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Brent K Hollenbeck

Publications and source records attributed to Brent K Hollenbeck.

At least 19 recordsLinked to original sources
PubMed2007

Volume-based referral for cancer surgery: informing the debate.

PURPOSE: Mounting evidence suggests a relationship between hospital volume and outcomes after major cancer surgery; however, the absolute benefits of volume-based referral on a national basis are unclear. PATIENTS AND METHODS: Data from the Nationwide Inpatient Sample were used to measure the likelihood of operative mortality and a prolonged length of stay (LOS) after six cancer surgeries (prostatectomy, cystectomy, esophagectomy, pancreatectomy, pneumonectomy, and liver resection) between 1993 and 2003. Using sampling weights, the adjusted likelihood of the outcomes was used to calculate the number of lives saved (or prolonged LOS avoided) in the United States. RESULTS: The magnitude of the volume-operative mortality effect varied from an adjusted odds ratio (OR) of 1.3 (95% CI, 0.8 to 2.3) for cystectomy to 4.9 (95% CI, 2.4 to 10.1) for pancreatectomy. After accounting for varying rates of procedure utilization, the lives saved per 100 surgeries regionalized ranged from 0.2 (95% CI, 0.12 to 0.24 lives saved) for prostatectomy to 9.2 (95% CI, 6.7 to 10.4 lives saved) for pancreatectomy. The volume-prolonged LOS effect varied from an adjusted OR of 0.9 (95% CI, 0.5 to 1.6) for liver resection to 4.8 (95% CI, 3.5 to 6.7) for prostatectomy. After accounting for procedure use, the number of prolonged hospitalizations avoided ranged from -1.7 (95% CI, -11.3 to 3.6 hospitalizations) to 14.3 (95% CI, 12.9 to 15.4 hospitalizations) per 100 surgeries regionalized for liver resection and prostatectomy, respectively. CONCLUSION: For patients undergoing major cancer surgery, the benefits of volume-based referral depend on the interplay between procedure utilization, the magnitude of effect, and the outcome chosen.

Aged↗
PubMed2006

Medical therapy to facilitate urinary stone passage: a meta-analysis.

BACKGROUND: Medical therapies to ease urinary-stone passage have been reported, but are not generally used. If effective, such therapies would increase the options for treatment of urinary stones. To assess efficacy, we sought to identify and summarise all randomised controlled trials in which calcium-channel blockers or alpha blockers were used to treat urinary stone disease. METHODS: We searched MEDLINE, Pre-MEDLINE, CINAHL, and EMBASE, as well as scientific meeting abstracts, up to July, 2005. All randomised controlled trials in which calcium-channel blockers or alpha blockers were used to treat ureteral stones were eligible for inclusion in our analysis. Data from nine trials (number of patients=693) were pooled. The main outcome was the proportion of patients who passed stones. We calculated the summary estimate of effect associated with medical therapy use using random-effects and fixed-effects models. FINDINGS: Patients given calcium-channel blockers or alpha blockers had a 65% (absolute risk reduction=0.31 95% CI 0.25-0.38) greater likelihood of stone passage than those not given such treatment (pooled risk ratio 1.65; 95% CI 1.45-1.88). The pooled risk ratio for alpha blockers was 1.54 (1.29-1.85) and for calcium-channel blockers with steroids was 1.90 (1.51-2.40). The proportion of heterogeneity not explained by chance alone was 28%. The number needed to treat was 4. INTERPRETATION: Although a high-quality randomised trial is necessary to confirm its efficacy, our findings suggest that medical therapy is an option for facilitation of urinary-stone passage for patients amenable to conservative management, potentially obviating the need for surgery.

Adrenal Cortex Hormones↗
PubMed2006

Rising incidence of small renal masses: a need to reassess treatment effect.

