Search

PurposeOur goal was to evaluate the comparative effectiveness of robot-assisted laparoscopic prostatectomy (RALP) and open radical prostatectomy (ORP) in a multicenter study.Materials and methodsWe evaluated men with localized prostate cancer at 11 high-volume academic medical centers in the United States from the PROST-QA (2003-2006) and the PROST-QA/RP2 cohorts (2010-2013) with a pre-specified goal of comparing RALP (549) and ORP (545). We measured longitudinal patient-reported health-related quality of life (HRQOL) at pre-treatment and at 2, 6, 12, and 24 months, and pathological and perioperative outcomes/complications.ResultsDemographics, cancer characteristics, and margin status were similar between surgical approaches. ORP subjects were more likely to undergo lymphadenectomy (89% vs 47%; p

ImportanceBlack men have a 2-fold increased risk of dying from prostate cancer compared with White men. However, race-specific differences in response to initial treatment remain unknown.ObjectiveTo compare overall and treatment-specific outcomes of Black and White men with localized prostate cancer receiving definitive radiotherapy (RT).Data sourcesA systematic search was performed of relevant published randomized clinical trials conducted by the NRG Oncology/Radiation Therapy Oncology Group between January 1, 1990, and December 31, 2010. This meta-analysis was performed from July 1, 2019, to July 1, 2021.Study selectionRandomized clinical trials of definitive RT for patients with localized prostate cancer comprising a substantial number of Black men (self-identified race) enrolled that reported on treatment-specific and overall outcomes.Data extraction and synthesisIndividual patient data were obtained from 7 NRG Oncology/Radiation Therapy Oncology Group randomized clinical trials evaluating definitive RT with or without short- or long-term androgen deprivation therapy. Unadjusted Fine-Gray competing risk models, with death as a competing risk, were developed to evaluate the cumulative incidences of end points. Cox proportional hazards models were used to evaluate differences in all-cause mortality and the composite outcome of distant metastasis (DM) or death. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed.Main outcomes and measuresSubdistribution hazard ratios (sHRs) of biochemical recurrence (BCR), DM, and prostate cancer-specific mortality (PCSM).ResultsA total of 8814 patients (1630 [18.5%] Black and 7184 [81.5%] White) were included; mean (SD) age was 69.1 (6.8) years. Median follow-up was 10.6 (IQR, 8.0-17.8) years for surviving patients. At enrollment, Black men were more likely to have high-risk disease features. However, even without adjustment, Black men were less likely to experience BCR (sHR, 0.88; 95% CI, 0.58-0.91), DM (sHR, 0.72; 95% CI, 0.58-0.91), or PCSM (sHR, 0.72; 95% CI, 0.54-0.97). No significant differences in all-cause mortality were identified (HR, 0.99; 95% CI, 0.92-1.07). Upon adjustment, Black race remained significantly associated with improved BCR (adjusted sHR, 0.79; 95% CI, 0.72-0.88; P

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

PurposeThe long-term effects of neoadjuvant androgen deprivation therapy (NADT) with radiation therapy on participant-reported health-related quality of life (HRQOL) have not been characterized in prospective multicenter studies. We evaluated HRQOL for 2 years among participants undergoing radiation therapy (RT) with or without NADT for newly diagnosed, early-stage prostate cancer.Methods and materialsWe analyzed longitudinal cohort data from the Prostate Cancer Outcomes and Satisfaction with Treatment Quality Assessment Consortium to ascertain the HRQOL trajectory of men receiving NADT with external beam RT (EBRT) or brachytherapy. HRQOL was measured using the expanded prostate cancer index composite 26-item questionnaire at 2, 6, 12, and 24 months after the initiation of NADT. We used the χ2 or Fisher exact test to compare the shift in percentages between groups that did or did not receive NADT. Analyses were conducted at the 2-sided 5% significance level.ResultsFor subjects receiving EBRT, questions regarding the ability to have an erection, ability to reach an orgasm, quality of erections, frequency of erections, ability to function sexually, and lack of energy were in a significantly worse dichotomized category for the patients receiving NADT. Comparing the baseline versus 24-month outcomes, 24%, 23%, and 30% of participants receiving EBRT plus NADT shifted to the worse dichotomized category for the ability to reach an orgasm, quality of erections, and ability to function sexually compared with 14%, 13%, and 16% in the EBRT group, respectively.ConclusionsCompared with baseline, at 2 years, participants receiving NADT plus EBRT compared with EBRT alone had worse HRQOL, as measured by the ability to reach orgasm, quality of erections, and ability to function sexually. However, no difference was found in the ability to have an erection, frequency of erections, overall sexual function, hot flashes, breast tenderness/enlargement, depression, lack of energy, or change in body weight. The improved survival in intermediate- and high-risk patients receiving NADT and EBRT necessitates pretreatment counseling of the HRQOL effect of NADT and EBRT.

