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ObjectiveTo assess whether private equity (PE) acquisitions of urology practices were associated with changes in Medicare payments and patient volume.MethodsWe identified PE acquisitions of urology practices through financial databases, industry news outlets, practice websites, and Google search. Using the Centers for Medicare and Medicaid Service's Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (2012-2019), we conducted descriptive statistics and trends analysis to examine whether PE acquisition was associated with changes in Medicare payments and patient volume in comparison to non-PE affiliated urologists within the same states.ResultsWe identified PE acquisitions of 10 independent urology practices across 6 states during the study period. In the preacquisition period, urologists later joining private-equity groups received greater mean inflation-adjusted Medicare payments ($246,977 vs $160,038; P

Introduction:Private equity firms have recently acquired several large urology practices in the United States. As little is known about these acquisitions, we sought to characterize trends ...

Injuries sustained in motorcycle collisions can be organized into distinct patterns to improve recognition and treatment. Lowside, highside, topside, and collision are the four main categories of motorcycle crash types. Within those four crash types, mechanisms of injury include head-leading collisions, direct vertical impact, motorcycle radius, motorcycle thumb, fuel tank injures, limb entrapment, tyre-spoke injury, and crash modifying manoeuvre. Cite this article: EFORT Open Rev 2020;5:544-548. DOI: 10.1302/2058-5241.5.190090

Objective Patients may call urgent care centers (UCCs) with urgent surgical conditions but may not be properly referred to a higher level of care. This study aims to characterize how UCCs manage Medicaid and privately insured patients who present with an emergent condition. Methods Using a standardized script, we called 1245 randomly selected UCCs in 50 states on 2 occasions. Investigators posed as either a Medicaid or a privately-insured patient with symptoms of an incarcerated inguinal hernia. Rates of direct emergency department (ED) referral were compared between insurance types. Results A total of 1223 (98.2%) UCCs accepted private insurance and 981 (78.8%) accepted Medicaid. At the 971 (78.0%) UCCs that accepted both insurance types, direct-to-ED referral rates for private and Medicaid patients were 27.9% and 33.8%, respectively. Medicaid patients were significantly more likely than private patients to be referred to the ED [odds ratio (OR) 1.32, 95% confidence interval (CI) 1.09-1.60]. Private patients who were triaged by a clinician compared to nonclinician staff were over 6 times more likely to be referred to the ED (OR 6.46, 95% CI 4.63-9.01). Medicaid patients were nearly 9 times more likely to have an ED referral when triaged by a clinician (OR 8.72, 95% CI 6.19-12.29). Conclusions Only one-third of UCCs across the United States referred an apparent emergent surgical case to the ED, potentially delaying care. Medicaid patients were more likely to be referred directly to the ED versus privately insured patients. All patients triaged by clinicians were significantly more likely to be referred to the ED; however, the disparity between private and Medicaid patients remained.

ObjectiveTo characterize appointment access for Medicaid-insured patients seeking care at urology practices affiliated with private equity firms in light of the recent national trends in practice consolidation.MethodsWe identified 214 urology offices affiliated with private equity firms that were geographically matched with 231 non-private equity affiliated urology offices. Using a standardized script, researchers posed as an adult patient with either Medicaid or commercial insurance in the clinical setting of new onset, painless hematuria. The primary outcome was whether the patient's insurance was accepted for an appointment. The secondary outcome was appointment wait time.ResultsWe conducted 815 appointment inquiry calls to 214 private equity (PE) and 231 non-PE-affiliated urology offices across 12 states. Appointment availability was higher for commercially-insured patients (99.0%; 95% CI: 98.1%-99.9%) vs Medicaid-insured patients (59.8%; 95% confidence interval [CI]: 55.0%-64.6%) (P < .0001). Medicaid acceptance was higher at non-PE affiliated (66.8%; CI 60.4%-73.2%) than PE-affiliated practices (52.1%; 95% CI 45.0%-59.2%) (P = .003). On multivariable logistic regression analysis, state Medicaid expansion status (odds ratio [OR] 2.20; CI 1.14-4.28; P = .020) was independently associated with Medicaid appointment availability, whereas PE-affiliation (OR 0.55; CI 0.37-0.83; P = .004) was independently associated with lower Medicaid access. Appointment wait times did not differ significantly for commercially-insured vs Medicaid patients (19.2 vs 20.1 days; p = .59), but PE-affiliated practices offered shorter mean wait times than non-PE offices (17.5 vs 21.4 days; P = .017).ConclusionAccess disparities for urologic evaluation in patients with Medicaid insurance at urology practices and were more pronounced at private equity acquired practices.

The optimal method of magnetic resonance imaging (MRI)-ultrasound (US) fusion biopsy to adequately sample regions of interest (ROIs) remains unknown. We sought to determine the number and location of cores needed to adequately detect clinically significant prostate cancer (PCa). We identified patients undergoing MRI-US fusion prostate biopsy at our institution for known history or clinical suspicion of PCa. Multiparametric MRI studies were reviewed using Likert and Prostate Imaging Reporting and Data System (PI-RADS) v2 schema. Multiple targeted cores were taken from each ROI followed by 12-core systematic biopsy. In a distinct cohort of patients, lesions were targeted using a predetermined five-core template. We estimated cancers detected through sampling of five or fewer cores, assessed by core number and core location. We identified 744 patients with 581 lesions with PCa. Seventy-seven percent (279/361) of Gleason (G) ≥3+4 tumors and 72% (137/189) of G >3+4 tumors were detected on two-core sampling. Relative to all targeted cores, a two-core approach missed 16% of clinically significant cancers at first biopsy, 27% in prior negative, and 32% in active surveillance patients. Detection of G ≥3+4 cancers did not differ by core location. Sampling of two cores of ROIs misses nearly one-quarter of clinically significant PCa detected on additional sampling. PATIENT SUMMARY: We aimed to understand how the number of cores obtained from a suspicious area during prostate magnetic resonance imaging-ultrasound fusion biopsy affects cancer detection. We found that sampling of five cores missed substantially fewer cancers compared to two cores.

