T3/4 stage (hazard ratio [HR] = 1.56), pathological N1/2 stage (HR = 2.38), and Fuhrman grades 3 and 4 (HR = 1.36 and HR = 2.41, respectively) were independent predictors of recurrence; however, this was not seen at 60 mo following surgery. These findings support that surveillance imaging should be performed beyond 5 yr following surgical resection of intermediate- to high-risk RCC. PATIENT SUMMARY: : Follow-up for surgically resected localized renal cell carcinoma should be performed beyond 5 yr, for the rates of recurrence remain significant beyond this 5 yr endpoint., (Copyright © 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: Radical cystectomy is the gold standard for nonmetastatic muscle invasive bladder cancer and for refractory nonmuscle invasive disease. Compared to open radical cystectomy, robot-assisted radical cystectomy has been shown to provide comparable early oncologic outcomes and improved perioperative outcomes. However, there is a paucity of data on long-term oncologic outcomes and concerns about a higher incidence of local recurrence after robot-assisted radical cystectomy. We report 10-year oncologic outcomes following robot-assisted radical cystectomy using a multinational database., Materials and Methods: We retrospectively reviewed the prospective International Robotic Cystectomy Consortium database. Consecutive patients who underwent robot-assisted radical cystectomy 10 years ago or earlier were included in analysis. Data were reviewed for demographics, and perioperative, pathological and oncologic outcomes. Kaplan-Meier curves were used to depict recurrence-free, disease specific and overall survival. Multivariate stepwise Cox regression models were applied to identify variables associated with recurrence-free, disease specific and overall survival., Results: We identified 446 patients with a median age of 67 years (IQR 59-76). Of the patients 10% received neoadjuvant chemotherapy, 51% experienced any complication, 23% had high grade complications and 4% died within 3 months of robot-assisted radical cystectomy. Disease was pT3 or greater in 43% of patients and pN+ in 24% while a positive soft tissue surgical margin was observed in 7%. At a median followup of 5 years (IQR 2-10, maximum 14) local and distant recurrence had developed in 15% and 29% of patients, respectively. Ten-year recurrence-free, disease specific and overall survival rates were 59%, 65% and 35%, respectively. Patients with pT3 or greater and pN+ disease showed worse recurrence-free, disease specific and overall survival., Conclusions: Long-term oncologic outcomes, and recurrence rates and patterns after robot-assisted radical cystectomy seem comparable to those in open series. Advanced disease stage and positive surgical margins remain the main determinants of survival after radical cystectomy.

Background: The use of neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) is supported by results from several randomized control trials, including SWOG-8710., Objective: To look at the effectiveness of NAC before RC in current real world practice in the USA., Design, Setting, and Participants: We used the National Cancer Data Base (NCDB) to identify patients with nonmetastatic muscle-invasive urothelial carcinoma of the bladder who underwent RC between 2004 and 2012., Intervention: Receipt of NAC before RC., Outcome Measurements and Statistical Analysis: The primary endpoint was overall survival (OS). Secondary endpoints were rates of complete pathologic response (pT0), positive pathologic lymph nodes (pN+), and margin status. Using a landmark analysis to adjust for an immortal-time bias, OS comparison was performed using Cox regression analysis. Furthermore, logistic regression models examining secondary outcomes were fitted. To adjust for potential selection bias, propensity score-weighted analyses were performed., Results and Limitations: Of 8732 patients who underwent RC, 1619 (19%) received NAC. Following propensity score adjustment, receipt of NAC was not associated with an OS benefit (hazard ratio 0.97; p=0.591). On secondary outcome analysis, higher pT0 rates (odds ratio 5.03; p<0.001) were recorded among patients who received NAC, although rates of pT0 were lower than for patients treated with NAC within the SWOG-8710 trial (13% vs 38%). Limitations include the retrospective design and limited details available regarding type of chemotherapy., Conclusions: Important baseline differences between patients from the SWOG-8710 trial and those in general urologic practice exist. After adjusting for immortal-time bias, we did not find a clear survival advantage of NAC before RC when compared to RC alone in current general urology practice in the USA., Patient Summary: The benefit of chemotherapy before radical cystectomy is supported by few randomized control trials. In this study, using a large national data set from the USA we found that preoperative chemotherapy is not associated with a survival benefit in all patients in general urology practice. Hence, better selection criteria are needed to determine who will benefit the most from chemotherapy before radical cystectomy., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: To evaluate the utilization of pelvic lymph node dissection (PLND) and its extent in contemporary US patients, and to correlate it to the detection of pN1 disease., Patients and Methods: A total of 328,710 individuals who received radical prostatectomy between the years 2004 and 2013 were identified within the National Cancer Data Base. The Cochran-Armitage test was used to assess the statistical significance of temporal trends. Logistic regression analysis tested the relationship between the number of lymph nodes removed (LNR) and pN1 rate., Results: Most patients had T2 disease (76.7%) and a Gleason score of 7 (55.9%). Overall, 63.5% of the patients received PLND; this ranged between 58.9% and 72.1% over the study period (P = .8). In patients receiving PLND, mean LNR increased from 6.1 nodes in 2004 to 7.2 nodes in 2013 (P < .001). When stratified by tumor risk, utilization and extent of PLND increased in intermediate- and high-risk tumors, while it decreased in low-risk tumors. Overall pN1 rate was 3.73%, and it increased from 2.9% to 5.3% between 2004 and 2013 (P < .001). In multivariable analysis, LNR was an independent predictor of pN1 (P < .001)., Conclusion: The utilization patterns of PLND in the United States have improved, with an increased focus on patients with intermediate- and high-risk disease. Likewise, the extent of PLND has improved to include more lymph nodes. This seems to translate into more accurate tumor, node, metastasis classification system staging, as more patients are being appropriately diagnosed with pN1 disease., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Regionalization of bladder cancer treatment is suggested to improve quality of care. As an unintended consequence some patients travel farther for care with unknown implications on outcomes. We characterized the relationship between distance and overall mortality in patients with invasive bladder cancer and those who underwent radical cystectomy., Materials and Methods: We performed a retrospective cohort study using NCDB (National Cancer Database) from 2004 to 2012 to identify patients with muscle invasive bladder cancer (cT2a-T4 N0 M0). We also extracted a subgroup of patients who underwent radical cystectomy. Multivariate Cox proportional hazards and multinomial logistic regression analyses were performed in each group, controlling for demographic, clinical, hospital and geographic factors., Results: For 34,729 patients with muscle invasive bladder cancer traveling farther for treatment was associated with a lower probability of overall mortality (referent less than 12.5 miles, 12.5 to 49.9 miles HR 0.96, 95% CI 0.92-0.99 and 50 to 249.9 miles HR 0.91, 95% CI 0.86-0.96). This was significant for patients with cT2 disease and those treated at academic centers (p ≤0.05). For 11,059 patients who underwent radical cystectomy this trend did not reach significance. However, longer distance was associated with surgery at a high volume institution and receipt of neoadjuvant chemotherapy (each p <0.001)., Conclusions: Patients who traveled farther for bladder cancer treatment did not experience inferior survival outcomes and traveling to academic institutions was associated with reduced mortality. For patients who undergo cystectomy this relationship was equivocal, although longer distance was associated with receiving neoadjuvant chemotherapy or surgery at a high volume facility. These findings may reflect a complex