ObjectiveTo examine the effectiveness of the 3 primary treatments for ureteropelvic junction obstruction (ie, open pyeloplasty, minimally invasive pyeloplasty, and endopyelotomy) as assessed by failure rates.Materials and methodsUsing MarketScan data, we identified adults (ages 18-64 years) who underwent treatment for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was failure (ie, need for a secondary procedure). We fit a Cox proportional hazards model to examine the effects of different patient, regional, and provider characteristics on treatment failure. We then implemented a survival analysis framework to examine the failure-free probability for each treatment.ResultsWe identified 1125 minimally invasive pyeloplasties, 775 open pyeloplasties, and 1315 endopyelotomies with failure rates of 7%, 9%, and 15%, respectively. Compared with endopyelotomy, minimally invasive pyeloplasty was associated with a lower risk of treatment failure (adjusted hazards ratio [aHR] 0.52; 95% confidence interval [CI], 0.39-0.69). Minimally invasive and open pyeloplasties had similar failure rates. Compared with open pyeloplasty, endopyelotomy was associated with a higher risk of treatment failure (aHR 1.78; 95% CI, 1.33-2.37). The average length of stay was 2.7 days for minimally invasive pyeloplasty and 4.2 days for open pyeloplasty (P

PurposeParents of children with vesicoureteral reflux are presented with a variety of management options, which in many cases offer a similar risk-benefit ratio. To facilitate shared decision making, parental preferences regarding vesicoureteral reflux treatment options need to be acknowledged. We aimed to characterize the clinical experience of parents and elicit core themes affecting decision making in regard to managing vesicoureteral reflux in their child.Materials and methodsA semistructured, qualitative interview script was developed and vetted by 25 pediatric urologists to discuss treatment options for vesicoureteral reflux. Additional patient interviews were conducted until new themes failed to arise. Content analysis was performed to extract all statements that described treatment options. Similar statements were combined until a final list of unique themes emerged.ResultsA total of 26 interviews were performed, yielding 689 statements about overall parent experiences with managing vesicoureteral reflux in the child and 450 statements (65%) pertaining to treatment options. Of the 13 themes that emerged, those most commonly considered were the prevention of future urinary tract infections by 85% of parents, the efficacy rate of treatment options by 85%, the burden of daily maintenance or compliance by 77%, antibiotic resistance by 69%, chronic kidney damage by 62% and invasiveness by 58%.ConclusionsOur study emphasizes that when choosing a treatment option for vesicoureteral reflux in their child, parent preferences regarding risks and benefits are variable. However, their chief concerns include whether a method decreases the risk of urinary tract infections, has an acceptable efficacy rate and aligns itself with the capabilities of the family. These themes help frame discussions between families and clinicians regarding vesicoureteral reflux management, and they can facilitate shared decision making.