Key Points Question Was the Patient Protection and Affordable Care Act (ACA) associated with changes in insurance coverage and stage of diagnosis for patients with renal cell carcinoma (RCC), and were differences based on income? Findings In this cohort study of 78 099 patients with RCC, the ACA was associated with increased insurance coverage through Medicaid for low-income patients and detection at an earlier stage of disease. Insurance coverage increased to a greater degree in states that expanded their Medicaid eligibility. Meaning These findings suggest that the ACA was associated with significant increases in insurance coverage for lower-income patients and early diagnosis of RCC., Importance The association of the Patient Protection and Affordable Care Act (ACA) with insurance status and cancer stage at diagnosis among patients with renal cell carcinoma (RCC) is unknown. Objective To test the hypothesis that the ACA may be associated with increased access to care through expansion of insurance, which may vary based on income. Design, Setting, and Participants This retrospective cohort analysis included patients diagnosed with RCC from January 1, 2010, to December 31, 2016, in the National Cancer Database. Data were analyzed from July 1 to December 31, 2020. The periods from 2010 to 2013 and from 2014 to 2016 were defined as pre- and post-ACA implementation, respectively. Patients were categorized as living in a Medicaid expansion state or not. Exposures Implementation of the ACA. Main Outcomes and Measures The absolute percentage change (APC) of insurance coverage was calculated before and after ACA implementation in expansion and nonexpansion states. Secondary outcomes included change in stage at diagnosis, difference in the rate of insurance change, and change in localized disease between expansion and nonexpansion states. Adjusted difference-in-difference modeling was performed. Results The cohort included 78 099 patients (64.7% male and 35.3% female; mean [SD] age, 54.66 [6.46] years), of whom 21.2% had low, 46.2% had middle, and 32.6% had high incomes. After ACA implementation, expansion states had a lower proportion of uninsured patients (adjusted difference-in-difference, −1.14% [95% CI, −1.98% to −1.41%]; P = .005). This occurred to the greatest degree among low-income patients through the acquisition of Medicaid (APC, 11.0% [95% CI, 8.6%-13.3%]; P, This cohort study tests the hypothesis that implementation of the Patient Protection and Affordable Care Act may be associated with increased access to care through expansion of insurance, which may vary based on income, among patients with renal cell carcinoma.

PURPOSE: We aimed to determine whether insurance expansions implemented through the Affordable Care Act (ACA) were associated with changes in coverage status, disease stage, and treatment of younger adults with testicular germ cell tumors (GCT). MATERIALS AND METHODS: We identified men aged 18–64 diagnosed with testicular GCTs between 2010 and 2015 in the National Cancer Data Base. We defined time periods as: pre-ACA (2010–2013) and post-ACA (2014–2015) and used difference-in-differences (DID) modeling to examine associations between state Medicaid expansion status and changes in insurance, stage at diagnosis, and treatment. RESULTS: Following the ACA, the proportion of patients with any health insurance increased 3.7% (95% CI 3–4.5) in Medicaid expansion states and 3.0% (95% CI 1.5–4.5) in non-expansion states, mainly by gaining Medicaid and private insurance, respectively. The largest increases occurred in low-income patients, where Medicaid expansion was associated with an adjusted increase of 14.5 percentage points (95% CI 7.2–21.8) in Medicaid coverage following the ACA. We did not observe reductions in late-stage diagnoses during the observation period. Changes in the proportion of patients receiving chemotherapy or radiation for advanced-stage cancers were ongoing prior to the ACA and differed between expansion and non-expansion states, limiting assessment of ACA-related effects on individual treatments. CONCLUSIONS: Post-ACA, the proportion of newly diagnosed testicular cancer patients with health insurance increased, with the largest effects seen among lowest income individuals. Our findings that changes in practice preceded the ACA and differed by expansion status highlight the need for caution in assessing the legislation’s impact.

Background In a response to the pandemic, urgent care centers (UCCs) have gained a critical role as a common location for COVID-19 testing. We sought to characterize the changes in testing accessibility at UCCs between March and August 2020 on the basis of testing availability (including rapid antigen testing), wait time for test results, cost of visits, and cost of tests. Methods Data were collected using a secret shopper methodology. Researchers contacted 250 UCCs in 10 states. Investigators used a standardized script to survey centers on their COVID-19 testing availability and policies. UCCs were initially contacted in March and re-called in August. T-tests and chi-square tests were conducted to identify differences between March and August data and differences by center classification. Results Our results indicate that both polymerase chain reaction (PCR) tests to detect COVID-19 genetic material and rapid antigen COVID-19 tests have increased in availability. However, wait times for PCR test results have significantly increased to an average of 5.79 days. Additionally, a high proportion of UCCs continue to charge for tests and visits and no significant decrease was found in the proportion of UCCs that charge for COVID-19 testing from March to August. Further, no state reported a majority of UCCs with rapid testing available, indicating an overall lack of rapid testing. Conclusions From March to August, COVID-19 testing availability gradually improved. However, many barriers lie in access to COVID-19 testing, including testing costs, visit costs, and overall lack of availability of rapid testing in the majority of UCCs. Despite the passage of the CARES Act, these results suggest that there is room for additional policy to improve accessibility to testing, specifically rapid testing.