association of regionalization of bladder cancer care with patient individual health and health care seeking behavior., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Active surveillance (AS) is increasingly recognized as a recommended treatment option for prostate cancer (PCa) patients with clinically localized, low-risk disease; however, previous studies suggested that its utilization is uncommon in the United States., Objective: We evaluated the nationwide utilization rate of AS in the contemporary era., Design, Setting, and Participants: We relied on the 2010-2011 Surveillance Epidemiology and End Results (SEER) database using all 18 SEER-based registries. We identified 9049 patients that fulfilled the University of California, San Francisco AS criteria (prostate-specific antigen level <10ng/ml, clinical T stage ≤2a, Gleason score ≤6 [no pattern 4 or 5], and percentage of positive biopsy cores <33%)., Outcome Measurements and Statistical Analysis: Logistic regression analysis tested the relationship between receiving local treatment and all available predictors., Results and Limitations: Only 32% of AS candidates did not receive any active local treatment. This proportion varied widely among the SEER-based registries, ranging from 13% to 49% (p<0.001). In multivariable analyses, clinical stage T2a (odds ratio [OR]: 1.23; p=0.04) and percentage of positive cores (OR: 1.10 for each 2% increase; p<0.001) were associated with a higher probability of receiving local treatment. Conversely, older age (OR: 0.89 for each 2-yr increase; p<0.001), not being married (OR: 0.64; p<0.001), and uninsured status (OR: 0.55; p=0.008) were associated with a lower probability of receiving active local treatment. The study is limited by the fact that SEER does not distinguish among patients undergoing observation, AS, watchful waiting, or initial hormonal therapy., Conclusions: In the United States, a considerable proportion of patients suitable for AS receive local treatment for PCa. Proportions differ significantly among SEER registries., Patient Summary: Having more extensive and palpable disease, having medical insurance, being married, and being younger are associated with an increased probability of receiving local treatment for low-risk prostate cancer., (Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: The PPACA (Patient Protection and Affordable Care Act) of 2010 included a provision to expand Medicaid by 2014. Six states and jurisdictions elected to expand Medicaid early before 2012. This provided a natural experiment to test the association between expanded insurance coverage and preventive service utilization, including prostate cancer screening., Materials and Methods: Using the 2012 and 2014 BRFSS (Behavioral Risk Factor Surveillance System) surveys we identified men 40 to 64 years old who reported prostate specific antigen testing in the preceding 12 months. Sociodemographic and access to care variables were extracted. Income was stratified by the relationship to Medicaid eligibility and the federal poverty level (less than 138%, 138% to 400% and greater than 400%). The weighted prevalence of prostate specific antigen was estimated. Multivariable logistic regression models were used to evaluate factors associated with prostate specific antigen screening. Interaction analysis for Medicaid expansion was performed., Results: Among 158,103 respondents individuals in nonexpansion states had the highest incidence of prostate specific antigen screening. Nationally screening decreased between 2011 and 2013 (OR 0.87, 95% CI 0.83-0.91). In only early expansion states there was a 3% absolute increase in screening among men in the less than 138% federal poverty level, which was associated with expansion status (p interaction = 0.04). Increased screening in early expansion states was also seen in men who were 55 to 59 years old, nonHispanic African American, Hispanic, previously married, not high school graduates and current smokers., Conclusions: Between 2011 and 2013 there were national declines in prostate cancer screening. However, there was significant narrowing of the gap in prostate specific antigen screening between higher and low income men in Medicaid early expansion states. This may reflect improved access to preventive services among populations with historic barriers to care., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: The management of locally advanced prostate cancer remains controversial. We compared the effect of primary external beam radiation therapy vs radical prostatectomy for locally advanced prostate cancer., Materials and Methods: We retrospectively analyzed the records of 2,935 elderly men 65 years old or older in the SEER (Surveillance, Epidemiology and End Results)-Medicare linked database who underwent external beam radiation therapy or radical prostatectomy for locally advanced prostate cancer. Propensity adjusted Cox proportional hazard and regression models were fit to examine urinary and gastrointestinal toxicities, the use of androgen deprivation therapy, and overall and prostate cancer specific mortality., Results: A total of 1,429 men (48.69%) underwent radical prostatectomy and had a median followup of 11.47 years (IQR 6.17-17.17) years. A total of 1,506 men (51.31%) received external beam radiation therapy and had a median followup of 7.04 years (IQR 4.11-10.51, p <0.001). Patients treated with radical prostatectomy were at significantly higher risk for urinary and sexual toxicities (HR 1.93, 95% CI 1.66-2.24 and HR 5.50, 95% CI 3.59-8.42, respectively). However, they were at lower risk for gastrointestinal toxicities (HR 0.75, 95% CI 0.65-0.86) than those treated with external beam radiation therapy. Radical prostatectomy was associated with lower odds of androgen deprivation therapy 5 years after primary treatment (OR 0.53, 95% CI 0.41-0.69, p <0.001). External beam radiation therapy was associated with higher overall and prostate specific mortality (HR 1.41, 95% CI 1.09-1.82 and HR 2.35, 95% CI 1.85-2.98, respectively)., Conclusions: We found significant toxicity and survival differences in elderly men who underwent primary external beam radiation therapy vs radical prostatectomy for locally advanced prostate cancer. While our findings must be interpreted within the limitations of studies that rely on administrative claims, they may yet help tailor individual therapies for elderly men who present with locally advanced prostate cancer., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To examine time-to-event data for 19 common postoperative complications within 30 days following radical cystectomy (RC)., Methods: Patients undergoing RC were identified within the American College of Surgeons National Surgical Quality Improvement Program database (2005-2011). The primary end point was time-to-complication; secondary end points included length of stay (LOS), reintervention, readmission, and 30-day mortality. Further, the complications were stratified into pre- and postdischarge, and the predictors were identified. Lastly, the effect of time-to-complication on secondary outcomes was evaluated., Results: Overall, 1118 patients underwent RC. The overall complication rate was 52.1%; the median LOS was 8 days. The vast majority of complications (85.2%) were contained within the first 2 weeks of surgery with a median time-to-complication of 8.5 days; 31.4% of the complications occurred post discharge. In adjusted analyses, increasing age (odds ratio [OR] = 1.02, P < .001), black race (OR = 1.67, P = .001), and creatinine ≥1.2 mg/dL (OR = 1.26, P = .002) were significant predictors of predischarge complications, whereas diabetes (OR = 1.40, P < .001), cardiopulmonary disease (OR = 1.27, P = .005), neoadjuvant therapy (OR = 1.35, P = .007), and continent diversions (OR = 1.30, P = .004) were significant predictors of postdischarge complications. A body mass index of ≥30 was associated with increased odds of pre- as well as postdischarge complications (P < .01). For a given complication, timing did not affect the mortality odds (P = .310), but the risk of reintervention, readmission, and prolonged LOS varied., Conclusion: One in 2 patients suffers a complication within 30 days of undergoing RC. A vast majority of complications occur early on postoperatively, either pre- or post discharge, highlighting the need for rigorous inpatient as well as outpatient surveillance during this period-knowledge regarding the time-to-complications, the effect of time-to-complications, and risk factors may facilitate improved patient-physician communication and allow patient-tailored