BackgroundBacillus Calmette-Guérin (BCG) is the reference standard treatment for patients with high-grade, non-muscle-invasive bladder cancer (NMIBC). We previously described noncompliance with guidelines for BCG use in patients with high-risk disease. In the current study, we sought to characterize how the number of endoscopic resections of bladder tumors affects BCG utilization using population-level data.Patients and methodsWe queried a Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to evaluate claims records of 4776 patients diagnosed with high-grade NMIBC between 1992 and 2002 and followed until 2007, who survived for at least 2 years and who did not undergo definitive treatment with cystectomy, radiotherapy, or systemic chemotherapy. We stratified patients on the basis of the number of endoscopic resections of bladder tumors. We used chi-square analysis to compare number of resections to BCG utilization and multinomial logistic regression analysis to quantify BCG utilization by patient and tumor characteristics.ResultsUtilization of BCG increases with increasing endoscopic resections from 40% at diagnosis to 72% after 6 resections. The cumulative rate of at least an induction course of BCG plateaus after 3 resections. Lower BCG utilization was associated with advanced age (≥ 80 years), while increased utilization was associated with being married, higher disease stage (Tis and T1) and grade (undifferentiated), and increasing endoscopic resections.ConclusionA significant fraction of patients with NMIBC do not receive induction BCG despite its proven benefit in minimizing recurrences. Most patients receive BCG only after multiple endoscopic resections. Strategies focused on earlier adoption of BCG to prevent recurrences instead of reacting to recurrences may limit progression and improve survival.

Background and purposeUreteropelvic junction obstruction is a common urologic condition that accounts for approximately $12 million in inpatient spending annually. Few studies have assessed the costs related to treatment. We sought to examine the cost of care for patients treated for ureteropelvic junction obstruction.Patients and methodsWe used the MarketScan® database to identify adults from 18 to 64 years old treated with minimally invasive pyeloplasty, open pyeloplasty, and endopyelotomy for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was total expenditures related to the surgical episode, defined as the period from 30 days prior until 30 days after the index surgery. We fit a multinomial linear regression model to evaluate cost of the surgical episode, adjusting for age, gender, comorbidity, benefit plan type, and region of residence.ResultsWe identified 1251 endopyelotomies, 717 open pyeloplasties, and 1048 minimally invasive pyeloplasties. The adjusted mean costs were $16,379 for endopyelotomy, $22,421 for open pyeloplasty, and $22,843 for minimally invasive pyeloplasty (p

Background and purposeUreteropelvic junction obstruction is a common condition that can be treated with open pyeloplasty, minimally invasive pyeloplasty, and endopyelotomy. While all these treatments are effective, the extent to which they are used is unclear. We sought to examine the dissemination of these treatments.Patients and methodsUsing the MarketScan® database, we identified adults 18 to 64 years old who underwent treatment for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was ureteropelvic junction obstruction treatment (i.e., open pyeloplasty, minimally invasive pyeloplasty, endopyelotomy). We fit a multilevel multinomial logistic regression model accounting for patients nested within providers to examine several factors associated with treatment.ResultsRates of minimally invasive pyeloplasty increased 10-fold, while rates of open pyeloplasty decreased by over 40%, and rates of endopyelotomy were relatively stable. Factors associated with receiving an open vs a minimally invasive pyeloplasty were largely similar. Compared with endopyelotomy, patients receiving minimally invasive pyeloplasty were less likely to be older (odds ratio [OR] 0.96; 95% confidence interval [CI], 0.95, 0.97) and live in the south (OR 0.52; 95% CI, 0.33, 0.81) and west regions (OR 0.57; 95% CI 0.33, 0.98) compared with the northeast and were more likely to live in metropolitan statistical areas (OR 1.52; 95% CI 1.08, 2.13).ConclusionsOver this 9-year period, the landscape of ureteropelvic junction obstruction treatment has changed dramatically. Further research is needed to understand why geographic factors were associated with receiving a minimally invasive pyeloplasty or an endopyelotomy.