To evaluate Medicaid insurance access disparities for urologic care at urgent care centers (UCCs) in the United States.We conducted a cross-sectional study using a "secret shopper" methodology. We sampled 240 UCCs across 8 states. Using a standardized script, researchers posed as a patient with either Medicaid or commercial insurance in the clinical setting of obstructing nephrolithiasis. The primary study endpoint was whether a patient's insurance (Medicaid vs commercial) was accepted. We assessed factors associated with Medicaid acceptance using logistic regression models adjusted for state-level and facility-level characteristics. Additionally, we calculated triage rates, emergency department referral rates, and the ability of a UCC to refer the patient to a specialist.Of 240 UCCs contacted, 239 (99.6%) accepted commercial insurance and 159 (66.2%) accepted Medicaid. UCCs in Medicaid expansion states more frequently accepted patients with Medicaid insurance (74.2% vs 58.3%, respectively, P.01). On multivariable logistic regression analysis, state Medicaid expansion (OR 1.84, 95% CI 1.04-3.26, P = .04) and affiliation with an institution (OR 2.97, 95% CI 1.59-5.57, P.01) were independently associated with greater odds of accepting Medicaid. Medicaid-insured patients were significantly less likely to be triaged or referred to the emergency department compared to commercial patients.We identified significant disparities in access to UCCs for Medicaid patients presenting with a urologic condition. Given the expanding national role of UCCs, these findings highlight potential sources of insurance disparity in the context of a urologic emergency.

BACKGROUND: As the urgent care landscape evolves, specialized musculoskeletal urgent care centers (MUCCs) are becoming more prevalent. MUCCs have been offered as a convenient, cost-effective option for timely acute orthopaedic care. However, a recent “secret-shopper” study on patient access to MUCCs in Connecticut demonstrated that patients with Medicaid had limited access to these orthopaedic-specific urgent care centers. To investigate how generalizable these regional findings are to the United States, we conducted a nationwide secret-shopper study of MUCCs to identify determinants of patient access. QUESTIONS/PURPOSES: (1) What proportion of MUCCs in the United States provide access for patients with Medicaid insurance? (2) What factors are associated with MUCCs providing access for patients with Medicaid insurance? (3) What barriers exist for patients seeking care at MUCCs? METHODS: An online search of all MUCCs across the United States was conducted in this cross-sectional study. Three separate search modalities were used to gather a complete list. Of the 565 identified, 558 were contacted by phone with investigators posing over the telephone as simulated patients seeking treatment for a sprained ankle. Thirty-nine percent (216 of 558) of centers were located in the South, 13% (71 of 558) in the West, 25% (138 of 558) in the Midwest, and 24% (133 of 558) in New England. This study was given an exemption waiver by our institution’s IRB. MUCCs were contacted using a standardized script to assess acceptance of Medicaid insurance and identify barriers to care. Question 1 was answered through determining the percentage of MUCCs that accepted Medicaid insurance. Question 2 considered whether there was an association between Medicaid acceptance and factors such as Medicaid physician reimbursements or MUCC center type. Question 3 sought to characterize the prevalence of any other means of limiting access for Medicaid patients, including requiring a referral for a visit and disallowing continuity of care at that MUCC. RESULTS: Of the MUCCs contacted, 58% (323 of 558) accepted Medicaid insurance. In 16 states, the proportion of MUCCs that accepted Medicaid was equal to or less than 50%. In 22 states, all MUCCs surveyed accepted Medicaid insurance. Academic-affiliated MUCCs accepted Medicaid patients at a higher proportion than centers owned by private practices (odds ratio 14 [95% CI 4.2 to 44]; p < 0.001). States with higher Medicaid physician reimbursements saw proportional increases in the percentage of MUCCs that accepted Medicaid insurance under multivariable analysis (OR 36 [95% CI 14 to 99]; p < 0.001). Barriers to care for Medicaid patients characterized included location restriction and primary care physician referral requirements. CONCLUSION: It is clear that musculoskeletal urgent care at these centers is inaccessible to a large segment of the Medicaid-insured population. This inaccessibility seems to be related to state Medicaid physician fee schedules and a center’s affiliation with a private orthopaedic practice, indicating how underlying financial pressures influence private practice policies. Ultimately, the refusal of Medicaid by MUCCs may lead to disparities in which patients with private insurance are cared for at MUCCs, while those with Medicaid may experience delays in care. Going forward, there are three main options to tackle this issue: increasing Medicaid physician reimbursement to provide a financial incentive, establishing stricter standards for MUCCs to operate at the state level, or streamlining administration to reduce costs overall. Further research will be necessary to evaluate which policy intervention will be most effective. LEVEL OF EVIDENCE: Level II, prognostic study.

While rapid and accessible diagnosis is paramount to monitoring and reducing the spread of disease, COVID-19 testing capabilities across the U.S. remain constrained. For many individuals, urgent care centers (UCCs) may offer the most accessible avenue to be tested. Through a phone survey, we describe the COVID-19 testing capabilities at UCCs and provide a snapshot highlighting the limited COVID-19 testing capabilities at UCCs in states with the greatest disease burden.