follow-up., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: National Comprehensive Cancer Network (NCCN) guidelines recommend a pelvic lymph node dissection (PLND) in prostate cancer (PCa) patients treated with radical prostatectomy (RP) if a nomogram predicted risk of lymph node invasion (LNI) is ≥2%. We examined this and other thresholds, including nomogram validation., Methods: We examined records of 26,713 patients treated with RP and PLND between 2010 and 2013, within the Surveillance, Epidemiology, and End Results database. Nomogram thresholds of 2-5% were tested and external validation was performed., Results: LNI was recorded in 4.7% of patients. Nomogram accuracy was 80.4% and maintained minimum accuracy of 75.6% in subgroup analyses, according to age, race, and nodal yield >10. With the NCCN recommended 2% nomogram threshold, PLND could be avoided in 22.3% of patients at the expense of missing 3.0% of individuals with LNI. Alternative thresholds of 3%, 4%, and 5% yielded respective PLND avoidance rates of 60.4%, 71.0%, and 79.8% at the expense of missing 17.8%, 27.2%, and 36.6% of patients with LNI. NCCN cut-off recommendation was best satisfied with a threshold of <2.6%, at which PLND could be avoided in 13,234 patients (49.5%) versus missing 141 patients with LNI (11.2%)., Conclusion: NCCN LNI nomogram remains accurate in contemporary patients. However, the 2% threshold appears to be too strict, since only 22.3% of PLNDs can be avoided, instead of the stipulated 47.7%. The optimal 2.6% threshold allows a higher rate of PLND avoidance (49.5%), at the cost of 11.2% missed instances of LNI, as recommended by NCCN guidelines. PATIENT SUMMARY. External validation in contemporary SEER prostate cancer patients showed that the NCCN nomogram remains accurate for predicting lymph node invasion and seems to be optimal at an alternative 2.6% threshold, with best ratio of avoided pelvic lymph node dissections (49.5%) and missed LNIs (11.2%), as recommended by NCCN guideline. Prostate 77:542-548, 2017. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Objectives: To examine contemporary rates of pathological features and mortality for adenocarcinoma of the urinary bladder in the USA using population-based data analysis., Methods: We relied on 10 024 patients with non-metastatic bladder cancer diagnosed between 2004 and 2013 within the Surveillance, Epidemiology and End Results registries. Logistic regression analyses focused on grade and stage. Kaplan-Meier analyses assessed cancer-specific mortality rates in adenocarcinoma and urothelial carcinoma of the bladder. Cox regression analyses assessed the impact of histological subtype on cancer-specific mortality., Results: Overall, 215 (2.1%) adenocarcinoma and 9809 (97.9%) urothelial carcinoma patients were identified. The rate of non-organ-confined disease was higher in adenocarcinoma (64.7% vs 50.8%, P < 0.001). In multivariable logistic regression analyses, adenocarcinoma patients had a 2.2-fold higher risk of harboring non-organ-confined disease (95% confidence interval 1.7-3.0; P < 0.001) than urothelial carcinoma patients. Cancer-specific mortality-free survival rates were lower in adenocarcinoma (P < 0.01). This disadvantage only applied to non-organ-confined disease (P = 0.044), and not to organ-confined disease (P = 0.9). In multivariable Cox regression analyses, adenocarcinoma conferred a 1.3-fold higher rate of cancer-specific mortality (hazard ratio 1.30, 95% confidence interval 1.05-1.60; P = 0.01). Among adenocarcinoma patients, 30.7% harbored signet-ring cell adenocarcinoma and portended particularly poor cancer-specific mortality rates., Conclusions: In bladder cancer, adenocarcinoma presents at higher stages than urothelial carcinoma. However, cancer-specific mortality rates do not differ. A more unfavorable stage at diagnosis and higher cancer-specific mortality apply to the signet-ring cell variant., (© 2016 The Japanese Urological Association.)

Objective: To externally validate the updated 2012 Partin Tables in contemporary North American patients treated with radical prostatectomy (RP) for localized prostate cancer (PCa) at community institutions., Materials and Methods: We examined records of 25,254 patients treated with RP and pelvic lymph node dissection (PLND) between 2010 and 2013, within the surveillance, epidemiology, and end results database. The ROC derived AUC assessed discriminant properties of the updated 2012 Partin Tables of organ confined disease (OC), extracapsular extension (ECE), seminal vesical invasion (SVI), and lymph node invasion (LNI). Calibration plots focused on calibration between predicted and observed rates., Results: Proportions of OC, ECE, SVI, and LNI at RP were 69.8%, 18.4%, 7.4%, and 4.4%, respectively. Accuracy for prediction of OC, ECE, SVI, and LNI was 70.4%, 59.9%, 72.9%, and 77.1%, respectively. In subgroup analyses in patients with nodal yield >10, accuracy for LNI prediction was 76.0%. Subgroup analyses in elderly patients and in African American patients revealed decreased accuracy for prediction of all four endpoints. Last but not least, SVI and LNI calibration plots showed excellent agreement, versus good agreement for OC (maximum underestimation of 10%) and poor agreement for ECE (maximum overestimation of 12%)., Conclusion: Taken together, the updated 2012 Partin Tables can be unequivocally endorsed for prediction of OC, SVI, and LNI in community-based patients with localized PCa. Conversely, ECE predictions failed to reach the minimum accuracy requirements of 70%. Prostate 77:105-113, 2017. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Background: More than a decade since its inception, the benefits and cost efficiency of robot-assisted radical prostatectomy (RARP) continue to elicit controversy., Objective: To compare outcomes and costs between RARP and open RP (ORP)., Design, Setting, and Participants: A cohort study of 629 593 men who underwent RP for localized prostate cancer at 449 hospitals in the USA from 2003 to 2013, using the Premier Hospital Database., Intervention: RARP was ascertained through a review of the hospital charge description master for robotic supplies., Outcome Measures and Statistical Analysis: Outcomes were 90-d postoperative complications (Clavien), blood product transfusions, operating room time (ORT), length of stay (LOS), and direct hospital costs. Propensity-weighted regression analyses accounting for clustering by hospitals and survey weighting ensured nationally representative estimates., Results and Limitations: RARP utilization rapidly increased from 1.8% in 2003 to 85% in 2013 (p<0.001). RARP patients (n=311 135) were less likely to experience any complications (odds ratio [OR] 0.68, p<0.001) or prolonged LOS (OR 0.28, p<0.001), or to receive blood products (OR 0.33, p=0.002) compared to ORP patients (n=318 458). The adjusted mean ORT was 131min longer for RARP (p=0.002). The 90-d direct hospital costs were higher for RARP (+$4528, p<0.001), primarily attributed to operating room and supplies costs. Costs were no longer signficantly different between ORP and RARP among the highest-volume surgeons (≥104 cases/yr; +$1990, p=0.40) and highest-volume hospitals (≥318 cases/yr; +$1225, p=0.39). Limitations include the lack of oncologic characteristics and the retrospective nature of the study., Conclusions: Our contemporary analysis reveals that RARP confers a perioperative morbidity advantage at higher cost. In the absence of large randomized trials because of the widespread adoption of RARP, this retrospective study represents the best available evidence for the morbidity and cost profile of RARP versus ORP., Patient Summary: In this large study of men with prostate cancer who underwent either open or robotic radical prostatectomy, we found that robotic surgery has a better morbidity profile but costs more., (Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: Although black men represent a high risk population for prostate specific antigen screening for prostate cancer, recommendations in black men are unclear. To our knowledge the resultant effect of conflicting recommendations and disparities in access to care on prostate specific antigen screening in black men is unknown., Materials and Methods: We compared the rate of self-reported prostate specific antigen screening in black men relative to that in nonHispanic white men. The BRFSS (Behavioral Risk Factor Surveillance System) 2012 data set was used to identify asymptomatic men 40 to 99 years old who reported undergoing prostate specific antigen screening in the last 12 months. Age, education, income, residence location, marital status, health