BackgroundCancer can challenge important life goals for young adult survivors. Poor goal navigation skills might disrupt self-regulation and interfere with coping efforts, particularly approach-oriented attempts. Two studies are presented that investigated relationships among goal navigation processes, approach-oriented coping, and adjustment (i.e., social, emotional, and functional well-being) in separate samples of young adults with testicular cancer.MethodsIn study 1, in-depth interviews (N = 21) were analyzed using thematic analysis to understand experiences of goal pursuit following cancer. In study 2, 171 men completed measures of goal navigation, coping, and adjustment to cancer.ResultsIn study 1, three prominent themes emerged: goal clarification, goal engagement and disengagement, and responses to disrupted goals. Regression analyses in study 2 revealed that goal navigation skills were positively associated with emotional (B = .35, p

ObjectiveTo determine the incidence and characteristics of women with uncomplicated recurrent urinary tract infections (UTIs) and to explore whether the use of culture-driven treatment affects rates of UTI-related complications and resource utilization.Materials and methodsUsing MarketScan claims from 2003 to 2011, we identified UTI-naive women ages 18-64 with incident-uncomplicated recurrent UTIs. Recurrent UTIs were defined as 3 UTI visits associated with antibiotics during a 12-month period. Cases were excluded if they had a UTI in the preceding year, or if they had any complicating factors (eg, abnormality of the urinary tract, neurologic condition, pregnancy, diabetes, or currently taking immunosuppression). We next assessed use of urine cultures, imaging, and cystoscopy, and performed propensity score matching with logistic regression to determine whether having a urine culture associated with >50% of UTIs affected rates of complications and downstream resource utilization.ResultsWe identified 48,283 women with incident-uncomplicated recurrent UTIs, accounting for an overall incidence of 102 per 100,000 women, highest among women ages 18-34 and 55-64. Sixty-one percent of these women had at least 1 urine culture, 6.9% had imaging, and 2.8% had cystoscopy. Having a urine culture >50% of the time was associated with fewer UTI-related hospitalizations and lower rates of intravenous antibiotic use, whereas demonstrating higher rates of UTI-related office visits and pyelonephritis.ConclusionThe incidence of uncomplicated recurrent UTIs increases with age. Urine culture-directed care is beneficial in reducing high-cost services including UTI-related hospitalizations and intravenous antibiotic use, making urine cultures a valuable component to management of these patients.

BackgroundInterpersonal sensitivity is characterized by the predisposition to perceive and elicit criticism, rejection, and negative social evaluation. It may be linked to poorer physical or functional health outcomes, particularly in the interpersonal context (cancer-related sexual dysfunction).PurposeThis study tested the association of interpersonal sensitivity with sexual functioning following testicular cancer in young men and whether this association is moderated by coping processes.MethodMen ages 18 to 29 (N = 171; M age = 25.2, SD = 3.32) with a history of testicular cancer were recruited via the California State Cancer Registry and completed questionnaire measures including assessments of interpersonal sensitivity, sexual functioning, and approach and avoidance coping.ResultsRegression analysis controlling for education, age, partner status, ethnic status, and time since diagnosis revealed that higher interpersonal sensitivity was significantly related to lower sexual functioning (β = -0.18, p

ObjectiveTo describe guideline adherence for patients with suspected upper tract stones.Patients and methodsWe performed a cross-sectional analysis of visits recorded by the National Hospital Ambulatory Medical Care Survey (emergency department [ED] component) in 2007-2010 (most recent data). We assessed adherence to clinical guidelines for diagnostic laboratory testing, imaging, and pharmacologic therapy. Multivariable regression models controlled for important covariates.ResultsAn estimated 4,956,444 ED visits for patients with suspected kidney stones occurred during the study period. Guideline adherence was highest for diagnostic imaging, with 3,122,229 (63%) visits providing optimal imaging. Complete guideline-based laboratory testing occurred in only 2 of every 5 visits. Pharmacologic therapy to facilitate stone passage was prescribed during only 17% of eligible visits. In multivariable analysis of guideline adherence, we found little variation by patient, provider, or facility characteristics.ConclusionGuideline-recommended care was absent from a substantial proportion of acute care visits for patients with suspected kidney stones. These failures of care delivery likely increase costs and temporary disability. Targeted interventions to improve guideline adherence should be designed and evaluated to improve care for patients with symptomatic kidney stones.

