The delivery of prostate cancer care in the United States: implications for delivery system reform.

Purpose: Since health care in the United States is fragmented and expensive, 1 reform option focuses on improving care coordination as in the medical home model. To better understand care coordination in the context of prostate cancer we examined how the delivery of prostate cancer care is partitioned across primary care providers and specialists.

Materials And Methods: We identified 105,961 patients diagnosed with prostate cancer between 1992 and 2005 using Surveillance, Epidemiology and End Results-Medicare data.

Robotic surgery in urologic oncology: gathering the evidence.

In less than a decade, the widespread application of robotic technology to the field of urologic oncology has permanently altered the way urologists approach malignancy. The short-term benefits of minimally invasive surgery using robotic assistance (i.e.

Does robotic technology mitigate the challenges of large prostate size?

Objectives: For radical prostatectomy, the advantages of robotic surgery may facilitate precise dissection and improve functional outcomes. However, patients with larger prostates may still pose increased challenges because of impaired visualization and mobility in the pelvis. For this reason, we undertook a study to better understand the relationships between large prostate size and robotic prostatectomy outcomes with respect to intraoperative and pathologic factors.

Ambulatory surgery center market share and rates of outpatient surgery in the elderly.

Relative to outpatient surgery in hospital settings, ambulatory surgery centers (ASCs) are more efficient and associated with a lower cost per case. However, these facilities may also spur higher overall procedure utilization and thus lead to greater overall health care costs. The authors used the State Ambulatory Surgery Database from the State of Florida to identify Medicare-aged patients undergoing 4 common ambulatory procedures in 2006, including knee arthroscopy, cystoscopy, cataract removal, and colonoscopy.

Delays in diagnosis and bladder cancer mortality.

Background: Mortality from invasive bladder cancer is common, even with high-quality care. Thus, the best opportunities to improve outcomes may precede the diagnosis. Although screening currently is not recommended, better medical care of patients who are at risk (ie, those with hematuria) has the potential to improve outcomes.

Opening ambulatory surgery centers and stone surgery rates in health care markets.

Purpose: Ambulatory surgery centers deliver surgical care more efficiently than hospitals but may increase overall procedure use and adversely affect competing hospitals. Motivated by these concerns we evaluated how opening of an ambulatory surgery center impacts stone surgery use in a health care market and assessed the effect of its opening on the patient mix at nearby hospitals.

Materials And Methods: In a 100% sample of outpatient surgery from Florida we measured annual stone surgery use between 1998 and 2006.

The economic burden of prostate cancer survivorship care.

Purpose: Most men live with rather than die of prostate cancer. As a result, survivors have a protracted course, harboring considerable clinical and economic implications. Thus, we investigated the extent to which health service use and expenditures vary during continuing prostate cancer care.

Understanding the variation in treatment intensity among patients with early stage bladder cancer.

Background: Given the uncertainty surrounding the optimal management for early stage bladder cancer, physicians vary in how they approach the disease. The authors of this report linked cancer registry data with medical claims to identify the sources of variation and opportunities for improving the value of cancer care.

Methods: By using data from the Surveillance, Epidemiology, and End Results-Medicare database (1992-2005), patients with early stage bladder cancer were abstracted (n=18,276).

Regional differences in early stage bladder cancer care and outcomes.

Objectives: In part because of its protracted natural history, bladder cancer is among the most expensive malignancies from diagnosis to death. In light of the uncertainty surrounding the optimal care, we evaluated regional differences in initial treatment intensity and outcomes among patients with early stage (ie, superficial) bladder cancer.

Methods: We identified 20,328 patients diagnosed with early stage bladder cancer between 1992 and 2002 using SEER-Medicare data.

Physician-ownership of ambulatory surgery centers linked to higher volume of surgeries.

Many physicians confronting declining reimbursement from insurers have invested in ambulatory surgery centers, where they perform outpatient surgical and diagnostic procedures. An ownership stake entitles physicians to a share of the facility's profits from self-referrals. This arrangement can create a potential conflict of interest between physicians' financial incentives and patients' clinical needs.

Patterns of care for early stage bladder cancer.

Background: Early stage bladder cancer is a heterogeneous disease with a variable risk of progression and mortality. Uncertainty surrounding the optimal care for these patients may result in a mismatch between disease risk and treatment intensity.

Methods: Using Surveillance, Epidemiology, End Results-Medicare data, we identified patients diagnosed with early stage bladder cancer (n = 24,980) between 1993 and 2002.

Development and validation of the Bladder Cancer Index: a comprehensive, disease specific measure of health related quality of life in patients with localized bladder cancer.