insurance, regular access to a health care provider and a health care provider recommendation to undergo screening were extracted. Subgroup analyses by race and age were performed using complex samples logistic regression models to assess the odds of undergoing prostate specific antigen screening., Results: In 2012 there were 122,309 survey respondents (weighted estimate 54.5 million) in the study population, of whom 29% of black and 32% of nonHispanic white men reported undergoing prostate specific antigen screening. Younger black males had higher rates and odds of screening than nonHispanic white men of a similar age (ages 45 to 49, 50 to 54 and 55 to 59 years OR 1.66, 1.58 and 1.36, respectively). Among black men only a higher education level (graduates vs nongraduates OR 2.12), regular access to a health care provider (OR 2.05) and a health care provider recommendation for screening (OR 8.43) were independently associated with prostate specific antigen screening., Conclusions: Despite long-standing disparities in health care access black males 45 to 60 years old have a higher rate and probability of prostate specific antigen screening than nonHispanic white men. Among black men educational attainment had a more pronounced association. In contrast the association with health care provider recommendations was less pronounced relative to that in nonHispanic white men. Future research may shed more light on the gamut of factors that influence the decision making process for prostate specific antigen testing., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To report on 30-day adverse event rates and timing of complications following adrenal surgery; further, to investigate the impact of specialty (general surgery vs urology) on these outcomes using a large prospective multi-institutional data registry., Materials and Methods: Within the American College of Surgeons National Surgical Quality Improvement Program (2005-2012), patients undergoing adrenalectomy were identified (CPT-codes: 60540, 60545, 60650). Outcomes evaluated included complications, blood transfusion, length of stay, reintervention, readmission, and mortality. Complications were further evaluated in relation to discharge status (pre-/postdischarge). Multivariable regression models assessed association between specialty and 30-day morbidity/mortality., Results: During the study period, 4844 patients underwent adrenalectomy (95.7% general surgery). The overall complication rate was 7.5% (n = 363); 43.2% of the complications occurred postdischarge with a substantial proportion of major complications, including cardiac, pulmonary, renal, neurologic, septic, and deep venous thrombosis/pulmonary embolism also occurring postdischarge (29.9%). The overall blood transfusion, reintervention, readmission, and mortality rates were 3.9%, 2.0%, 6.4%, and 0.6%, respectively. In adjusted analyses, specialty did not have an effect on any of the outcomes (P  >  .05 all)., Conclusion: One in 13 patients suffers a complication postadrenalectomy. Approximately 40% of these complications occur postdischarge, primarily within the first 2 weeks of surgery. Accurate knowledge regarding 30-day adverse event rates and timing of complications that this study provides may facilitate improved patient-physician communication and encourage early patient follow-up in this critical window. Lastly, specialty does not seem to affect outcomes in American College of Surgeons National Surgical Quality Improvement Program participant hospitals., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Importance: There is extensive evidence suggesting that black men with localized prostate cancer (PCa) have worse cancer-specific mortality compared with their non-Hispanic white counterparts., Objective: To evaluate racial disparities in the use, quality of care, and outcomes of radical prostatectomy (RP) in elderly men (≥ 65 years) with nonmetastatic PCa., Design, Setting, and Participants: This retrospective analysis of outcomes stratified according to race (black vs non-Hispanic white) included 2020 elderly black patients (7.6%) and 24,462 elderly non-Hispanic white patients (92.4%) with localized PCa who underwent RP within the first year of PCa diagnosis in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database between 1992 and 2009. The study was performed in 2014., Main Outcomes and Measures: Process of care (ie, time to treatment, lymph node dissection), as well as outcome measures (ie, complications, emergency department visits, readmissions, PCa-specific and all-cause mortality, costs) were evaluated using Cox proportional hazards regression. Multivariable conditional logistic regression and quantile regression were used to study the association of racial disparities with process of care and outcome measures., Results: The proportion of black patients with localized prostate cancer who underwent RP within 90 days was 59.4% vs 69.5% of non-Hispanic white patients (P <  001). In quantile regression of the top 50% of patients, blacks had a 7-day treatment delay compared with non-Hispanic whites. (P <  001). Black patients were less likely to undergo lymph node dissection (odds ratio [OR], 0.76 [95% CI, 0.66-0.80]; P < .001) but had higher odds of postoperative visits to the emergency department (within 30 days: OR, 1.48 [95% CI, 1.18-1.86]); after 30 days or more (OR, 1.45 [95% CI, 1.19-1.76]) and readmissions (within 30 days: OR, 1.28 [95% CI, 1.02-1.61]); ≥ 30 days (OR, 1.27 [95% CI, 1.07-1.51]) compared with non-Hispanic whites. The surgical treatment of black patients was associated with a higher incremental annual cost (the top 50% of blacks spent $1185.50 (95% CI , $804.85-1 $1566.10; P < .001) more than the top 50% of non-Hispanic whites). There was no difference in PCa-specific mortality (P = .16) or all-cause mortality (P = .64) between black and non-Hispanic white men., Conclusions and Relevance: Blacks treated with RP for localized PCa are more likely to experience adverse events and incur higher costs compared with non-Hispanic white men; however, this does not translate into a difference in PCa-specific or all-cause mortality., Competing Interests: disclosures: All other authors have nothing to disclose All authors confirm that all here with-reported conflict of interest disclosure information is accurate, complete, up-to-date.

Purpose: The rates of complications following radical/partial nephrectomy (RN/PN) are well known; however, the data regarding timing are opaque. Accordingly, we sought to assess the median time-to-event for 19 principal postoperative complications within 30 days following surgery., Methods: Patients undergoing RN/PN were identified within the American College of Surgeons National Surgical Quality Improvement Program database (2005-2011). Primary endpoint was time-to-complication. Secondary endpoints included length-of-stay (LOS), re-intervention, re-admission and 30-day mortality. Multivariable regression models assessed the predictors for pre-/post-discharge complications and the effect of time-to-complication on secondary outcomes., Results: Overall, 3820 patients underwent nephrectomy (RN = 63.6 %). The overall complication rate was 16.8 %, and the median LOS was 4 days. The majority of major complications (88.1 %), including bleeding/transfusion, renal, septic, deep venous thrombosis or pulmonary embolism, pulmonary, cardiac and neurologic, occurred prior to discharge. Conversely, the relatively minor complications, including wound and urinary tract infections, occurred predominantly post-discharge (70.7 %). The median time to major complications was 3 versus 13 days for minor complications. In multivariable analyses, age [odds ratio (OR) 1.02, p < 0.001], American Society of Anesthesiologists score ≥ 2 (p < 0.01) and PN (p < 0.001) were predictors of pre-discharge complications, while female gender (OR 1.67, p < 0.001), hypertension (OR 1.28, p = 0.007) and diabetes (OR 1.48, p < 0.001) were predictors of post-discharge complications. Creatinine ≥ 1.2 mg/dl and hematocrit < 30 increased (p < 0.01), whereas a minimally invasive approach decreased the odds (p < 0.05) for both pre-/post-discharge complications. For a given complication, time-to-complication did not affect the odds for mortality (p = 0.343) or re-intervention (p = 0.872)., Conclusions: Approximately one in six patients suffers a complication following RN/PN; major complications tend to occur early with the majority occurring pre-discharge. Knowledge regarding the timing and risk factors for complications may facilitate improved patient-physician communication, both at admission and at discharge.