Background Patients on warfarin with traumatic intracranial hemorrhage often have the warfarin effects pharmacologically reversed. We compared outcomes among patients who received 4-factor prothrombin complex concentrate (PCC), fresh frozen plasma (FFP), or no reversal to assess the real-world impact of PCC on elderly patients with traumatic intracranial hemorrhage (ICH). Materials and Methods This was a retrospective analysis of 150 patients on preinjury warfarin. Data were manually abstracted from the electronic medical record of an academic level 1 trauma center for patients admitted between January 2013 and December 2018. Outcomes were ICH progression on follow-up computed tomography scan, mortality, need for surgical intervention, and trends in the use of reversal agents. Results Of 150 patients eligible for analysis, 41 received FFP, 60 PCC, and 49 were not reversed. On multivariable analysis, patients not reversed [OR 0.25 95% CI (0.31-0.85)] and women [OR 0.38 95% CI (0.17-0.88)] were less likely to experience progression of their initial bleed on follow-up computed tomography while subdural hemorrhage increased the risk [OR 3.69 95% CI (1.27-10.73)]. There was no difference between groups in terms of mortality or need for surgery. Over time use of reversal with PCC increased while use of FFP and not reversing warfarin declined (P Conclusions Male gender and using a reversal agent were associated with progression of ICH. Choice of reversal did not impact the need for surgery, hospital length of stay, or mortality. Some ICH patients may not require warfarin reversal and may bias studies, especially retrospective studies of warfarin reversal.

The choice of anesthetic for carotid endarterectomy (CEA) continues to be controversial. Recent literature suggests improved outcomes with the use of regional anesthesia (RA) compared with general anesthesia (GA). The objective of this study was to examine the utilization and outcomes of RA for CEA using a national database.The targeted CEA files of the American College of Surgeons' National Surgical Quality Improvement Program (2011-2017) were reviewed. Patients were stratified based on anesthesia type into RA and GA, and patients' characteristics were compared between the 2 groups. The outcomes of CEA under GA and RA were compared after 2:1 propensity matching.There were 26,206 CEAs, and 14% (n = 3,664) were performed under RA, with no change in relative utilization during the study period (P = 0.557). Patients treated under RA were more likely to be older than 65 years (80.6% vs. 75.8%; P 0.001) and White (90.8% vs. 83.5%; P 0.001) but less likely to have diabetes (28.2% vs. 31.2%; P = 0.001), chronic obstructive pulmonary disease (10.2% vs. 10.5%; P 0.001), and heart failure (1.0% vs. 1.5%; P = 0.02) and be symptomatic (37.4% vs. 42.7%; P 0.001). After matching, there was no significant difference in baseline characteristics between the 2 groups. Patients undergoing RA were less likely to experience the combined end point of stroke, myocardial infarction, or mortality compared with GA. GA patients were more likely to have longer operating time and hospital length of stay.CEA performed under RA is associated with improved outcomes compared with GA. RA is underutilized in carotid surgery, and strategies to optimize its use are needed.

To evaluate trends in the utilization of active surveillance (AS) in a nationally representative cancer database. AS has been increasingly recognized as an effective strategy for patients with small renal masses but little is known about national usage patterns.We identified patients with clinical T1a renal masses within the National Cancer Database in 2010 through 2014. Patients were classified according to initial management strategy received including AS, surgery, ablation, or other treatment. We characterized time trends in the use of AS vs definitive therapy and examined clinical and socio-demographic determinants of AS among patients with small renal masses using multivariable logistic regression models.We identified 59,189 patients who satisfied the inclusion criteria. Of the total cohort, 1733 (2.9%) individuals received initial management with AS, while 57,456 (97.1%) received definitive treatment. Surveillance rates remained below 5% in all years. On multivariate analysis, patient age (OR: 1.08, 95% CI 1.08-1.09), smaller tumor size of2 cm vs ≥2 cm (OR: 2.43, 95% CI: 2.20-2.7, P.0001), management at an academic center vs community center (OR: 2.05, 95% CI: 1.83-2.29), and African American vs Caucasian race (OR: 1.56, 95% CI:1.35-1.80) were independently associated with use of AS as initial management.In a representative national cohort of patients with small renal masses, we observed clinical and facility-level differences in the utilization of active surveillance in patients with T1a renal masses. Further investigation is warranted to better understand the forces underlying initial management decisions for patients with small renal masses.

Introduction Increased use of opioids has led to higher rates of overdose and hospital admissions. Studies in trauma populations have focused on outcomes associated with acute intoxications rather than addiction. We hypothesize that clinical outcomes after injury would be inferior for opioid-dependent patients compared to opioid-naive patients. Methods We identified all opioid-dependent adult patients admitted to an academic level I trauma center in 2016 with an Injury Severity Score (ISS) ≥ 5. Patients were further categorized by their pattern of opioid dependency into prescription abuse, illicit abuse, or chronic pain subgroups. Outcome measures included length of stay (LOS), major complications, mortality, non-home discharge, ventilator days, and readmissions. Regression models were adjusted for patient demographics, insurance, ISS, and comorbidities. Results Of the 1450 patients who met the inclusion criteria, 18% were opioid-dependent. Among opioid-dependent patients, 30%, 27%, and 43% were prescription abuse, illicit abuse, and chronic pain patients, respectively. Compared to opioid-naive (non-users) patients, opioid-dependent patients had longer LOS, more ventilator days, more non-home discharges, and higher readmission rates. Subgroup analysis revealed significant differences among all cohorts when compared to non-users in LOS, non-home discharge, readmissions, and major complications. Opioid dependency was not associated with mortality. Conclusion Opioid dependency was detected in 18% of trauma patients and was independently associated with inferior outcomes. The impact of opioid dependency affects each opioid subgroup differently with all cohorts demonstrating increased 30-day readmissions. Opioid dependent patients may be targeted for risk interventions to reduce LOS, non-home discharge, complications and readmissions.