The incidence of kidney cancer has been rising over the last two decades, especially in cases where the disease is localized. Although rates of renal surgery parallel this trend, mortality rates have continued to rise. To investigate the basis of this "treatment disconnect" (i.e., increased rates of treatment accompanied by increased mortality rates), we analyzed patient data from nine registries of the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. We assembled a cohort of 34,503 kidney cancer patients and derived incidence, treatment, and mortality trends for kidney cancer, overall and as a function of tumor size. From 1983 to 2002, the overall age-adjusted incidence rate for kidney cancer rose from 7.1 to 10.8 cases per 100,000 US population; tumors < or = 4 cm in size accounted for most of the increase. Adjusted rates of renal surgery increased concurrently, most notably for tumors < or = 4 cm (0.9-3.6 surgeries per 100,000 US population). However, among kidney cancer patients, all-cause mortality per 100,000 US population increased from 1.5 deaths in 1983 to 6.5 deaths in 2002, with the greatest absolute increase noted for patients with lesions > 7 cm. Our results demonstrate that the rising incidence of kidney cancer is largely attributable to an increase in small renal masses that are presumably curable. The fact that increased detection and treatment of small tumors is not reducing mortality argues for a reassessment of the current treatment paradigm.

Aged↗
PubMed2006

Incidence of initial local therapy among men with lower-risk prostate cancer in the United States.

BACKGROUND: The frequently indolent nature of early-stage prostate cancer in older men and in men with low- or moderate-grade tumors and the demonstration that the survival benefits of radical prostatectomy are primarily among men younger than 65 years have led to concerns about prostate cancer overtreatment. METHODS: Using data from 13 Surveillance, Epidemiology, and End Results registries, we performed a retrospective cohort study of 71,602 men who were diagnosed with localized or regional prostate cancer between 2000 and 2002. We quantified the incidence of initial curative therapy (i.e., surgery or radiation therapy) among men with lower-risk cancers as defined by their limited likelihood of either dying from expectantly managed prostate cancer or achieving a survival benefit from local therapy. Stratified analyses and multinomial logistic regression models were used to quantify the absolute and relative rates of curative therapy among men in various age-grade strata. All statistical tests were two-sided. RESULTS: We identified 24,405 men with lower-risk prostate cancers and complete data for the first course of treatment. Initial curative therapy was undertaken in 13,537 of these men (55%); 81% of treated men received radiation therapy. The likelihood of curative therapy, relative to expectant management, varied statistically significantly among lower-risk age-grade strata (all P<.05). Assuming that initial expectant management is appropriate for all lower-risk cancers, 2564 men (10%) in this population-based sample were overtreated with radical prostatectomy and 10,973 (45%) with radiation therapy. CONCLUSIONS: These data quantify a target population for whom greater use of expectant approaches may reduce overtreatment and improve the quality of localized prostate cancer care.

Aged↗
PubMed2006

Risk factors for adverse outcomes after transurethral resection of bladder tumors.

BACKGROUND: Risk factors for adverse outcomes after transurethral resection of bladder tumors (TURBT) have not been identified to date. Such information would facilitate preoperative risk stratification and case-mix-adjusted outcome comparison, and lead to the development of processes of care directed at improving outcomes and ultimately the quality of care for bladder carcinoma patients. METHODS: The National Surgical Quality Improvement Program (NSQIP) is a prospective quality management initiative of 123 Veterans Affairs Medical Centers nationwide. Since 1991, a total of 21,515 TURBTs have been prospectively registered by the NSQIP; these cases compose the current study population. Using multivariable logistic regression, the authors determined the independent association between preoperative patient risk factors and perioperative elements of structure/process and morbidity, mortality, and prolonged length of stay (LOS) outcomes. RESULTS: The postoperative complication, 30-day, and 90-day mortality rates were 4.3%, 1.3%, and 3.3%, respectively. The median, 75th percentile, and 90th percentile for LOS among patients undergoing TURBT was 2 days, 3 days, and 8 days, respectively. Robust preoperative patient risk factors that were found to be uniformly associated with all adverse outcomes included the presence of disseminated disease (odds ratio [OR], 1.9-5.2) weight loss (OR, 1.8-3.8), low serum albumin (OR, 2.3-7.1), elevated serum creatinine (OR, 1.3-2.9), a dependent functional status (OR, 1.5-2.7), and emergent case status (OR, 1.8-3.1). Compared with models using preoperative patient factors alone, models including perioperative structure and process measures explained further variation in surgical outcomes (each likelihood ratio test, P < .0001). CONCLUSIONS: The findings of the current study highlight the fact that there are a wide array of patient risk factors that are associated with adverse outcomes after TURBT. Validation of those processes implemented to modify such elements can provide a basis for quality metrics in the context of TURBT.

