In this article, members of the Urology Times editorial advisory board weigh in on the themes and specific sessions that annual meeting attendees should watch for across a variety of health policy and clinical topics.
Cost. Quality. Value. These terms are not new to urologists, but at this year’s AUA annual meeting in Boston, the degree that these buzzwords permeate the meeting program is unprecedented.
Of course, the emphasis on value-based care is no accident. It is what drives physician reimbursement under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which rewards providers for better value through the Quality Payment Program. (Also see, “MACRA: A practical perspective for urologists")
“In contrast to years past, when there was an effort to divide cost and quality of care issues from the science of urology, this year’s meeting emphasizes many aspects of health policy impact across all elements of urologic care delivery and across all formats of the program: plenary sessions, moderated posters, instructional courses, and specific forums,” said Jeffrey E. Kaufman, MD, a urologist in private practice in Orange County, CA. “It’s a reflection of how important considerations of value, cost, and quality have become that they’re integrated into everything we do.”
Dr. Kaufman and other members of the Urology Times editorial advisory board weighed in on the themes and specific sessions that annual meeting attendees should watch for across a variety of health policy and clinical topics. Their insights follow.
Dr. KaufmanReviewing the wealth of presentations on health policy issues at this year’s meeting “is like giving an overview of the entire meeting agenda,” Dr. Kaufman said. “Issues ranging from quality metrics, cost considerations, outcomes, enhancing practice efficiency, coding and reimbursement, integrated use of APNs/PAs in practice, contracting, medicolegal concerns-even a discussion on enhancing creativity and developing intuitive abilities-are integrated into the program.”
Of special interest, he said, are the Practice Management Course (separate registration required) that takes place Thursday and Friday at the Hilton Boston Logan Airport Hotel and several courses related to advanced practice nurses and physician assistants, including instructional courses on how best to integrate these providers into your practice. Other popular courses, reprised from prior years, include those on contract negotiation and an update on coding and reimbursement.
“Several moderated posters address the increasing use of PAs in urologic surgery, use of scribes to facilitate EHR use, and quality of life and shared decision-making practices, in addition to others on value of care,” Dr. Kaufman said. “For those who feel the presentations can be overwhelming, there is even a discussion of international urologist burnout.”
Dr. WolfNew findings about telemedicine, urologists’ role in quality improvement efforts, and the success (or lack thereof) of quality reporting programs are key topics to watch for in the poster and podium sessions on General Epidemiologic Trends/Value, Quality Improvement and Patient Safety, according to J. Stuart Wolf, MD, professor of urology at The Dell Medical School at the University of Texas, Austin.
Regarding these themes, Dr. Wolf said: “Telehealth, which is becoming increasingly supported at the regulatory level, has great potential to improve the cost-effectiveness of health care. Systematically engaging urologists in quality improvement efforts aimed at reducing cost and/or improving processes of care has demonstrated positive effects. Some federal quality reporting programs are effective and some are not.”
Specific abstracts will examine the cost-effectiveness of telehealth in the evaluation of hematuria, patients’ opinion of the United Kingdom’s “Consultant Outcome Publication” regarding individual surgeons’ outcomes, the relationship between the Centers for Medicare & Medicaid Services’ new Hospital Compare ranking system and outcomes after major urologic cancer surgery, whether individualized physician feedback improves adherence to a value-based care pathway, and the effect of the Hospital Readmission Reduction Program on targeted and non-targeted surgical conditions.
Here are the abstracts to watch for in this area, according to Dr. Wolf:
MP32-19: Cost analysis for initial evaluation of hematuria: impact of tele-urology clinics
MP96-13: Consultant outcome publication: patients’ opinions of a new mandatory health policy
PD14-02: Centers for Medicare and Medicaid Services' (CMS) hospital compare star rankings and short-term outcomes after major urological cancer surgery
Deborah R. Kaye
PD32-10: Data feedback affords modest effect in driving physician behavior toward value-based care for BPH surgery
Alan L. Kaplan
PD32-12: Understanding the effect of the hospital readmission reduction program on surgical readmissions
Dr. AlbertsenThree-year functional outcomes after commonly used treatments for localized prostate cancer, antimuscarinic use in the elderly, and a financial analysis of scribe use in ambulatory urologic practice are among the top papers in the “General & Epidemiologic Trends & Socieoconomics: Practice Patterns, Quality of Life and Shared Decision Making” portion of the program. That is the assessment of Peter C. Albertsen, MD, chief of urology at the University of Connecticut Health Center, Farmington.