As of March 22, 2020, the number of confirmed COVID-19 cases in the U.S. has reached nearly 30,000. While rapid and accessible diagnosis is paramount to monitoring and reducing the spread of disease, COVID-19 testing capabilities across the U.S. remain constrained. For many individuals, urgent care centers (UCCs) may offer the most accessible avenue to be tested. Through a phone survey, we describe the COVID-19 testing capabilities at UCCs and provide a snapshot highlighting the limited COVID-19 testing capabilities at UCCs in states with the greatest disease burden.

The treatment landscape for metastatic renal cell carcinoma (mRCC) continues to evolve with ongoing advancements in systemic therapy, raising further questions about the optimal role of surgery in the management of mRCC. Herein, we provide a context and review of the recent evidence concerning the role of surgical therapy for patients with mRCC including cytoreductive nephrectomy and distant metastatectomy. One randomized trial has been published in the targeted therapy era suggesting that initial systemic therapy is non-inferior to cytoreductive nephrectomy among patients with intermediate and poor-risk mRCC. Delaying cytoreductive nephrectomy until after systemic therapy may be a viable treatment approach, although a high level of evidence is lacking. Additional questions remain regarding the sequence of surgery with systemic therapy, utility of distant metastatectomy, as well as the application of these findings to the current generation of immunotherapy. Recent evidence challenges the need of upfront cytoreductive nephrectomy for unselected patients with mRCC. However, surgical therapy continues to play an important role in the management of the disease.

Introduction: To provide breast cancer care during the COVID-19 pandemic, many centers shifted toward offering telehealth visits. We sought to determine the availability of telehealth services at Commission on Cancer (CoC)-accredited centers in the United States and factors associated with this virtual accessibility. Methods: Using a secret shopper model from June-September 2020, we contacted 371 CoC-accredited centers providing breast cancer care to determine whether they offered telehealth appointments. We analyzed factors associated with telehealth availability using bivariate and multivariate logistic regression analyses. Results: There were 316 of 371 (85.2%) hospitals that reported having telehealth capacity for breast cancer patients. Facility type (p=0.027), teaching hospital status (p=0.0001), geographic location (p=0.014), and hospital size (based on bed number, p=0.036) were all associated with telemedicine use on bivariate analysis (see table). For-profit vs not-for-profit status and the population base in which a center was located did not affect telehealth availability. On multivariate analysis, controlling for facility type, teaching hospital status and hospital size, only geographic location (p=0.004) was found to be an independent predictor of telehealth access, with centers located in the West being more than 6 times more likely to offer this provision than other regions, including the Northeast (OR:6.38;95% CI:1.27-32.00, p=0.024). Conclusion: While several hospital characteristics, including CoC designation, size, and teaching hospital status affected availability of telehealth visits, significant geographic disparities remained in telehealth provision independent of these factors. As COVID-19 forces medicine to increase its telehealth focus, particular attention should be paid to the geographic variation that may exacerbate access disparities. [Formula presented]

INTRODUCTION AND OBJECTIVES:Young adults are historically the least likely to have health insurance in the United States. We aimed to investigate whether implementation of key provisions of the Aff...

6535 Background: The COVID-19 pandemic has dramatically accelerated the availability of telehealth services for patients with cancer. However, little national cross-sectional data is available to inform potential gaps in access. We aimed to characterize overall access to and trends in telehealth availability for new cancer care patients at hospitals across the United States. Methods: We performed a cross sectional secret-shopper study to evaluate the availability of telehealth services for new patients for three major cancer types—colorectal, breast, and skin cancer—at Commission on Cancer accredited hospitals during the period of April to November 2020. American Hospital Association and Center for Medicare and Medicaid Service databases were queried to determine hospital characteristics. We described hospital variation in access to telehealth services using descriptive statistics. Univariable and multivariable logistic regression were used to identify factors associated with telehealth availability. Results: Of 334 successfully contacted facilities, 248 (74%) offered new patient telehealth services for at least one cancer type. However, access differed by cancer site: telehealth availability for new patients with skin, colorectal, and breast cancer was 47%, 42%, and 38%, respectively. Of the facilities sampled, 47% offered telehealth for one cancer type, 40% for two cancer types, and 14% for all three cancer types. Rates of any telehealth access among the cancer types ranged from 61% at Community Cancer Programs to 100% at NCI Designated Programs. In multivariable logistic regression, facility type was significantly associated with telehealth access while factors such as bed size, ownership, and volume were not significantly associated. Conclusions: Although access to telehealth services for patients with cancer has increased, overall gaps in access remain. Within facility differences in telehealth access imply opportunities to better align services within institutions, though further investigation is warranted as these offerings mature.[Table: see text]

281 Background: We aimed to determine whether insurance expansions implemented through the Patient Protection and Affordable Care Act (ACA) were associated with changes in insurance coverage status, stage at diagnosis, and overall survival for patients with renal cell carcinoma (RCC). Methods: We identified patients 40 to 64 years old diagnosed with RCC between 2010 and 2016 in the National Cancer Database. States were categorized as participating on time in Medicaid expansion or not participating. We stratified patients into advanced cancer (stage III + IV) and localized cancer (stage I + II) groups. We stratified patients into low, middle, and high income groups. Stage trend and insurance trend analysis were performed to based on income status amongst patients living in expansion and non-expansion states. Absolute percentage change (APC) was calculated for insurance status and stage migration. Cox Regression Multivariable Analysis was conducted to assess risk of all-cause mortality (ACM) for patients before and after the implementation of the ACA, adjusting for insurance status, income, education, age, race, ethnicity, comorbidity, and living in an expansion state. Results: We identified 78,099 patients who met inclusion criteria. Following implementation of ACA, APC of patients with insurance increased in both Medicaid and non-expansion states by 4.0% and 2.10% (p