Aged↗
PubMed2006

Racial disparities in resource utilization for cystectomy.

OBJECTIVES: To examine the association of race with mortality and resource use among patients requiring cystectomy for bladder cancer, given the known racial differences with regard to bladder cancer incidence and survival. METHODS: Using the Nationwide Inpatient Sample (a nationally representative data set), 22,088 patients who underwent cystectomy for bladder cancer from 1988 to 2000 were identified using the International Classification of Disease, Ninth Revision, codes. The outcomes included in-hospital mortality, length of stay (LOS), and discharge status. Multivariable models were developed to perform risk-adjusted analyses and identify factors associated with these outcomes. RESULTS: The overall mortality rate after cystectomy was 2.9%. Unadjusted analyses revealed significant racial differences with respect to in-hospital mortality, LOS, and discharge disposition. Whites had a mortality rate of 2.8% compared with 4.2% for blacks and 3.9% for Hispanics (P = 0.006). Whites had a prolonged LOS 24.9% of the time compared with 38.2% for blacks and 24.6% for Hispanics (P < 0.001). The rate at which whites were discharged to subacute care facilities was 9.9% compared with 11.2% for black patients and 7.7% for Hispanics (P < 0.001). After adjusting for confounding factors, blacks were more likely to experience in-hospital mortality and prolonged LOS (odds ratios 1.66 and 2.10, respectively) compared with whites, although no significant differences were observed for Hispanics. No significant racial differences were noted for discharge status after risk adjustment. CONCLUSIONS: Black patients undergoing cystectomy for bladder cancer had greater mortality and greater LOS than did white patients. Additional study using detailed clinical data is necessary to identify the underlying causes of these differences.

Black or African American↗
PubMed2006

National utilization trends of partial nephrectomy for renal cell carcinoma: a case of underutilization?

OBJECTIVES: Partial nephrectomy is perceived to be more technically demanding than radical nephrectomy; concurrently, the increasing incidence of small renal tumors has suggested a greater role for nephron-sparing techniques. From a quality-of-care perspective, the underuse of partial nephrectomy may represent suboptimal delivery of healthcare. METHODS: A total of 66,621 subjects undergoing radical and partial nephrectomy for kidney cancer between 1988 and 2002 were identified from the Nationwide Inpatient Sample, a nationally representative data set of hospital discharges. Adjusted models were developed to identify clinical factors and structural measures independently associated with the use of partial nephrectomy. RESULTS: Overall, 7.5% of patients treated underwent partial nephrectomy. The utilization rates for partial nephrectomy ranged from 0.21 cases per 100,000 U.S. residents in 1988 to 1.6 cases per 100,000 U.S. residents in 2002. The percentage of patients with renal cell carcinoma treated with partial nephrectomy has increased more than threefold during the study interval (3.7% in 1988 to 1990 compared with 12.3% in 2000 to 2002, P <0.0001 for trend). Patients treated at urban (odds ratio 1.1), teaching (odds ratio 1.3), and high nephrectomy volume (odds ratio 2.5) hospitals were more likely to undergo partial nephrectomy (each, P <0.01). CONCLUSIONS: The national use of partial nephrectomy has increased but remains lower than expected in certain settings, suggesting underuse or selective referral. Subjects with kidney cancer are more likely to be treated with partial nephrectomy at teaching institutions with high surgical volumes. The practice patterns of physicians at institutions more commonly using partial nephrectomy may reflect a better quality of care, although additional work in delineating the disparate utilization rates is warranted.