These are the abstracts Dr. Albertsen says to watch for at this year's meeting:
PD09-03: Three-year functional outcomes after radiation, surgery or observation for localized prostate cancer in the CEASAR study
MP69-01: Antimuscarinic use in the elderly: A poisoned apple?
MP76-01: Sharp decrease in prostate biopsy incidence with wide geographic variation following task force prostate cancer screening recommendations
MP76-02: Urologist practice affiliation and intensity modulated radiation therapy for prostate cancer
MP76-13: Scribes in ambulatory urologic practice: financial analysis and practice management considerations
PD09-06: Can a simple count of several common comorbidities accurately predict long-term, other cause mortality in men with prostate cancer?
Dr. LoebDevelopments in markers for prostate cancer and active surveillance for men with low-risk disease continue to be major topics at the AUA annual meeting, says Stacy Loeb MD, MSc, assistant professor of urology and population health at New York University Langone and the Manhattan VA, New York.
“Several new serum and urine markers are being presented for use in prostate cancer diagnosis and prognostication. For men with prostate cancer, multiple studies look at the use of genomic tissue tests (eg, Prolaris, Oncotype Dx, and Decipher) to improve patient selection for upfront treatment versus active surveillance, or for decisions about secondary therapy,” she said.
Other major biomarker-related themes are the utility of commercially available markers in African-American men, the incremental value of marker tests in the context of multiparametric MRI, and the role of markers in advanced disease.
While active surveillance is now the recommended management option for most men with low-risk prostate cancer, some studies suggest that it remains underutilized in the United States, Dr. Loeb pointed out.
“Correspondingly, several studies attempt to define potential barriers to surveillance among health care providers and patients, such as the risk of prostate biopsy complications,” she said. “For men who choose active surveillance, look out for numerous studies on the role of MRI during follow-up and what is the optimal biopsy protocol to use.”
Specifically, Dr. Loeb pointed to these abstracts in the area of prostate cancer markers/surveillance:
MP28-11: Impact of the 17-gene panel on active surveillance persistence in contemporary urologic practices: An interim analysis in an observational cohort
PD28-03: Correlation between a genomics test and adverse pathology after radical prostatectomy among active surveillance candidates
MP43-03: Do prostate biopsy-associated complications influence treatment selection for patients with newly diagnosed, clinically localized prostate cancer?
MP43-20: Rates of non-definitive management for low and intermediate risk prostate cancer are similar between African Americans and Caucasians
PD71-01: Decipher test impacts decision-making among patients considering adjuvant and salvage treatment following radical prostatectomy: interim results from the multicenter prospective pro-impact study
John L. Gore
PD28-06: Variation in the use of active surveillance for low-risk prostate cancer
PD28-07: Tracking of prior positive sites by mri/us fusion improves detection of gleason score upgrading
PD28-09: Does MRI-fusion prostate biopsy improve risk reclassification for patients with prostate cancer on active surveillance compared to transrectal ultrasound-guided saturation biopsy
Ahmed El Shafei
Dr. GomellaHow MRI use affects management of localized prostate cancer and the nuances of focal therapy are two of the hot topics in localized prostate cancer at this year’s meeting, according to Leonard G. Gomella, MD, professor and chairman of urology at Thomas Jefferson University, Philadelphia.
“The robot frenzy seems to be dying down and the interest in focal therapy seems to be the flavor of this year’s group of AUA papers,” Dr. Gomella said.
Here are Dr. Gomella's abstract picks in localized prostate cancer treatment:
MP47-10: MRI use alters prostate cancer management patterns: Treatment trends in the image-guided biopsy era.