IMPORTANCE: Over the past 2 decades, a variety of new care options have emerged for acute care, including urgent care centers, retail clinics, and telemedicine. Trends in the utilization of these newer care venues and the emergency department (ED) have not been characterized. OBJECTIVE: To describe trends in visits to different acute care venues, including urgent care centers, retail clinics, telemedicine, and EDs, with a focus on visits for treatment of low-acuity conditions. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used deidentified health plan claims data from Aetna, a large, national, commercial health plan, from January 1, 2008, to December 31, 2015, with approximately 20 million insured members per study year. Descriptive analysis was performed for health plan members younger than 65 years. Data analysis was performed from December 28, 2016, to February 20, 2018. MAIN OUTCOMES AND MEASURES: Utilization, inflation-adjusted price, and spending associated with visits for treatment of low-acuity conditions. Low-acuity conditions were identified using diagnosis codes and included acute respiratory infections, urinary tract infections, rashes, and musculoskeletal strains. RESULTS: This study included 20.6 million acute care visits for treatment of low-acuity conditions over the 8-year period. Visits to the ED for the treatment of low-acuity conditions decreased by 36% (from 89 visits per 1000 members in 2008 to 57 visits per 1000 members in 2015), whereas use of non-ED venues increased by 140% (from 54 visits per 1000 members in 2008 to 131 visits per 1000 members in 2015). There was an increase in visits to all non-ED venues: urgent care centers (119% increase, from 47 visits per 1000 members in 2008 to 103 visits per 1000 members in 2015), retail clinics (214% increase, from 7 visits per 1000 members in 2008 to 22 visits per 1000 members in 2015), and telemedicine (from 0 visits in 2008 to 6 visits per 1000 members in 2015). Utilization and spending per person per year for low-acuity conditions had net increases of 31% (from 143 visits per 1000 members in 2008 to 188 visits per 1000 members in 2015) and 14% ($70 per member in 2008 to $80 per member in 2015), respectively. The increase in spending was primarily driven by a 79% increase in price per ED visit for treatment of low-acuity conditions (from $914 per visit in 2008 to $1637 per visit in 2015). CONCLUSIONS AND RELEVANCE: From 2008 to 2015, total acute care utilization for the treatment of low-acuity conditions and associated spending per member increased, and utilization of non-ED acute care venues increased rapidly. These findings suggest that patients are more likely to visit urgent care centers than EDs for the treatment of low-acuity conditions.

This survey study uses data from the Medical Group Management Association’s voluntary physician compensation survey from 2008 to 2017 to examine trends in compensation for primary care and specialist physicians after passage of the Affordable Care Act.

INTRODUCTION AND OBJECTIVE:Urgent care centers (UCC) have rapidly expanded in the United States as a venue for primary and emergency medical services. As UCCs are subject to fewer regulations in th...

Background Outcomes of serial multiparametric magnetic resonance imaging (mpMRI) and subsequent biopsy in monitoring prostate cancer (PCa) in men on active surveillance (AS) have not been defined clearly. Objective To determine whether changes in serial mpMRI can predict pathological upgrade among men with grade group (GG) 1 PCa managed with AS. Design, setting, and participants Retrospective analysis of men with GG1 on AS with at least two consecutive mpMRI examinations during 2012–2018 who underwent mpMRI/ultrasound fusion or systematic biopsies. Outcome measurements and statistical analysis Progression on serial mpMRI was evaluated as a predictor of pathological upgrading to GG ≥ 2 on a follow-up biopsy using clinical, pathological, and imaging factors in binary logistic regression. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were determined. Results and limitations Of 122 patients, 29 men (23.8%) experienced pathological upgrade on the follow-up biopsy. Progression on mpMRI was not associated with pathological upgrade. The sensitivity, specificity, PPV, and NPV of mpMRI progression for predicting pathological upgrade were 41.3%, 54.8%, 22.2%, and 75%, respectively. Age (odds ratio [OR] 1.17, p = 0.006), Prostate Imaging Reporting and Data System (PI-RADS) score on initial mpMRI (4–5 vs ≤3, OR 7.48, p = 0.01), number of positive systematic cores (OR 1.84, p = 0.03), number of positive targeted cores (OR 0.44, p = 0.04), and maximum percent of targeted core tumor involvement (OR 1.04, p = 0.01) were significantly associated with pathological upgrade. Conclusions We did not observe an association between mpMRI progression and pathological upgrade; however, a PI-RADS score of 4–5 on initial mpMRI was predictive of subsequent pathological progression. The continued use of systematic and fusion biopsies appears necessary due to risks of reclassification over time. Patient summary Progression on serial multiparametric magnetic resonance imaging during active surveillance (AS) is not associated with progression on the follow-up biopsy. Both systematic and fusion biopsies are necessary to sufficiently capture progression during AS.