Aged↗
PubMed2006

Laparoscopy for renal cell carcinoma: diffusion versus regionalization?

PURPOSE: Recognizing the emergence of laparoscopy as a standard of care for surgical treatment in many patients with organ confined renal cell carcinoma, we explored the diffusion of this technology by examining temporal trends in the nationwide use of laparoscopic total and partial nephrectomy in patients with renal cell carcinoma. MATERIALS AND METHODS: Data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample were abstracted for 1991 through 2003. International Classification of Diseases-Ninth Revision, Clinical Modification 9 codes were used to identify patients undergoing open and laparoscopic total and partial nephrectomy for renal cell carcinoma. Using hospital sampling weights we calculated annual incidence rates for open and laparoscopic nephrectomy, thereby estimating the diffusion of laparoscopy. Bivariate and multivariate analyses were used to identify patient and hospital characteristics associated with the more frequent use of laparoscopic techniques. RESULTS: Data on 63,812 patients were abstracted from the Nationwide Inpatient Sample, yielding a weighted national estimate of 323,979 who underwent laparoscopic (4.9%) or open (95.1%) nephrectomy (total or partial) for renal cell carcinoma between 1991 and 2003. Although it is still infrequent, the use of laparoscopy has increased steadily since 1998 with a utilization peak in 2003 of 1.7 laparoscopic nephrectomies per 100,000 American population, representing 16% of all total and partial nephrectomies for renal cell carcinoma in 2003. Treatment year, overall hospital nephrectomy volume and teaching hospital status were the most robust determinants of increased laparoscopic use (each p <0.001). CONCLUSIONS: Although its use has increased progressively in the last decade, the dissemination of laparoscopy for renal cell carcinoma has been generally slow and limited in scope. The next step in this body of work is to identify specific technical, educational and policy interventions that will influence the diffusion of this alternative standard of care.

Carcinoma, Renal Cell↗
PubMed2006

The effects of adjusting for case mix on mortality and length of stay following radical cystectomy.

PURPOSE: Prior studies evaluating quality of care following radical cystectomy have been constrained by the use of retrospective reviews of single institutional series and limited ability to examine risk factors in a comprehensive manner. Characterization of these factors could enhance preoperative patient counseling and facilitate perioperative management, thereby improving the quality of patient care. MATERIALS AND METHODS: The National Surgical Quality Improvement Project is a prospective quality management initiative at 123 Veterans Affairs Medical Centers nationwide. The project collects preoperative clinical and intraoperative data, and outcomes on a wide variety of surgical procedures from multiple surgical disciplines. Since 1991, 2,538 radical cystectomies have been captured by the National Surgical Quality Improvement Project. Modeling using logistic regression was performed to identify preoperative risk factors associated with mortality and prolonged length of stay (greater than 90th percentile) after radical cystectomy. RESULTS: The 30 and 90-day mortality rates following cystectomy were 2.9% and 6.8%, respectively, and median hospital stay was 11 days (90th percentile 30). Robust preoperative factors associated with mortality and prolonged length of stay that uniformly increased risk were older patient age (OR 1.2 to 1.4), American Society of Anesthesiologists class 3 or greater (OR 1.5 to 3.3), dependent functional status (OR 1.7 to 2.0) and low serum albumin (OR 2.1 to 12.0). CONCLUSIONS: A defined set of preoperative risk factors is independently associated with greater mortality and hospital stay following radical cystectomy. The breadth of these factors suggests that complex case mix adjustment is mandatory when comparing outcomes. Implementation of novel processes directed toward minimizing patient risk has the potential to improve outcomes following cystectomy.

Age Factors↗
PubMed2006

Discharge practice patterns following cystectomy for bladder cancer: evidence for the shifting of the burden of care.