Objective: To determine the association between race/ethnicity and perioperative outcomes in individuals undergoing major oncologic and nononcologic surgical procedures in the United States., Background: Prior work has shown that there are significant racial/ethnic disparities in perioperative outcomes after several types of major cardiac, general, vascular, orthopedic, and cancer surgical procedures. However, recent evidence suggests attenuation of these racial/ethnic differences, particularly at academic institutions., Methods: We utilized the American College of Surgeons National Surgical Quality Improvement Program database to identify 142,344 patients undergoing one of the 16 major cancer and noncancer surgical procedures between 2005 and 2011., Results: Eighty-five percent of the cohort was white, with black and Hispanic individuals comprising 8% and 4%, respectively. In multivariable analyses, black patients had greater odds of experiencing prolonged length of stay after 10 of the 16 procedures studied (all P < 0.05), though there was no disparity in odds of 30-day mortality after any surgery. Hispanics were more likely to experience prolonged length of stay after 5 surgical procedures (all P < 0.04), and were at greater odds of dying within 30 days after colectomy, heart valve repair/replacement, or abdominal aortic aneurysm repair (all P < 0.03). Fewer disparities were observed for Hispanics, than for black patients, and also for cancer, than for noncancer surgical procedures., Conclusions: Important racial/ethnic disparities in perioperative outcomes were observed among patients undergoing major cancer and noncancer surgical procedures at American College of Surgeons National Surgical Quality Improvement Program institutions. There were fewer disparities among individuals undergoing cancer surgery, though black patients, in particular, were more likely to experience prolonged length of stay.

Introduction and Objectives: The quality of medical care to US veterans, as provided by the Veterans Health Administration, has recently been subjected to heightened scrutiny. We sought to report prostate-specific antigen screening (PSAS) in a contemporary cohort of veteran men (VM) vs. nonveteran men (NVM). We hypothesize that VM are less likely to receive age-appropriate PSAS compared with NVM., Materials and Methods: We identified VM and NVM aged 55 to 69 years without history of prostate cancer who underwent PSA testing in the year preceding that of the 2012 Behavioral Risk Factor and Surveillance System survey. The prevalence of PSAS among VM and NVM was determined in aggregate and on a state-by-state basis. Complex samples logistic regression models calculated the odds of PSAS based on veteran status, adjusted for patient/demographic characteristics., Results: In all, 56,962 responses were collected, yielding a weighted estimate of 23.7 million men, of which 30.5% were VM. Overall, 45.2% (CI: 43.9%-46.5%) of VM reported PSAS compared with only 37.5% (CI: 36.5%-38.5%) of NVM. VM were more likely to have health insurance (92.0%; CI: 91.3%-92.8% vs. 86.2%; CI: 85.4%-87.0%) and a regular health care provider (89.0%; CI: 88.2%-89.8% vs. 85.9%; CI: 85.1%-86.6%) compared with NVM. Unadjusted prevalence of PSAS varied widely across the United States for VM and NVM. In multivariable analyses, VM had higher odds for PSAS (odds ratio = 1.10, CI: 1.02%-1.18%)., Conclusions: Contrary to our initial hypothesis, our findings suggest a continued pattern of greater preventive health services use by veterans. VM were more likely to undergo PSAS than NVM. This is, in part, attributable to better access to primary care and health insurance. Nonetheless, heterogeneity in screening practices remained largely dependent on geography., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To examine the potential relationship between androgen deprivation therapy and other-cause mortality (OCM) in patients with prostate cancer treated with medical primary-androgen deprivation therapy, prostatectomy, or radiation., Methods: A total of 137,524 patients with non-metastatic PCa treated between 1995 and 2009 within the Surveillance Epidemiology and End Results Medicare-linked database were included. Cox-regression analysis tested the association of ADT with OCM. A 40-item comorbidity score was used for adjustment., Results: Overall, 9.3% of patients harbored stage III-IV disease, and 57.7% of patients received ADT. The mean duration of ADT exposure was 22.9 months (median: 9.1; IQR: 2.8-31.5). Mean and median follow-up were 66.9, and 60.4 months, respectively. At 10 years, overall-OCM rate was 36.5%; it was 30.6% in patients treated without ADT vs. 40.1% in patients treated with ADT (p < 0.001). In multivariable-analysis, ADT was associated with an increased risk of OCM (Hazard-ratio [HR]: 1.11, 95% Confidence-interval [95% CI]: 1.08-1.13). Patients with no comorbidity (10-year OCM excess risk: 9%) were more subject to harm from ADT than patients with high comorbidity (10-year OCM excess risk: 4.7%)., Conclusions: In patients with PCa, treatment with medical ADT may increase the risk of mortality due to causes other than PCa. Whether this is a simple association or a cause-effect relationship is unknown and warrants further study in prospective studies., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Approximately 15% of the US population does not have health insurance. The objective of this study was to evaluate the impact of insurance status on tumor characteristics and treatment selection in patients with prostate cancer., Materials and Methods: We identified 20,393 patients younger than 65 years with prostate cancer in the 2010-2011 SEER database. Multivariable logistic regression analysis tested the relationship between insurance status and 2 end points: (1) presenting with low-risk prostate cancer at diagnosis and (2) receiving local treatment of the prostate. Locally weighted scatterplot smoothing methods were used to graphically explore the interaction among insurance status, use of local treatment, and baseline risk of cancer recurrence. The latter was defined using the Stephenson nomogram and CAPRA score., Results: Overall, 18,993 patients (93%) were insured, 849 (4.2%) had Medicaid coverage, and 551 (2.7%) were uninsured. At multivariable analysis, Medicaid coverage (odds ratio [OR], 0.67; 95% CI, 0.57, 0.80; P<.0001) and uninsured status (OR, 0.57; 95% CI, 0.46, 0.71; P<.0001) were independent predictors of a lower probability of presenting with low-risk disease. Likewise, Medicaid coverage (OR, 0.72; 95% CI, 0.60, 0.86; P=.0003) and uninsured status (OR, 0.45; 95% CI, 0.37, 0.55; P<.0001) were independent predictors of a lower probability of receiving local treatment. In uninsured patients, treatment disparities became more pronounced as the baseline cancer recurrence risk increased (10% in low-risk patients vs 20% in high-risk patients)., Conclusions: Medicaid beneficiaries and uninsured patients are diagnosed with higher-risk disease and are undertreated. The latter is more accentuated for patients with high-risk prostate cancer. This may seriously compromise the survival of these individuals., (Copyright © 2015 by the National Comprehensive Cancer Network.)