Background The expansion of Medicaid under the Affordable Care Act extended coverage to any individual with an income up to 138% of the federal poverty level. Our study of surgeon practice management investigated the impact of the type of insurance on access to elective inguinal hernia repair and the disparities in access between Medicaid expansion and nonexpansion states. Methods Practices of 240 hernia repair surgeons across 8 states were randomly selected from the American College of Surgeons Find a Surgeon Database. Investigators posed as simulated patients seeking an evaluation for an inguinal hernia. Physician offices were contacted using a standardized script on separate occasions to assess appointment success rates and waiting periods for 3 different insurance types (BlueCross, Medicaid, Medicare). Results Of 240 surgical practices contacted, 75.4% scheduled appointments for Medicaid patients, compared to 98.8% for Medicare patients and 98.3% for those with private insurance. In states that expanded Medicaid, fewer offices accepted Medicaid patients compared to those in nonexpanded states. No differences in wait times between expanded and nonexpanded states were observed. Surgeons in either solo practices or urban settings were less likely to accept Medicaid patients than those in either group practices or non-urban offices. Conclusions Simulated Medicaid patients were less successful at scheduling appointments for surgical consultation than BlueCross or Medicare patients. Fewer surgical practices in expansion states accepted Medicaid patients despite increased coverage due to Medicaid expansion. These findings should be further investigated amidst future changes in Medicaid to understand their impact on access to surgical care.

Kidney masses suspicious for malignancy are frequently detected by cross-sectional imaging; however, little is known about the burden of surgical treatment for tumors found to be benign following excision.We queried the National Inpatient Sample to identify records of individuals who received surgical treatment for renal neoplasms between 2004 and 2014. We characterized temporal treatment trends, patient demographics, treatment related complications, and charges.We identified 7,099 (8.5%) and 76,892 (91.5%) patients who were treated for benign and malignant tumors, respectively. Benign masses accounted for 14.8% of partial and 5.5% of radical nephrectomies. The rates of surgery for benign tumors have remained steady (P = 0.058). The frequency of inpatient death was higher in those with malignant disease (0.63% vs. 0.18%, P0.0001). Median length of stay was longer for individuals with malignant renal tumors (4.86 vs. 4.12 days, P0.0001). The total discharge bill adjusting for inflation for benign or malignant renal surgery increased each year (R8.5% of inpatient renal surgical admissions are performed for benign masses. There has been a trend toward decreased operative management for benign renal tumors over time. Surgical management remains a significant economic burden. Efforts to prospectively evaluate modalities for pretreatment identification should be further pursued.

Medicaid patients are known to have reduced access to care compared with privately insured patients; however, quantifying this disparity with large controlled studies remains a challenge. This meta-analysis evaluates the disparity in health services accessibility of appointments between Medicaid and privately insured patients through audit studies of health care appointments and schedules. Audit studies evaluating different types of outpatient physician practices were selected. Studies were categorized based on the characteristics of the simulated patient scenario. The relative risk of appointment availability was calculated for all different types of audit scenario characteristics. As a secondary analysis, appointment availability was compared pre- versus post-Medicaid expansion. Overall, 34 audit studies were identified, which demonstrated that Medicaid insurance is associated with a 1.6-fold lower likelihood in successfully scheduling a primary care appointment and a 3.3-fold lower likelihood in successfully scheduling a specialty appointment when compared with private insurance. In this first meta-analysis comparing appointment availability between Medicaid and privately insured patients, we demonstrate Medicaid patients have greater difficulty obtaining appointments compared with privately insured patients across a variety of medical scenarios.

144 Background: The National Comprehensive Cancer Network (NCCN) risk classification scheme for prostate cancer (PCa) encompasses several definitions and has been shown to contain significant heterogeneity. Because patients possessing a single intermediate-risk (IR) feature may be regarded as ineligible for active surveillance (AS), we aimed to compare pathologic and early oncologic outcomes between those with low-risk (LR) and IR features based on the number of criteria met. Methods: We queried the National Cancer Database (NCDB) to identify men with NCCN LR (cT1-T2a, prostate-specific antigen [PSA] < 10 ng/mL, and Gleason score (GS)≤6) and IR PCa diagnosed from 2010-2014 who were treated with radical prostatectomy (RP). Patients with IR PCa were stratified based on a single factor: clinical stage (cT2b-T2c), PSA (10-20 ng/mL), GS 3+4, or GS 4+3 alone. The pathologic outcomes including any Gleason upgrade, and adverse pathology (primary Gleason 4 or ≥pT3 at RP), and receipt of adjuvant radiation therapy (RT) were compared between the LR and IR groups. Odds ratios for pathologic outcomes and receipt of adjuvant RT were computed using logistic regression analyses. Results: Of 181,847 men treated with RP, we identified 30.7% and 37.1% with LR and IR PCa, respectively. Of 67,623 with IR PCa, 4,075 (6%) were due to clinical stage alone, 5,004 (7.4%) by PSA, 43,409 (64.2%) by GS 3+4, and 15,135 (22.4%) by GS 4+3. Patients meeting IR by clinical stage alone had similar risks of adverse pathology as LR patients (OR 1.03, 95%CI 0.94-1.13, p = 0.49). In contrast, those meeting IR by PSA alone had higher risks of adverse pathology compared with LR individuals (OR 2.20, 95%CI 2.05-2.36, p < 0.001). Moreover, receipt of adjuvant RT was similar among LR and IR patients by clinical stage alone (p = 0.62), and higher among patients meeting IR by PSA alone (OR 2.99, 95% CI 2.43-3.69, p < 0.001). Conclusions: Based on national cancer registry data, early outcomes among men meeting the NCCN IR definition for PCa are heterogeneous. IR patients by clinical stage alone had similar rates of adverse pathology as did LR group. Broadened eligibility for AS should be considered to include those meeting favorable IR definitions.