ObjectivesKidney stones affect nearly one in 11 persons in the United States, and among those experiencing symptoms, emergency care is common. In this population, little is known about the incidence of and factors associated with repeat emergency department (ED) visits. The objective was to identify associations between potentially mutable factors and the risk of an ED revisit for patients with kidney stones in a large, all-payer cohort.MethodsThis was a retrospective cohort study of all patients in California initially treated and released from EDs for kidney stones between February 2008 and November 2009. A multivariable regression model was created to identify associations between patient-level characteristics, area health care resources, processes of care, and the risk of repeat ED visits. The primary outcome was a second ED visit within 30 days of the initial discharge from emergent care.ResultsAmong 128,564 patients discharged from emergent care, 13,684 (11%) had at least one additional emergent visit for treatment of their kidney stone. In these patients, nearly one in three required hospitalization or an urgent temporizing procedure at the second visit. On multivariable analysis, the risk of an ED revisit was associated with insurance status (e.g., Medicaid vs. private insurance; odds ratio [OR] = 1.52, 95% confidence interval [CI] = 1.43 to 1.61; p < 0.001). Greater access to urologic care was associated with lower odds of an ED revisit (highest quartile OR = 0.88, 95% CI = 0.80 to 0.97; p < 0.01 vs. lowest quartile). In exploratory models, performance of a complete blood count was associated with a decreased odds of revisit (OR = 0.86, 95% CI = 0.75 to 0.97; p = 0.02).ConclusionsRepeat high-acuity care affects one in nine patients discharged from initial emergent evaluations for kidney stones. Access to urologic care and processes of care are associated with lower risk of repeat emergent encounters. Efforts are indicated to identify preventable causes of ED revisits for kidney stone patients and design interventions to reduce the risk of high-cost, high-acuity, repeat care.

BACKGROUND: Men with major comorbidities are at risk for overtreatment of prostate cancer due to uncertainty regarding their life expectancy. We sought to characterize life expectancy and treatment in a population-based cohort of men with differing ages and comorbidity burdens at diagnosis. METHODS: We sampled 96,032 men aged ≥66 years with early-stage prostate cancer who had Gleason scores ≤7 and were diagnosed during 1991 to 2007 from the Surveillance, Epidemiology, and End Results-Medicare database. We calculated cumulative incidence of other-cause mortality and determined treatment patterns among subgroups defined by age and Charlson comorbidity index scores. RESULTS: Overall, life expectancy was 50%) for 50,049 of 96,032 men (52%). Life expectancy differed by age and comorbidity score and was

BackgroundDecisional conflict is a source of anxiety and stress for men diagnosed with prostate cancer given uncertainty surrounding myriad treatment options. Few data exist to help clinicians identify which patients are at risk for decisional conflict. The purpose of this study was to examine factors associated with decisional conflict in economically disadvantaged men diagnosed with prostate cancer before any treatment choices were made.MethodsA total of 70 men were surveyed at a Veterans Administration clinic with newly diagnosed localized prostate cancer enrolled in a randomized trial testing a novel shared decision-making tool. Baseline demographic, clinical, and functional data were collected. Independent variables included age, race, education, comorbidity, relationship status, urinary/sexual dysfunction, and prostate cancer knowledge. Tested outcomes were Decisional Conflict Scale, Uncertainty Subscale, and Perceived Effectiveness Subscale. Multiple linear regression modeling was used to identify factors associated with decisional conflict.ResultsMean age was 63 years, 49% were African American, and 70% reported an income less than $30,000. Poor prostate cancer knowledge was associated with increased decisional conflict and higher uncertainty (P