Background: The Emergency Department (ED) is being increasingly utilized as a pathway for management of acute conditions such as the urinary tract infections (UTIs)., Objective: We sought to assess the contemporary trends in pediatric UTI associated ED visits, subsequent hospitalization, and corresponding financial expenditure, using a large nationally representative pediatric cohort. Further, we describe the predictors of admission following a UTI associated ED visit., Methods: The Nationwide Emergency Department Sample (NEDS; 2006-2011) was queried to assess temporal-trends in pediatric (age ≤17 years) ED visits for a primary diagnosis of UTI (ICD9 CM code 590.X, 595.0, and 599.0), subsequent hospital admission, and total charges. These trends were examined using the estimated annual percent change (EAPC) method. Multivariable regression models fitted with generalized estimating equations (GEE) identified the predictors of hospital admission., Results: Of the 1,904,379 children presenting to the ED for management of UTI, 86 042 (4.7%) underwent hospital admission. Female ED visits accounted for almost 90% of visits and increased significantly (EAPC 3.28%; p = 0.003) from 709 visits per 100 000 in 2006 to 844 visits per 100 000 in 2011. Male UTI incidence remained unchanged over the study-period (p = 0.292). The overall UTI associated ED visits also increased significantly during the study-period (EAPC 3.14%; p = 0.006) because of the increase in female UTI associated ED visits. Overall hospital admissions declined significantly over the study-period (EAPC -5.59%; p = 0.021). Total associated charges increased significantly at an annual rate of 18.26%, increasing from 254 million USD in 2006 to 464 million USD in 2011 (p < 0.001; Figure). This increase in expenditure was likely driven by increased utilization of diagnostic CT scanning in these patients (EAPC 22.86%; p < 0.001). Ultrasonography (p = 0.805), X-ray (p = 0.196), and urine analysis/culture use (p = 0.121) did not change over the study-period. In multivariable analysis, the independent predictors of admission included younger age (p < 0.001), male gender (OR = 2.05, p < 0.001), higher comorbidity status (OR = 14.81, p < 0.001), pyelonephritis (OR = 4.45, p < 0.001) and concurrent hydronephrosis (OR = 49.42, p < 0.001), stone disease (OR = 6.44, p < 0.001), or sepsis (OR = 18.83, p < 0.001)., Discussion: We show that the incidence of ED visits for pediatric UTI is on the rise. This rise in incidence could be due to several factors, including increasing prevalence of metabolic conditions such as obesity, diabetes and metabolic syndrome in children predisposing them to infections, or could be secondary to increasing sexual activity amongst adolescents and changing patterns of contraceptive use (increased use of OCP in place of condoms), or more simply might just be a reflection of changing practice patterns. Second, we demonstrate that total charges for management of UTI in the ED setting are increasing rapidly; the increase is primarily driven by increasing utilization of diagnostic imaging in the ED setting, as has been demonstrated in other ED based studies as well., Conclusions: In children presenting to the ED with a primary diagnosis of UTI, total ED charges are increasing at an alarming rate not commensurate with the increase in overall ED visits. While the preponderance of children presenting to the ED for UTI are treated and discharged, 4.7% of patients were admitted to the hospital for further management. The strongest predictors of inpatient admission were pyelonephritis, younger age, male gender, higher comorbidity status, and concurrent hydronephrosis, stone disease, or sepsis. Managing these at-risk patients more aggressively in the outpatient setting may prevent unnecessary ED visits and subsequent hospitalizations, and reduce associated healthcare costs., (Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: To examine racial disparities in end-of-life (EOL) care among black and white patients dying of prostate cancer (PCa)., Methods: Relying on the SEER-Medicare database, 3789 patients who died of metastatic PCa between 1999 and 2009 were identified. Information was assessed regarding diagnostic care, therapeutic interventions, hospitalizations, intensive care unit (ICU) admissions, and emergency department visits in the last 12 months, 3 months, and 1 month of life. Logistic regression tested the relationship between race and the receipt of diagnostic care, therapeutic interventions, and high-intensity EOL care., Results: Overall, 729 patients (19.24%) were black. In the 12-months preceding death, laboratory tests (odds ratio [OR], 0.51; 95% CI, 0.36-0.72), prostate-specific antigen test (OR, 0.54; 95% CI, 0.43-0.67), cystourethroscopy (OR, 0.71; 95% CI, 0.56-0.90), imaging procedure (OR, 0.58; 95% CI, 0.41-0.81), hormonal therapy (OR, 0.53; 95% CI, 0.44-0.65), chemotherapy (OR, 0.59; 95% CI, 0.48-0.72), radiotherapy (OR, 0.74; 95% CI, 0.61-0.90), and office visit (OR, 0.38; 95% CI, 0.28-0.50) were less frequent in black versus white patients. Conversely, high-intensity EOL care, such as ICU admission (OR, 1.27; 95% CI, 1.04-1.58), inpatient admission (OR, 1.49; 95% CI, 1.09-2.05), and cardiopulmonary resuscitation (OR, 1.72; 95% CI, 1.40-2.11), was more frequent in black versus white patients. Similar trends for EOL care were observed at 3-month and 1-month end points., Conclusions: Although diagnostic and therapeutic interventions are less frequent in black patients with end-stage PCa, the rate of high-intensity and aggressive EOL care is higher in these individuals. These disparities may indicate that race plays an important role in the quality of care for men with end-stage PCa., (Copyright © 2015 by the National Comprehensive Cancer Network.)

The impact of preoperative stable angina pectoris on postoperative cardiovascular outcomes in patients with previous myocardial infarction (MI) who underwent major noncardiac surgery is not well studied. We studied patients with previous MI who underwent elective major noncardiac surgeries within the American College of Surgeons-National Surgical Quality Improvement Program (2005 to 2011). Primary outcome was occurrence of an adverse cardiac event (MI and/or cardiac arrest). Multivariable logistic regression models evaluated the impact of stable angina on outcomes. Of 1,568 patients (median age 70 years; 35% women) with previous MI who underwent major noncardiac surgery, 5.5% had postoperative MI and/or cardiac arrest. Patients with history of preoperative angina had significantly greater incidence of primary outcome compared to those without anginal symptoms (8.4% vs 5%, p = 0.035). In secondary outcomes, reintervention rates (22.5% vs 11%, p <0.001) and length of stay (median 6-days vs 5-days; p <0.001) were also higher in patients with preoperative angina. In multivariable analyses, preoperative angina was a significant predictor for postoperative MI (odds ratio 2.49 [1.20 to 5.58]) and reintervention (odds ratio 2.40 [1.44 to 3.82]). In conclusion, our study indicates that preoperative angina is an independent predictor for adverse outcomes in patients with previous MI who underwent major noncardiac surgery, and cautions against overreliance on predictive tools, for example, the Revised Cardiac Risk Index, in these patients, which does not treat stable angina and previous MI as independent risk factors during risk prognostication., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To compare patients with inflammatory bowel disease (IBD) to a general population of urinary stone formers who present to US emergency departments with infected urolithiasis. Patients with IBD are at risk for both infection and stone formation, however studies investigating emergent urolithiasis presentations for this population are limited., Methods: Using the Nationwide Emergency Department Sample (2006-2009) we identified all patients presenting to the US emergency departments with a diagnosis of upper tract urolithiasis. We then described a subgroup with the concomitant diagnosis of IBD. We compared rates of urinary tract infection (UTI), sepsis, organ failure, admission, and mortality between the 2 groups. Using multivariate analysis, we determined whether or not IBD was a predictor of UTI, sepsis, and hospitalization., Results: Overall, 14,352 patients had concomitant IBD and urolithiasis. IBD patients with urolithiasis presented with infections (10.4% vs 9.1%; P <.001), sepsis (0.6% vs 0.2%; P <.001), and end-organ failure (6.3% vs 1.6%; P <.001) more frequently than non-IBD patients. They were also more likely to have characteristics independently associated with infection and sepsis, such as older age and female gender. In adjusted analyses, IBD was an independent predictor of infection (odds ratio [OR] = 1.3 [1.14-1.46]; P <.0001), sepsis (OR = 1.8 [1.09-2.92]; P <.0001), and admission (OR = 3.3 [3.04-3.64]; P <.0001)., Conclusion: IBD patients with urinary calculi have greater odds of UTI, renal failure, and sepsis compared to the general stone-forming population. The increased occurrence and severity of infected urolithiasis in this select group of patients warrants screening for stone disease, improved outpatient medical management, and early elective surgery for detected stones., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Numerous studies have recorded racial disparities in access to care for major cancers. We investigate contemporary national disparities in the quality of perioperative surgical oncological care using a nationally representative sample of American patients and hypothesize that disparities in the quality of surgical oncological care also exists., Methods: A retrospective, serial, and cross-sectional analysis of a nationally representative cohort of 3,024,927 patients, undergoing major surgical oncological procedures (colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, pneumonectomy, pancreatectomy, and prostatectomy), between 1999 and 2009., Results: After controlling for multiple factors (including socioeconomic status), Black patients undergoing major surgical oncological procedures were more likely to experience postoperative complications (OR: 1.24; p < 0.001), in-hospital mortality (OR: 1.24; p < 0.001), homologous blood transfusions (OR: 1.52; p < 0.001), and prolonged hospital stay (OR: 1.53; p < 0.001). Specifically, Black patients have higher rates of vascular (OR: 1.24; p < 0.001), wound (OR: 1.10; p = 0.004), gastrointestinal (OR: 1.38; p < 0.001), and infectious complications (OR: 1.29; p < 0.001). Disparities in operative outcomes were particularly remarkable for Black patients undergoing colectomy, prostatectomy, and hysterectomy. Importantly, substantial attenuation of racial disparities was noted for radical cystectomy, lung resection, and pancreatectomy relative to earlier reports. Finally, Hispanic patients experienced no disparities relative to White patients in terms of in-hospital mortality or overall postoperative complications for any of the eight procedures studied., Conclusions: Considerable racial disparities in operative outcomes exist in the United States for Black patients undergoing major surgical oncological procedures. These findings should direct future health policy efforts in the allocation of resources for the amelioration of persistent disparities in specific procedures.