Joseph A. Baiocco
MP70-03: Clinical performance of multi parametric magnetic resonance imaging in the follow-up of partial gland ablation for prostate cancer
MP70-05: Defining the index lesion for salvage partial gland ablation after radiation therapy for localized prostate cancer
MP70-06: Predicting oncological control following focal ablation (FA) of prostate cancer (PCa)
MP70-10: New approach to focal therapy of localized prostate cancer with “fusion” integrated path and high intensity focused ultrasound (HIFU): Initial experience
MP70-12: Predicting extensive disease among potential candidates for hemi-ablative focal therapy for prostate cancer
MP93-16: Impact of obesity on prostate cancer recurrence after radical prostatectomy
MP93-19: Prostate MRI prior to prostatectomy does not impact surgical outcomes
PD10-09: Effect of dehydrated human amnion/chorion membrane allograft on urinary continence following robot-assisted radical prostatectomy
PD51-11: Pathological findings at radical prostatectomy after initial active surveillance in low-risk prostate cancer patients. Did we miss the chance to cure?
Dr. ThrasherJ. Brantley Thrasher, MD, pointed out several high-interest abstracts related to advanced prostate cancer treatment and prognosis, including a study comparing the time period from initiation of androgen deprivation therapy (ADT) to salvage chemotherapy in African American and Caucasian men with castrate-resistant disease, an investigation of metformin’s effect on survival in men receiving ADT, and multiple studies on whether the addition of radical prostatectomy to surgical castration improves survival in node-positive patients.
“Attendees will see a number of abstracts reviewing serum testosterone levels prior to and after ADT and the prognostic implications of these levels on patients with advanced disease,” said Dr. Thrasher, professor of urology at the University of Kansas Medical Center, Kansas City. “Also, several abstracts outline the use of radical surgery locally or at distant metastatic sites as an adjunct and the long-term oncologic outcomes. Multiple abstracts address the impact of ADT on multiple metabolic markers and medications that may affect the metabolic changes.”
Here are Dr. Thrasher's abstract picks in advanced prostate cancer:
MP53-04: Comparison of the length of time from initiation of androgen deprivation therapy to salvage chemotherapy in African American males and Caucasian males with castrate resistant prostate cancer
MP53-08: Metformin use is associated with improved survival in veterans with advanced prostate cancer on androgen deprivation therapy
MP53-16: Long-term oncologic outcomes of adding radical prostatectomy to castration for pathological node-positive prostate cancer
MP53-17: Current management of prostate cancer with node-positive disease after radical prostatectomy and its impact on overall survival
MP53-18: Efficacy of local treatment in prostate cancer patients with clinically pelvic lymph node-positive disease at initial diagnosis
PD24-06: Trends in management of bone health in men with metastatic prostate cancer: Analysis from the Surveillance, Epidemiology, and End Results Medicare database
William R. Boysen
PD37-04: Statins and oral treatments in patients with metastatic castration resistant prostate cancer (mCRPC): Real-world outcomes
Dr. MatlagaThree major themes emerge from the meeting’s sessions on surgical treatment of stone disease: the role of single-use ureteroscopes, hospital readmissions after stone surgery, and stone-free rate-as defined by computed tomography-after ureteroscopy. So says Brian R. Matlaga, MD, MPH, professor of urology at the Johns Hopkins University School of Medicine in Baltimore.
“Although single-use ureteroscopes have been around for some time, the recent introduction of a digital single-use ureteroscope has generated great interest in defining the role of these devices in clinical practice,” Dr. Matlaga said. “The podium and poster sessions at this year’s meeting will feature studies that will provide a better understanding of how these devices may fit into a urology practice.
“There are multiple studies which will nicely detail the clinical efficacy of these devices, characterizing how they may function in the surgical environment, he said, adding that other studies will provide an important understanding of how the cost of a single-use endoscope will affect the economics of a ureteroscopic procedure.
“The present health care environment is placing an increasing emphasis on the postoperative experience, particularly with regard to emergency department utilization and hospital readmission, following ureteroscopy,” Dr. Matlaga pointed out. “The annual meeting program has several studies which utilize large-scale datasets to provide better context for this increasingly important metric.”