PurposeAfter being diagnosed with prostate cancer men must assimilate information regarding the cancer. Satisfaction with information reflects the evaluation of information sources used before treatment to select a therapy. We describe the use and helpfulness of several information sources available to prostate cancer survivors. We also identified factors associated with satisfaction with information.Materials and methodsA total of 1,204 men with newly diagnosed prostate cancer were enrolled in the prospective, multicenter Prostate Cancer Outcomes and Satisfaction with Therapy Quality Assessment study. The validated satisfaction with information domain of the Service Satisfaction Scale-Cancer was administered to subjects 2 months after treatment. The relationship between several factors, such as demographics, socioeconomic factors, cancer severity and types of information sources, and satisfaction with information were evaluated using multiple regression.ResultsSources of information endorsed by subjects varied by race, education and study site. The most helpful sources were treatment description by the treating physician (33.1%), Internet sites (18.9%) and books (18.1%). In multiple variable models patient age (p = 0.005) and information provided by the physician regarding outcomes in their patients (p = 0.01) were independently associated with patient satisfaction with the information provided.ConclusionsVarious information sources were used and endorsed as helpful by subjects, although results for physician patients was the only source independently associated with satisfaction with information. Providing patients with information about possible or expected courses of care and outcomes may improve satisfaction.

BackgroundUnplanned follow-up care is the focus of intense health policy interest, as evidenced by recent financial penalties imposed under the Affordable Care Act. To date, however, unplanned postoperative care remains poorly characterized, particularly for patients with kidney stones. Our objective was to describe the frequency, variation, and financial impact of unplanned, high-acuity, follow-up visits in the treatment of patients with urinary stone disease.MethodsWe identified privately insured patients undergoing percutaneous nephrostolithotomy, ureteroscopy, or shock-wave lithotripsy for stone disease. The primary outcome was occurrence of an emergency department visit or hospital admission within 30 days of the procedure. Multivariable models estimated the odds of an unplanned visit and the incremental cost of those visits, controlling for important covariates.ResultsWe identified 93,523 initial procedures to fragment or remove stones. Overall, 1 in 7 patients had an unplanned postprocedural visit. Unplanned visits were least common after shock-wave lithotripsy (12%) and occurred with similar frequency after ureteroscopy and percutaneous nephrostolithotomy (15%). Procedures at high-volume facilities were substantially less likely to result in an unplanned visit (odds ratio 0.80, 95% confidence interval [95% CI] 0.74-0.87, P < .001). When an unplanned visit occurred, adjusted incremental expenditures per episode were greater after shock-wave lithotripsy ($32,156 [95% CI $30,453-33,859]) than after ureteroscopy ($23,436 [95% CI $22,281-24,590]).ConclusionPatients not infrequently experience an unplanned, high-acuity visit after low-risk procedures to remove urinary stones, and the cost of these encounters is substantial. Interventions are indicated to identify and reduce preventable unplanned visits.

BackgroundPatient-reported outcome instruments are needed to measure health-related quality of life (HRQOL) in young adults with cancer. The purpose of this project was to establish a conceptual model and measurement instrument for assessment of HRQOL in young men with testicular cancer.MethodsPatient interviews and a literature review were used to develop a conceptual framework of biopsychosocial domains of cancer-related quality of life and an initial pool of questionnaire items. Items were piloted and refined. Revised items were administered to a sample (N = 171) of young (ages 18-29) men with testicular cancer and repeated 4 weeks later. Rasch measurement methods guided item reduction and scale construction. Traditional psychometric analyses were also performed to allow for comparison with existing measures.ResultsThe conceptual framework included seven biopsychosocial domains: physical, sexual, intrapersonal, cognitive-emotional, social-relational, educational-vocational-avocational, and spiritual to form independent scales of the resulting questionnaire, the Cancer Assessment for Young Adults-Testicular (CAYA-T). Each scale fulfilled Rasch and traditional psychometric criteria (i.e., person separation index, 0.34-0.82; Cronbach's alpha, 0.70-0.91; and an expected pattern of convergent and discriminant validity correlations).ConclusionsThe CAYA-T can be used to assess HRQOL across a comprehensive set of domains as identified by young men with cancer. It passes strict psychometric criteria and has potential as a useful research and clinical tool.Implications for cancer survivorsThe CAYA-T has potential research and clinical value for addressing inter-related aspects of HRQOL in young adult men with cancer. The measure may assist with assessing and monitoring HRQOL across a range of domains and contributing to more comprehensive assessment of biopsychosocial needs of young adults.