Background: Cancer patients undergoing procedures are at increased risk of sepsis. We sought to evaluate the incidence of postoperative sepsis following major cancer surgeries (MCS), and to describe patient and/or hospital characteristics associated with heightened risk., Methods: Patients undergoing 1 of 8 MCS (colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy, and prostatectomy) within the Nationwide Inpatient Sample from 1999-2009 were identified (N = 2,502,710). Logistic regression models fitted with generalized estimating equations were used to estimate primary predictors (procedure, age, gender, race, insurance, Charlson Comorbidity Index, hospital volume, and hospital bed size) effect on sepsis and sepsis-associated mortality. Trends were evaluated with linear regression., Results: The incidence of MCS-related sepsis increased 2.0% per year (P < 0.001), whereas mortality remained stable. Odds of sepsis were highest among esophagectomy patients (odds ratio [OR]: 3.13, 2.76-3.55) and those with non-private insurance (OR: 1.33, 1.19-1.48 to OR: 1.89, 1.71-2.09). Odds of sepsis-related mortality were highest among lung resection patients (OR: 2.30, 2.00-2.64) and those experiencing perioperative liver failure (OR: 5.68, 4.30-7.52). Increasing hospital volume was associated with lower odds of sepsis and sepsis-related mortality (OR: 0.89, 0.84-0.95 to OR: 0.58, 0.53-0.62 and OR: 0.88, 0.77-0.99 to OR: 0.78, 0.67-0.93)., Conclusions: Between 1999 and 2009, the incidence of MCS-related sepsis increased; however, sepsis-related mortality remained stable. Significant disparities exist in patient and hospital characteristics associated with MCS-related sepsis. Hospital volume is an important modifiable risk factor associated with improved sepsis-related outcomes following MCS., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: To evaluate baseline renal dysfunction among patients undergoing urological oncological surgery and its impact on early postoperative outcomes., Methods: Between 2005 and 2011, patients who underwent minimally-invasive or open radical prostatectomy, partial nephrectomy and radical nephrectomy, or open radical cystectomy, respectively, were identified in the National Surgical Quality Improvement Program dataset. Preoperative kidney function was assessed using estimated glomerular filtration rate and staged according to National Kidney Foundation definitions. Multivariable logistic regression was used to model the association between preoperative renal function and the risk of 30-day mortality and major complications. Furthermore the impact of chronic kidney disease on operation time and length of hospital stay was assessed., Results: Overall, 13,168 patients underwent radical prostatectomy (65.4%), partial nephrectomy (10.7%) and radical nephrectomy (16.1%) and radical cystectomy (7.8%), respectively; 50.1% of evaluable patients had reduced kidney function (chronic kidney disease II), and a further 12.6, 0.7 and 0.9% were respectively classified into chronic kidney disease stages III, IV, and V. Chronic kidney disease was an independent predictor of 30-day major postoperative complications (chronic kidney disease III: odds ratio 1.61, P < 0.001; chronic kidney disease IV: odds ratio 2.24, P = 0.01), of transfusions (chronic kidney disease III: odds ratio 2.14, P < 0001), of prolonged length of stay (chronic kidney disease III: odds ratio 2.61, P < 0.001; chronic kidney disease IV: odds ratio 3.37, P < 0.001; and chronic kidney disease V: odds ratio 1.68; P = 0.03) and of 30-day mortality (chronic kidney disease III: odds ratio 4.15, P = 0.01; chronic kidney disease IV: odds ratio 10.10, P = 0.003; and chronic kidney disease V: odds ratio 17.07, P < 0.001) compared with patients with no kidney disease., Conclusions: Renal dysfunction might be underrecognized in patients undergoing urological cancer surgery. Chronic kidney disease stages III, IV and V are independent predictors for poor 30-day postoperative outcomes., (© 2014 The Japanese Urological Association.)