In addition, studies will discuss stone-free rate, one of the primary criteria for treatment success with ureteroscopy.
“The published literature has great heterogeneity in the way in which stone-free is defined,” Dr. Matlaga said. “At the annual meeting, two centers will report on their stone-free outcome following ureteroscopic stone treatment. The unique nature of these studies is twofold: meticulous attention was paid to complete stone fragment extraction, and the stone-free outcome was rigorously defined with CT imaging.”
Specifically, these are the stone disease abstracts to take note of at this year's meeting, according to Dr. Matlaga:
MP50-07: Comparison of parameters of standard reusable flexible uretero-renoscopes with a single use uretero-renoscope (Lithovue)
MP50-08: Limitations of the Lithovue single use digital flexible ureteroscope
MP50-16: Initial clinical experience with a single-use digital flexible ureteroscope
PD35-10: A prospective case cohort study demonstrates that Lithovue, a single-use flexible disposable ureteroscope, reduces operative time
PD35-11: New digital single-use flexible ureteroscope (Pusen): first clinical experience
José A. Salvadó
MP75-02: Predictors of ED visits following ureteroscopy
MP75-03: Unplanned 30-day encounters after uretero-renoscopy for urolithiasis
MP75-12: Prospective evaluation of stone free rates by computed tomography after aggressive ureteroscopy
PD21-09: True stone free rates of flexible ureteroscopy for renal calculi utilizing strict CT criteria
Nadya E. York
Dr. Kaplan“This year’s abstracts in BPH are notable for examination of large databases in the use of both medical and surgical therapy for BPH,” said Steven A. Kaplan, MD, professor of urology, Icahn School of Medicine at Mount Sinai, New York. “There will be many presentations on the long-term use of laser and electrosurgical therapy. Updates on minimally invasive surgical alternatives including Rezum, UroLift, and Aquablation will be presented.
“Finally,” Dr. Kaplan said, “long-term data and adverse events of medical therapies for BPH as well as their predictive role in surgical therapy will be presented.”
Below are the BPH/LUTS abstracts to watch for at this year's meeting:
MP02-18: Trends in minimally invasive simple prostatectomy for benign prostatic enlargement in the United States
MP09-10: Tamsulosin prescribing patterns based on a united states health plan claims database
MP09-17: 5-alpha reductase inhibitors for treatment of benign prostatic hyperplasia does not increase the risk of erectile dysfunction
PD23-11: Aquablation of the prostate for symptomatic benign prostatic hyperplasia: Two-year results
PD27-02: Comparison of convective radiofrequency water vapor energy ablation of prostate (Rezum) to MTOPS trial cohort
PD27-11: Comparative effectiveness of transurethral resection techniques for benign prostatic hyperplasia – Analysis of an all payer inpatient discharge database
Christian P. Meyer
Dr. BurnettIn reviewing the abstracts on sexual dysfunction, Arthur L. Burnett, II, MD, MBA, said several exciting presentations will be delivered on a range of sexual medicine topics.
“Penile prosthetics remain an area of focus,” said Dr. Burnett, professor of urology at Johns Hopkins University, Baltimore. “Highlights include presentations on: patient and disease risk factors as well as clinical practice trends that impact surgical outcomes; biomechanical properties and performance characteristics of prosthetic devices; and new prosthetic materials and design features as well as innovative surgical techniques.”
Male hypogonadism also continues to be a major area of interest, Dr. Burnett noted. “Presentations of particular interest center on: long-term studies and registry data pertaining to the indications, safety, and efficacy of testosterone therapy; and clinical and genetic associations for testosterone deficiency,” he said.
“Peyronie’s disease is a major condition with presentation highlights to include: studies on natural history and patient clinical characteristics and analyses of protocols and trends in utilization of surgery and intralesional collagenase clostridium histolyticum (XIAFLEX) therapy.”