PURPOSE: Between 1985 and 2000 the incidence of bladder cancer in this country increased by 33%. Radical cystectomy is the primary treatment modality in patients with invasive disease. We characterized trends in cystectomy use and discharge practice patterns following cystectomy during a recent 13-year period. MATERIALS AND METHODS: The Nationwide Inpatient Sample comprises a 20% probability sample of hospital discharges in the United States each year. Patients who underwent cystectomy for bladder cancer from 1988 to 2000 were identified using International Classification of Disease, 9th Revision, Clinical Modification codes. Outcome variables included in-hospital mortality, length of stay and hospital discharge status. RESULTS: From 1988 to 2000 an estimated 119,491 patients underwent cystectomy for bladder cancer. Cystectomy rates decreased by 17% from 3.91/100,000 (1988 to 1990) to 3.25/100,000 (1997 to 2000), largely due to a decreasing number of partial cystectomies. In-hospital mortality decreased from 3.3% (1988 to 1990) to 2.5% (1997 to 2000) (p = 0.027). Similarly median length of stay decreased from 13 days (1988 to 1990) to 9 (1997 to 2000) (p <0.001). During the same period the percent of patients being discharged to subacute care facilities increased from 5.3% to 13.2% (p <0.001), as did the percent of patients requiring home health care services (24.1% to 38.7%, p <0.001). CONCLUSIONS: From 1988 to 2000 there was a decrease in the rate of cystectomies being performed for bladder cancer with a substantial decrease in partial cystectomy use. During this period short-term outcomes following cystectomy improved, while the use of subacute care facilities and home health services increased dramatically, underscoring a shift in the burden of care in this patient population.

Aftercare↗
PubMed2006

Use of nephrectomy at select medical centers--a case of follow the crowd?

PURPOSE: Regionalization of high risk surgical procedures to larger, teaching hospitals has been suggested as a means to improve the quality of care. We determined the extent to which the regionalization of nephrectomy has occurred and describe the potential causes and implications of any observed regionalization. MATERIALS AND METHODS: The Nationwide Inpatient Sample comprises a 20% sampling of hospital discharges in the United States yearly. Patients undergoing nephrectomy for kidney cancer between 1988 and 2002 were identified using International Classification of Disease, Ninth Revision, Clinical Modification codes. Regionalization was assessed using 6 structural hospital measures, including teaching status, urban location, discharge volume, nephrectomy volume, bed capacity and for-profit status. Adjusted models were developed to identify the significance of temporal trends in each regionalization measure. RESULTS: We identified 66,621 patients undergoing nephrectomy during the study period. Compared to procedures performed between 1988 and 1990 the likelihood of undergoing nephrectomy at teaching, high nephrectomy volume and high throughput (all diagnoses) hospitals increased by 2.0 (CI 1.9 to 2.2), 7.4 (CI 7.1 to 7.7) and 2.2 times (CI 2.1 to 2.2), respectively, in 2000 to 2002. Conversely nephrectomy was less likely to be performed at for-profit hospitals (OR 0.5, CI 0.5 to 0.6). Patients were more likely to undergo partial nephrectomy at teaching, high volume, high throughput, urban hospitals. CONCLUSIONS: Regionalization of nephrectomy to teaching and high volume (nephrectomy and all diagnoses) hospitals is currently under way. Although the implications are not entirely clear, this study provides further evidence for the crowding of complex surgical procedures into these institutions.

Aged↗
PubMed2006

Partial nephrectomy for small renal masses: an emerging quality of care concern?