Purpose: We developed and validated a reliable, responsive multidimensional instrument to measure disease specific health related quality of life in bladder cancer survivors treated with local cancer therapy.

Materials And Methods: Instrument content was based on qualitative information obtained from a panel of bladder cancer providers and from patient focus groups. Draft items were piloted and revised, resulting in the 36-item Bladder Cancer Index consisting of urinary, bowel and sexual health domains.

Androgen ablation augments human HLA2.1-restricted T cell responses to PSA self-antigen in transgenic mice.

Background: In recent years, there has been an increasing interest in targeting human prostate tumor-associated antigens (TAAs) for prostate cancer immunotherapy as an alternative to other therapeutic modalities. However, immunologic tolerance to TAA poses a significant obstacle to effective, TAA-targeted immunotherapy. We sought to investigate whether androgen deprivation would result in circumventing immune tolerance to prostate TAA by impacting CD8 cell responses.

Robot-assisted salvage prostatectomy: evaluation of initial patient-reported outcomes.

Background And Purpose: For patients who experience a localized recurrence after definitive radiation therapy for prostate cancer, salvage prostatectomy provides a chance for cure. We sought to assess whether robot assistance would decrease the technical challenges and mitigate the considerable morbidity associated with the procedure.

Patients And Methods: Using institutional data, we identified six patients who underwent robot-assisted prostatectomy after definitive radiation therapy.

Racial differences in treatment and outcomes among patients with early stage bladder cancer.

Background: Black patients are at greater of risk of death from bladder cancer than white patients. Potential explanations for this disparity include a more aggressive phenotype and delays in diagnosis resulting in higher stage disease. Alternatively, black patients may receive a lower quality of care, which may explain this difference.

Changes in gender distribution of urinary stone disease.

Objectives: To explore using population-based data the extent to which gender-specific rates of stone disease are changing. Historically, stone disease has been more common among men than women. However, differential changes in dietary intake patterns, fluid intake, and obesity in men and women may cause shifts in stone disease incidence and prevalence.

Trends in medical expulsive therapy use for urinary stone disease in U.S. emergency departments.

Objectives: Between 2000 and 2006, 11 randomized controlled trials were published, demonstrating the efficacy of medical expulsive therapy (MET) for promoting upper tract stone passage. Although its use is gaining traction among urologists, they evaluate a minority of patients who present to the emergency department (ED) for acute renal colic before discharge. As such, measuring the uptake of MET into the broader medical community is important.

Differences in initial benign prostatic hyperplasia management between primary care physicians and urologists.

Purpose: The introduction of efficacious pharmacotherapies has effectively transformed benign prostatic hyperplasia into a chronic disease that requires ongoing medical care. With this transformation primary care physicians have become more involved in the management of benign prostatic hyperplasia. The impact of the increasing role of the primary care physician on the use of benign prostatic hyperplasia related health services remains unknown.

Patient-reported recovery after abdominal and pelvic surgery using the Convalescence and Recovery Evaluation (CARE): implications for measuring the impact of surgical processes of care and innovation.

Background: Recovery is an integral part of the surgical process and measuring it provides insight into the impact of surgical innovation. This study used a recently validated instrument, the Convalescence and Recovery Evaluation (CARE), to measure return to baseline health after surgery and explore clinical factors associated with recovery.

Study Design: Patient health was measured among 96 patients before and after abdominal and pelvic surgery.

Disparities in the use of ambulatory surgical centers: a cross sectional study.

Background: Ambulatory surgical centers (ASCs) provide outpatient surgical services more efficiently than hospital outpatient departments, benefiting patients through lower co-payments and other expenses. We studied the influence of socioeconomic status and race on use of ASCs.

Methods: From the 2005 State Ambulatory Surgery Database for Florida, a cohort of discharges for urologic, ophthalmologic, gastrointestinal, and orthopedic procedures was created.

Changing practice locations for upper urinary tract stone disease.

Purpose: Complex surgical procedures are migrating out of hospitals and into ambulatory surgery centers. We evaluated the extent to which surgery for urolithiasis could be a candidate for such migration.

Materials And Methods: Patients undergoing stone surgery in Florida (107,417) between 1998 and 2004 were included in the study.

Understanding the relationship between health care quality and the renal mass.

Quality is increasingly important to all stakeholders of the U.S. health care system.

Urologist ownership of ambulatory surgery centers and urinary stone surgery use.

Objectives: To understand how physician ownership of ambulatory surgery centers (ASCs) relates to surgery use.

Data Source: Using the State Ambulatory Surgery Databases, we identified patients undergoing outpatient surgery for urinary stone disease in Florida (1998-2002).

Study Design: We empirically derived a measure of physician ownership and externally validated it through public data.