Here are Dr. Burnett's abstract selections in sexual dysfunction:
MP25-04: Cost-effectiveness of ipp versus injection treatment in patients who fail oral medication
MP25-14: Surgery for infected penile prostheses in new york state: practice patterns, outcomes and impact of surgeon factors
Michael J. Lipsky
PD22-07: Subtunical versus conventional penile prosthesis implantation a prospective randomized study
PD22-11: A cut-off HbA1c value of 8.5% predicts increased risk of penile implant infection
MP56-10: National trends in utilization of penile prosthesis surgery in the treatment of Peyronie′s disease
MP91-13: The association between testosterone and vitality: the role of genetic variation in the androgen receptor
Dr. KoganStudies on various aspects of vesicoureteral reflux, circumcision’s effect on urinary tract infection in patients with hydronephrosis, an inguinal approach to ureteral reimplantation, and testing for adolescent varicocele are among the top abstracts in pediatrics this year, according to Barry A. Kogan, MD.
“Urinary tract infection and reflux continue to me topics of major interest in pediatric urology,” said Dr. Kogan, chief of urology at Albany Medical College, Albany, NY. “This is despite the fact that most clinicians feel reflux is not as significant a problem as we felt years ago. Clearly the biggest challenge is ‘risk assessment.’ We all want to limit workup and treatment to those of highest risk, and that is the subject of a number of abstracts.
“Testicular problems are also high on the list of interesting topics,” Dr. Kogan said. “This is particularly true for the topic of adolescent varicocele. We are still very anxious to find a test that will help determine who would benefit from early repair. Several abstracts help us to evaluate this question.”
Here are the abstracts Dr. Kogan says to watch for at this year's meeting:
MP61-11: A reevaluation of the RIVUR trial with a validated risk stratification model
Zhan Tao (Peter) Wang
MP61-14: Effect of newborn circumcision on urinary tract infections in patients with an early diagnosis of hydronephrosis.
MP61-19: An inguinal approach to complex extravesical ureteral reimplantation
Adam S. Howe
MP61-20: Acute ureteral jet angled measured by preoperative ultrasound correlates with resolution of vesicoureteral reflux treated with endoscopic injection of subureteric bulking agents
MP66-10: Contralateral metachronous undescended testis: is it predictable?
MP66-13: Novel sonographic evaluation of adolescent varicoceles
Dr. HannoThe 2017 AUA annual meeting “highlights how clinicians and investigators around the world are trying to move the field of bladder pain syndrome ahead,” said Philip M. Hanno, MD, MPH, clinical professor of urology at Stanford University School of Medicine, Stanford, CA. “The program committee scheduled both a podium session and a poster session focusing on the subject and including a total of 31 presentations combined.
“For the clinician, you may learn how safe and effective it is to limit botulinum toxin injections to 100 units confined to the trigone,” Dr. Hanno said.
“You will learn if the commonly held belief among patients and providers that recurrent hydrodistention tends to damage the bladder is true, and how often non-Hunner disease ‘progresses’ to Hunner type ESSIC 3C disease,” he added.
Meeting attendees should also watch for the presentation of data on the treatment of Hunner lesions with steroid intralesional injection.
“How good are you at predicting a Hunner lesion when you first see a patient? The answer may surprise you,” Dr. Hanno said.
Below are Dr. Hanno's abstract picks from this year's IC/BPS program:
PD01-01: Results from a randomized, double blind, placebo-controlled trial to evaluate efficacy and safety of intra-trigonal injection of onabotulinum toxin a in patients with bladder pain syndrome/interstitial cystitis.
PD01-04: Stress induced visceral pain is mediated by alpha 1A adrenoceptors
PD01-10: Effects of repeat hydrodistention for interstitial cystitis
MP29-05: Pain relief after triamcinolone infiltration in patients with bladder pain syndrome with Hunner's ulcers
Laura Mateu Arrom
MP29-13: Histamine intolerance and microbiota changes in patients with painful bladder syndrome / interstitial cystitis
MP29-19: Characterization of urologic and non-urologic features of interstitial cystitis patients with Hunner lesions
H. Henry Lai
Dr. HotalingThe top abstracts in infertility at the 2017 meeting discuss “novel uses of male androgen profiles and manipulations to help prognosticate and treat male factor infertility, profiling and culturing of human spermatogonial stem cells, and molecular profiling of men with nonobstructive azoospermia,” said James M. Hotaling, MD, MS, assistant professor of surgery (urology) at the University of Utah Health Care, Salt Lake City.