ObjectiveTo characterize urine test use in ambulatory, antibiotic-treated pediatric urinary tract infection (UTI).MethodsWe studied children

ObjectiveTo investigate whether orchiopexies are occurring later than recommended by American Academy of Pediatrics 1996 guidelines (around age 1). Adherence to guidelines is poorly studied.MethodsThe main cohort consisted of 4103 boys insured from birth (Innovus i3, insurance claims database). The complementary cohort consisted of 17 010 insured and noninsured boys (Pediatric Health Information System, PHIS). The inclusion criteria was age ≤ 5 years at time of International Classification of Disease, 9th revision-defined cryptorchidism diagnosis. The primary outcome was timely surgery (orchiopexy by age 18 months).ResultsIn Innovus, 87% of boys who underwent an orchiopexy had a timely orchiopexy. Of those who did not undergo surgery (n = 2738), 90% had at least 1 subsequent well-care visit. Those who underwent timely surgery were referred to a surgeon at a younger age compared with those who underwent late surgery (4.1 vs 16.1 months, P < .00005). Predictors of timely surgery were number of well-care visits (odds ratio 1.5, 95% confidence interval 1.3-1.7), continuity of primary care (odds ratio 1.9, 95% confidence interval 1.3-2.7), and use of laparoscopy (odds ratio 4.5, 95% confidence interval 1.4-14.9). Family/internal medicine as referring provider was predictive of delayed surgery (odds ratio 0.5, 95% confidence interval 0.3-0.8). In the Pediatric Health Information System, 61% of those with private insurance had timely surgery compared with 54% of those without private insurance (P < .0001).ConclusionWe found an unexpectedly high adherence to guidelines in our continuously insured since birth Innovus population. Primary care continuity and well-care visits were associated with timely surgery. Further studies can confirm these findings in nonprivately insured patients with the ultimate goal of instituting quality improvement initiatives.

ContextSexual function is the health-related quality of life (HRQOL) domain most commonly impaired after prostate cancer treatment; however, validated tools to enable personalized prediction of erectile dysfunction after prostate cancer treatment are lacking.ObjectiveTo predict long-term erectile function following prostate cancer treatment based on individual patient and treatment characteristics.DesignPretreatment patient characteristics, sexual HRQOL, and treatment details measured in a longitudinal academic multicenter cohort (Prostate Cancer Outcomes and Satisfaction With Treatment Quality Assessment; enrolled from 2003 through 2006), were used to develop models predicting erectile function 2 years after treatment. A community-based cohort (community-based Cancer of the Prostate Strategic Urologic Research Endeavor [CaPSURE]; enrolled 1995 through 2007) externally validated model performance. Patients in US academic and community-based practices whose HRQOL was measured pretreatment (N = 1201) underwent follow-up after prostatectomy, external radiotherapy, or brachytherapy for prostate cancer. Sexual outcomes among men completing 2 years' follow-up (n = 1027) were used to develop models predicting erectile function that were externally validated among 1913 patients in a community-based cohort.Main outcome measuresPatient-reported functional erections suitable for intercourse 2 years following prostate cancer treatment.ResultsTwo years after prostate cancer treatment, 368 (37% [95% CI, 34%-40%]) of all patients and 335 (48% [95% CI, 45%-52%]) of those with functional erections prior to treatment reported functional erections; 531 (53% [95% CI, 50%-56%]) of patients without penile prostheses reported use of medications or other devices for erectile dysfunction. Pretreatment sexual HRQOL score, age, serum prostate-specific antigen level, race/ethnicity, body mass index, and intended treatment details were associated with functional erections 2 years after treatment. Multivariable logistic regression models predicting erectile function estimated 2-year function probabilities from as low as 10% or less to as high as 70% or greater depending on the individual's pretreatment patient characteristics and treatment details. The models performed well in predicting erections in external validation among CaPSURE cohort patients (areas under the receiver operating characteristic curve, 0.77 [95% CI, 0.74-0.80] for prostatectomy; 0.87 [95% CI, 0.80-0.94] for external radiotherapy; and 0.90 [95% CI, 0.85-0.95] for brachytherapy).ConclusionStratification by pretreatment patient characteristics and treatment details enables prediction of erectile function 2 years after prostatectomy, external radiotherapy, or brachytherapy for prostate cancer.