PURPOSE: The recent popularization of laparoscopic radical nephrectomy may beget underuse of partial nephrectomy. To evaluate this concern we used the SEER registry to characterize national practice patterns for the surgical management of small renal masses. MATERIALS AND METHODS: Between 1988 and 2001, 14,647 patients with primary tumor size 7 cm or less were treated surgically for locoregional kidney cancer. The proportion of patients treated with PN was determined and stratified by year of diagnosis and tumor size. Multivariate models were developed to identify independent determinants of PN use and overall survival following surgical treatment of kidney cancer. RESULTS: Overall 1,401 patients (9.6%) were treated with PN vs 13,246 (90.4%) who underwent total nephrectomy. For tumors 7 cm or less, the use of PN increased progressively between 1988 (4.6%) and 2001 (17.6%, p < 0.001). Despite this trend PN remained fairly uncommon even for the smallest renal masses. Among patients with tumors less than 2 cm, 14% underwent PN in 1988 to 1989 vs 42% in 2000 to 2001. For tumors 2 to 4 cm the corresponding proportions were 5% and 20%, respectively (p < 0.001). Younger patient age, smaller tumor size and more recent diagnostic year were independent determinants of PN use (all p values < 0.05). All cause mortality was similar for patients treated with PN vs TN (HR 0.9, 95% CI 0.8-1.1). CONCLUSIONS: Despite more frequent application during the last 2 decades, nationwide use of PN remains relatively uncommon, even for the smallest renal masses. Recognizing the favorable outcomes associated with preservation of renal parenchyma, our findings identify a possible quality of care concern that should be addressed by the urological community.

Aged↗
PubMed2006

Temporal trends in the use of percutaneous nephrolithotomy.

PURPOSE: Treatment for nephrolithiasis has evolved because of the dissemination of less invasive techniques, such as ureteroscopy and shock wave lithotripsy. We examined temporal trends in PCNL use and characterized the determinants of a prolonged LOS and in-hospital mortality to provide insight into the evolution of practice patterns for nephrolithiasis treatment. MATERIALS AND METHODS: We abstracted data on 12,948 patients undergoing percutaneous procedures for urinary calculi between 1988 and 2002 from the Nationwide Inpatient Sample using International Classification of Disease, 9th revision, Clinical Modification procedure and diagnostic codes. A weighted sample was used to estimate national PCNL use rates. Adjusted models were constructed to measure the association of hospital structure and patient demographics with mortality and a prolonged LOS (greater than 90th percentile). RESULTS: Annual PCNL use increased temporally during the study from 1.2/100,000 to 2.5/100,000 United States residents (p <0.0001). The in-hospital mortality rate was low at 0.2%, although a volume-outcome relationship was still evident (high and low volume 0.1% and 0.2%, respectively, p = 0.002). Treatment at hospitals with lower hospital PCNL volume and lower discharge volume (all diagnoses) was associated with an increasing likelihood of in-hospital mortality (each p <0.01). CONCLUSIONS: Despite the advent of less invasive techniques PCNL remains a popular means of managing stone disease. Although mortality was rare, it was significantly lower at high than at low volume hospitals. Low short-term mortality rates coupled with shorter LOS and high success rates may make PCNL increasingly palatable from a patient perspective and provide a potential basis for its increasing use.

Adult↗
PubMed2006

Acute integrity of closure for partial nephrectomy: comparison of 7 agents in a hypertensive porcine model.

PURPOSE: We assessed the acute effectiveness of closure after partial nephrectomy of 7 techniques in a large hypertensive porcine model using shallow and deep resections to approximate clinical situations. MATERIALS AND METHODS: Open surgical partial nephrectomy with hilar clamping was performed in pigs weighing 150 to 200 lbs, including small-a quarter length and a quarter width of kidney, medium-a third length and a third width of kidney, and into the renal sinus and up to the collecting system, and large-lower pole heminephrectomy at the renal sinus. Seven agents were compared after a single application, namely thrombin/collagen granules, polyethylene glycol hydrogel, fibrin glue, thrombin/gelatin granules, cyanoacrylate glue, fibrin glue/gelatin sponge and sutured bolster. Failure and success were determined by the presence or absence of bleeding, respectively, after unclamping and by an increase in SBP to 100 and then to 200 mm Hg with dopamine infusion. RESULTS: Of 70 partial nephrectomies the success rates were 33% and 14% for thrombin/collagen granules, and 67% and 0% for polyethylene glycol hydrogel in small and medium resections; 100%, 71% and 0% for fibrin glue, and 100%, 86% and 0% for thrombin/gelatin granules in small, medium and large resections; and 67% and 80% for cyanoacrylate glue, 100% and 20% for fibrin glue/gelatin sponge, and 100% for sutured bolster in medium and large resections, respectively. Of the kidneys that did not bleed at an SBP of 100 mm Hg 31% bled at 200 mm Hg. CONCLUSIONS: There is considerable variability among agents. Most were effective for small resections and some worked for medium resections but for large resections only sutured bolster was consistently effective. SBP also appears to be an important factor. These results bear on the selection of techniques during laparoscopic partial nephrectomy.