694 Background: Active surveillance (AS) has been increasingly recognized as a viable management strategy for patients with small renal masses (SRM). To better understand the contemporary management landscape of SRMs we examined practice patterns in a nationally representative cancer database. Methods: We identified patients with clinical T1a renal masses within the National Cancer Database (NCDB) between 2010 to 2014. Patients were classified according to initial management received including AS, surgery, ablation, or other treatment. We characterized time trends in the use of surveillance versus definitive therapy and examined clinical and socio-demographic determinants of AS among patients with small renal masses using multivariate logistic regression models. Results: We identified 59,189 patients who satisfied the inclusion criteria. Of the total cohort, 1,733 (2.9%) individuals received initial management with AS, while 57,456 (97.1%) received definitive treatment. There was a slight increase in initial management with surveillance however rates remained less than 5% in all years. On multivariate analysis, patient age (OR: 1.08, 95% CI 1.08-1.09), treatment at an academic center vs. community center (OR: 2.05, 95% CI: 1.83-2.29), and African American vs. Caucasian race (OR: 1.56, 95% CI:1.35-1.80) were independently associated with use of active surveillance. Moreover, regional-level differences were observed with the highest utilization of AS in the West North Central census division. Conclusions: Based on cancer registry data, national utilization of AS for SRMs remains very low, and we observed clinical and facility-level differences. Further investigation is warranted to better understand the factors underlying management for patients with SRMs.

111 Background: The optimal management approach for patients with positive surgical margins (PSM) at radical prostatectomy (RP) has not been definitively assessed. To better understand contemporary patterns of care, we sought to examine time trends and determinants of adjuvant therapy in a large national sample of men with prostate cancer (PCa) treated with RP. Methods: We queried the National Cancer Database (NCDB) to identify men with clinically-localized PCa diagnosed from 2010 to 2014 who had PSM at RP performed as initial primary definitive treatment. We used descriptive statistics to examine subsequent management strategies, assessed as no adjuvant therapy as part of the initial planned course of management, receipt of adjuvant radiation therapy (RT), and receipt of adjuvant RT in combination with androgen deprivation therapy (ADT). Binary logistic regression models were constructed to identify patient, tumor, and facility features associated with receipt of adjuvant therapy. Results: During the study period, we identified 44,523 patients with PSM. Of those, 5,179 (11.6%) men received any adjuvant RT (+/- ADT), while only 1,380 (3%) received adjuvant RT with ADT. Use of adjuvant RT did not change over the study period ( p= 0.61). On multivariable analysis men of uninsured status (p = 0.003), Medicaid insurance (p = 0.001), and patients treated in non-academic facilities (p < 0.001) were more likely to receive adjuvant RT. In addition, use of adjuvant RT was associated with higher pre-treatment PSA (p < 0.001), pathologic stage (p < 0.001) and Gleason grade group (p < 0.001), decreasing distance from the treatment center (p < 0.001), and shorter duration between diagnosis and RP (p < 0.001). Receipt of adjuvant ADT with RT was associated with clinical and pathologic features; however, not with sociodemographic factors. Conclusions: The majority of patients experiencing PSM at RP did not receive adjuvant RT, and rates of adjuvant therapy have remained stable over time. In addition to adverse clinical and pathologic features, sociodemographic and facility factors were significantly associated with receipt of adjuvant RT; however, the addition of ADT appears largely driven by disease characteristics.

114 Background: The utility of serial magnetic resonance imaging (MRI)/ultrasound (US) fusion targeted prostate biopsy in men with prostate cancer (PCa) on active surveillance (AS) have not been clearly defined. We sought to investigate the rate of Gleason upgrading both on sequential fusion targeted and systematic biopsies among men with low-risk PCa managed with AS. Methods: We retrospectively queried an institutional database of 800 patients undergoing MRI/US fusion biopsy to identify 209 patients on AS with at least two fusion biopsies between December 2013 and November 2016. Men with National Comprehensive Cancer Network (NCCN) very low-risk and low-risk criteria were included. Gleason upgrade was defined as detection of Gleason score >=3+4. The proportion of patients experiencing upgrade on systematic, fusion, or both biopsy techniques was tabulated. Associations of clinical, pathologic, and imaging factors with biopsy upgrade were analyzed by logistic regression. Results: Of 209 patients undergoing MRI/US fusion biopsy, 73 (35.0%) had at least two targeted biopsies (66% very low-risk and 34% low-risk PCa). The time between biopsies was 12.6 months (11.2-17.7). The median PSA and PSA density were 5.4 ng/mL (4.2-7.1) and 0.11 ng/mL/mL (0.07-0.18), respectively. 21 (29%) patients experienced Gleason upgrade on subsequent biopsy. Of those, 6 (8%), 5 (7%), and 10 (14%) had upgrade on systematic biopsy only, fusion biopsy only, and both systematic and fusion biopsy, respectively. Patients with upgrade on subsequent biopsy had higher PSA (p=0.02) and PSA density (p=0.02), and were among low-risk disease population (p=0.03). In logistic regression models, greater number of positive cores in systematic biopsy (OR 1.88; 95% CI 1.23-2.92; p=0.005) was associated with the total Gleason upgrade on repeated biopsy. Conclusions: In men with favorable risk prostate cancer managed with AS, Gleason upgrade was detected in a 29% of patients on a second MRI/US fusion biopsy including both targeted and systematic regions. These findings support the continued use of both MRI fusion and systematic biopsy during surveillance due to risks of reclassification over time.