As healthcare spending in the United States continues to rise at an unsustainable rate, recent policy decisions introduced at the national level will rely on precepts of evidence-based medicine to promote the determination, dissemination, and delivery of "best practices" or quality care while simultaneously reducing cost. We discuss the influence of evidence-based medicine on policy and, in turn, the impact of policy on the developing clinical evidence base with an eye to the potential effects of these relationships on the practice and provision of urologic care.

Abstract Background To date, the morbidity of urethral stricture disease among American men has not been analyzed using national datasets. We sought to analyze the morbidity of urethral stricture disease by measuring the rates of urinary tract infections and urinary incontinence among men with a diagnosis of urethral stricture. Methods We analyzed Medicare claims data for 1992, 1995, 1998, and 2001 to estimate the rate of dual diagnoses of urethral stricture with urinary tract infection and with urinary incontinence occurring in the same year among a 5% sample of beneficiaries. Male Medicare beneficiaries receiving co-incident ICD-9 codes indicating diagnoses of urethral stricture and either urinary tract infection or urinary incontinence within the same year were counted. Results The percentage of male patients with a diagnosis of urethral stricture who also were diagnosed with a urinary tract infection was 42% in 2001, an increase from 35% in 1992. Eleven percent of male Medicare beneficiaries with urethral stricture disease in 2001 were diagnosed with urinary incontinence in the same year. This represents an increase from 8% in 1992. Conclusions Among male Medicare beneficiaries diagnosed with urethral stricture disease in 2001, 42% were also diagnosed with a urinary tract infection, and 11% with incontinence. Although the overall incidence of stricture disease decreased over this time period, these rates of dual diagnoses increased from 1992 to 2001. Our findings shed light into the health burden of stricture disease on American men. In order to decrease the morbidity of stricture disease, early definitive management of strictures is warranted.

BackgroundUnlike other malignancies, there is no literature supporting the accuracy of medical claims data for identifying surgical treatments among patients with kidney cancer. We sought to validate externally a previously published Medicare-claims-based algorithm for classifying surgical treatments among patients with early-stage kidney cancer. To achieve this aim, we compared procedure assignments based on Medicare claims with the type of surgery specified in SEER registry data and clinical operative reports.MethodsUsing linked SEER-Medicare data, we calculated the agreement between Medicare claims and SEER data for identification of cancer-directed surgery among 6,515 patients diagnosed with early-stage kidney cancer. Next, for a subset of 120 cases, we determined the agreement between the claims algorithm and the medical record. Finally, using the medical record as the reference-standard, we calculated the sensitivity, specificity, and positive and negative predictive values of the claims algorithm.ResultsAmong 6,515 cases, Medicare claims and SEER data identified 5,483 (84.1%) and 5,774 (88.6%) patients, respectively, who underwent cancer-directed surgery (observed agreement = 93%, kappa = 0.69, 95% CI 0.66 - 0.71). The two data sources demonstrated 97% agreement for classification of partial versus radical nephrectomy (kappa = 0.83, 95% CI 0.81 - 0.86). We observed 97% agreement between the claims algorithm and clinical operative reports; the positive predictive value of the claims algorithm exceeded 90% for identification of both partial nephrectomy and laparoscopic surgery.ConclusionMedicare claims represent an accurate data source for ascertainment of population-based patterns of surgical care among patients with early-stage kidney cancer.