Objective: To examine the burden of mental health issues (MHI), namely anxiety, depressive disorders, and suicide, in a population-based cohort of older men with localized prostate cancer and to evaluate associations with primary treatment modality., Patients and Methods: A total of 50,856 men, who were 65 years of age or older with clinically localized prostate cancer diagnosed between 1992 and 2005 and without a diagnosis of mental illness at baseline, were abstracted from the Surveillance, Epidemiology, and End Results-Medicare database. The primary outcome of interest was the development of MHI (anxiety, major depressive disorder, depressive disorder not elsewhere classified, neurotic depression, adjustment disorder with depressed mood, and suicide) after the diagnosis of prostate cancer., Results: A total of 10,389 men (20.4%) developed MHI during the study period. Independent risk factors for MHI included age ≥ 75 years (hazard ratio [HR] = 1.29); higher comorbidity (Charlson comorbidity index ≥ 3, HR = 1.63); rural hospital location (HR = 1.14); being single, divorced, or widowed (HR = 1.12); later year of diagnosis (HR = 1.05); and urinary incontinence (HR = 1.47). Black race (HR = 0.79), very high-income status (HR = 0.87), and definitive treatment (radical prostatectomy [RP], HR = 0.79; radiotherapy [RT], HR= 0.85, all P<0.001) predicted a lower risk of MHI. The rates of MHI at 10 years were 29.7%, 29.0%, and 22.6% in men undergoing watchful waiting (WW), RT, and RP, respectively., Conclusion: Older men with localized prostate cancer had a significant burden of MHI. Men treated with RP or RT were at a lower risk of developing MHI, compared with those undergoing WW, with median time to development of MHI being significantly greater in those undergoing RP compared with those undergoing RT or WW., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Importance: Surgical site infection (SSI) represents the second most common cause of hospital-acquired infection and the most common type of infection in patients undergoing surgery. However, evidence is scarce regarding the effect of the surgical approach (open surgery vs minimally invasive surgery [MIS]) on the risk for SSIs., Objective: To evaluate the role of the surgical approach on the risk for SSIs in a large contemporary cohort of patients undergoing surgery across different specialties., Design, Setting, and Participants: The American College of Surgeons National Surgical Quality Improvement Program database is a national, prospective perioperative database specifically developed to assess quality of surgical care. We queried the database from January 1, 2005, through December 31, 2011, for patients undergoing appendectomy (n = 97,780), colectomy (n = 118,407), hysterectomy (n = 26,639), or radical prostatectomy (n = 11,183)., Exposures: Thirty-day SSIs., Main Outcomes and Measures: We abstracted the data on 30-day SSIs and compared patients undergoing open procedures and MIS using propensity score matching. Logistic regression analyses of the matched cohorts tested the association between the surgical approach and risk for SSIs., Results: The overall 30-day rates of SSIs were 5.4% for appendectomy, 12.1% for colectomy, 2.8% for hysterectomy, and 1.7% for prostatectomy. After propensity score matching, MIS was associated with lower rates of postoperative SSIs in patients undergoing MIS vs open procedures for appendectomy (3.8% vs 7.0%; P < .001), colectomy (9.3% vs 15.0%; P < .001), hysterectomy (1.8% vs 3.9%; P < .001), and radical prostatectomy (1.0% vs 2.4%; P < .001). In logistic regression analyses, MIS was associated with lower odds of SSIs in patients treated with appendectomy (odds ratio [OR], 0.52 [95% CI, 0.48-0.58]; P < .001), colectomy (OR, 0.58 [95% CI, 0.55-0.61]; P < .001), hysterectomy (OR, 0.44 [95% CI, 0.37-0.53]; P < .001), and radical prostatectomy (OR, 0.39 [95% CI, 0.25-0.61]; P < .001)., Conclusions and Relevance: The proportion of patients developing SSIs within 30 days after surgery can be substantial and depends on the type of surgery. Minimally invasive surgery is significantly associated with reduced odds of SSIs. This advantage should be considered when assessing the overall benefits of minimally invasive techniques.

Purpose: Previous studies examining the management of urinary tract infections (UTI) showed marked variability in the economical burden of care, with a tenfold increase in costs when patients require admission to the hospital. We sought to examine the patient and emergency department (ED) characteristics associated with hospitalization in patients presenting to the ED with UTI., Methods: An estimate of 10,798,343 patients with a primary diagnosis of UTI was presented to the ED from 2006 to 2009 and was abstracted from the Nationwide Emergency Department Sample. Univariable and multivariable analyses examined patient and hospital characteristics of those admitted with UTI., Results: Between 2006 and 2009, 10.8 million patients presented to the ED in the United States for the treatment of UTI and 1.8 million patients (16.7 %) were admitted to the hospital for further management. Admitted patients were older, and a higher proportion had pyelonephritis, was male, and had Medicare. Admitted patients were also more likely to be seen at urban teaching hospitals, and/or treated at zip codes with higher median incomes. Following multivariable analysis, the independent predictors of admission included pyelonephritis (OR 5.29, 95 % CI 5.23-5.35), male gender (OR 1.58, 95 % CI 1.56-1.59), and advancing age (OR 1.037, 95 % CI 1.037-1.037)., Conclusions: Expansion in ED utilization for the management of UTI has exceeded previous estimates. While the preponderance of patients presenting to the ED for UTI is discharged home, 16.7 % are admitted for further management. Predictors of inpatient admission on multivariable analyses included pyelonephritis, advancing age, and male gender.

Purpose: We determined practice patterns and perioperative outcomes of open and minimally invasive partial nephrectomy in the United States since the introduction of a robot-assisted modifier in the Nationwide Inpatient Sample., Materials and Methods: We identified all patients with nonmetastatic disease treated with open, laparoscopic or robotic partial nephrectomy in the Nationwide Inpatient Sample between October 2008 and December 2010. Utilization rates were assessed by year, patient and hospital characteristics. We evaluated the perioperative outcomes of open vs robotic and open vs laparoscopic partial nephrectomy using binary logistic regression models adjusted for patient and hospital covariates., Results: In a weighted sample of 38,064 partial nephrectomies 66.9%, 23.9% and 9.2% of the procedures were open, robotic and laparoscopic operations, respectively. In 2010 the relative annual increase in open, robotic and laparoscopic partial nephrectomy was 7.9%, 45.4% and 6.1%, respectively. Compared to open partial nephrectomy patients treated with minimally invasive partial nephrectomy were less likely to receive blood transfusion (robotic vs laparoscopic OR 0.56, p <0.001 vs OR 0.68, p = 0.016), postoperative complication (OR 0.63, p <0.001 vs OR 0.78, p <0.009) or prolonged length of stay (OR 0.27 vs OR 0.41, each p <0.001). Only patients who underwent the robotic procedure were less likely to experience an intraoperative complication (robotic vs laparoscopic OR 0.69, p = 0.014 vs OR 0.67, p = 0.069). Excess hospital charges were higher after robotic surgery (OR 1.35, p <0.001)., Conclusions: The dissemination of robotic surgery for partial nephrectomy in the United States has been rapid and safe. Compared to open partial nephrectomy the robotic procedure had lower odds than laparoscopic partial nephrectomy for most study outcomes except hospital charges. Robotic partial nephrectomy has now supplanted laparoscopic partial nephrectomy as the most common minimally invasive approach for partial nephrectomy., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: Among considerable efforts to improve quality of surgical care, expedited measures such as a selective referral to high-volume institutions have been advocated. Our objective was to examine whether racial, insurance and/or socioeconomic disparities exist in the use of high-volume hospitals for complex surgical oncological procedures within the USA., Design, Setting and Participants: Patients undergoing colectomy, cystectomy, oesophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy or prostatectomy were identified retrospectively, using the Nationwide Inpatient Sample, between years 1999 and 2009. This resulted in a weighted estimate of 2 508 916 patients., Primary Outcome Measures: Distribution of patients according to race, insurance and income characteristics was examined according to low-volume and high-volume hospitals (highest 20% of patients according to the procedure-specific mean annual volume). Generalised linear regression models for prediction of access to high-volume hospitals were performed., Results: Insurance providers and county income levels varied differently according to patients' race. Most Caucasians resided in wealthier counties, regardless of insurance types (private/Medicare), while most African Americans resided in less wealthy counties (≤$24 999), despite being privately insured. In general, Caucasians, privately insured, and those residing in wealthier counties (≥$45 000) were more likely to receive surgery at high-volume hospitals, even after adjustment for all other patient-specific characteristics. Depending on the procedure, some disparities were more prominent, but the overall trend suggests a collinear effect for race, insurance type and county income levels., Conclusions: Prevailing disparities exist according to several patient and sociodemographic characteristics for utilisation of high-volume hospitals. Efforts should be made to directly reduce such disparities and ensure equal healthcare delivery.