Animals↗
PubMed2006

Obesity adversely affects health related quality of life before and after radical retropubic prostatectomy.

PURPOSE: Obesity adversely affects surgical procedures and outcomes. We used a validated health related quality of life measure to examine the effects of obesity on disease specific health related quality of life before and following radical retropubic prostatectomy. MATERIALS AND METHODS: From June 2000 to April 2003, 575 consecutive patients with prostate cancer were approached to participate in a prospective, health related quality of life study. Health related quality of life was assessed before surgery, and 1, 4, 12, 24 and 36 months postoperatively. Repeated measures mixed models were constructed to determine the independent effects of body mass index on health related quality of life. RESULTS: Of 472 consenting subjects 376 (80%) completed a baseline and at least 1 followup survey. Higher body mass index was associated with worse preoperative hormonal/vitality function (p = 0.0009) and bother (p = 0.02), and delayed recovery of bowel function (p = 0.01) and bother (p = 0.01) health related quality of life. There were no measurable differences postoperatively in hormonal/vitality, urinary or sexual health related quality of life associated with higher body mass index. Increased body mass index was associated with prostate specific antigen recurrence (p = 0.05) and adjuvant treatment (p = 0.02). Adjuvant treatment was independently associated with worse bowel function (p = 0.01) and bother (p = 0.01) health related quality of life in obese patients. At 24 months bowel health related quality of life in obese patients no longer significantly differed from that in nonobese patients. CONCLUSIONS: Obesity is associated with worse preoperative hormonal/vitality health related quality of life, slower recovery of bowel function and bother health related quality of life after radical retropubic prostatectomy, and prostate specific antigen recurrence. Impaired health related quality of life recovery in obese patients is influenced by disease recurrence and resultant adjuvant therapies. Despite these findings obese patients should not be dissuaded from considering prostatectomy as definitive treatment for localized prostate cancer.

Body Mass Index↗
PubMed2006

Regionalization of percutaneous nephrolithotomy: evidence for the increasing burden of care on tertiary centers.

PURPOSE: The regionalization of procedures to specialized medical centers has been suggested as a means to improve the quality of care for select high risk procedures. Prior work has demonstrated the spontaneous regionalization of high risk procedures to tertiary centers. Similar concentration of complex, low risk procedures (e.g. percutaneous nephrolithotomy) to these centers would underscore the increasing burden of care placed on these hospitals. MATERIALS AND METHODS: We used the Nationwide Inpatient Sample to identify 12,948 patients who underwent percutaneous nephrolithotomy for stones between 1988 and 2002. Regionalization was measured based on the 6 structural hospital qualities of teaching status, urban location, bed capacity, hospital throughput (all diagnoses), annual percutaneous nephrolithotomy volume and for-profit status. Logistic regression was used to determine the propensity of percutaneous nephrolithotomy to concentrate to these medical centers. RESULTS: Compared to procedures performed between 1988 and 1990, patients were more likely to undergo percutaneous nephrolithotomy at teaching (OR 1.6, 95% CI 1.3-1.9), high percutaneous nephrolithotomy volume (OR 1.7, 95% CI 1.6-1.9), large bed capacity (OR 1.2, 95% CI 1.1-1.3) and high throughput hospitals (OR 1.4, 95% CI 1.3-1.4) in the years 2000 to 2002. CONCLUSIONS: Percutaneous nephrolithotomy, a technically complex but low risk procedure, has spontaneously regionalized to tertiary centers, suggesting the migration of complex surgical care to these centers. The impact of this increasing burden of care on tertiary centers is unclear but may be problematic in the current reimbursement environment.

Adult↗