Specific meeting abstracts of interest, Dr. Hotaling pointed out, will examine the cost-effectiveness of fertility preservation in testis cancer patients, sex hormone-binding globulin as an independent predictor of oligospermia, how advanced paternal age will impact the next generation, and the effect of fellowship training on microsurgical operations for infertility.
Here are the infertility abstracts to watch for at this year's meeting, according to Dr. Hotaling:
PD13-11: Cost-effectiveness of fertility preservation in testis cancer patients
MP35-03: Sex hormone binding globulin independently predicts oligospermia in male fertility patients
PD08-09: How does advanced paternal age affect the next generation?
MP89-18: The effect of fellowship training on operative times and outcomes for microsurgical cases
Dr. RazNew research in the area of female urology, including urodynamics and voiding dysfunction, will highlight two alternatives to tibial nerve stimulation presented at the meeting, according to Shlomo Raz, MD, professor of surgery/urology at the UCLA School of Medicine, Los Angeles.
“Posterior tibial nerve stimulation (PTNS) is used in the treatment of overactive bladder. The treatment requires frequent office visit and time off for weekly treatments,” Dr. Raz said. “Two alternatives are being presented at the meeting. One uses surface electrodes (similar to EKG pads). This is what I use in my practice. The patient buys a transcutaneous electric nerve stimulator unit ($30 at Amazon) and uses the tibial stimulation at home.
“The other paper describes the use of a small permanent implant in close proximity to the tibial nerve, eliminating the need of office treatments and insertion of acupuncture needles,” he said.
Dr. Raz also said meeting attendees should keep an eye out for abstracts discussing the use of physical therapy for pain and voiding symptoms in women with pelvic pain, effects of bariatric surgery on female pelvic floor disorders, and whether mid-urethral position is critical for continence following sling placement.
Here are Dr. Raz's can't-miss abstracts in female urology from this year's meeting:
PD39-07: Pelvic floor physical therapy significantly improves pain and voiding symptoms in women with pelvic pain
PD50-03: Effects of bariatric surgery on female pelvic floor disorders
PD50-06: Mid-urethral position: is this critical to achieving continence following sling placement for stress incontinence?
PD54-11: Electrical stimulation of afferent nerves in the foot with transcutaneous adhesive pad electrodes in women with refractory overactive bladder: Defining ideal stimulation duration
Christopher J. Chermansky
PD64-11: New novel chronic tibial neuromodulation (CTNM) treatment option for OAB significantly improves urgency (UI)/urge incontinence (UUI) and normalizes sleep patterns
Dr. MoreyData on the risk of complications related to delaying urethroplasty in patients with urethral stricture will be the focus of two key studies from the trauma and reconstruction poster and podium sessions, said Allen F. Morey, MD, professor of urology at UT Southwestern Medical Center, Dallas.
“Evidence indicates that urethral stricture patients not treated by early urethroplasty experience more complications,” Dr. Morey said.
Other high-interest abstracts in the trauma/reconstruction space include those discussing endoscopic realignment for pelvic fracture urethral injuries, outcomes of endoscopic treatment of stricture recurrence after urethroplasty, and perinephric hematoma size as an independent predictor of the need for urologic intervention in blunt renal trauma.
These are the key abstracts in trauma/reconstruction this year:
MP79-08: Updated outcomes of early endoscopic realignment for pelvic fracture urethral injuries at a level 1 trauma center
Paul H. Chung
PD34-11: Multi-institutional outcomes of endoscopic management of stricture recurrence after urethroplasty
PD60-01: Incidence and predictors of complications due to urethral stricture in patients awaiting urethroplasty
PD60-02: Delay of urethroplasty is assiciated with longer strictures and more complicated repairs
PD63-07: Perinephric hematoma size is independently associated with the need for urologic intervention in blunt renal trauma
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