Method used to identify adenomyosis and potentially undiagnosed adenomyosis in a large, U.S. electronic health record database.

BACKGROUND: The prevalence of adenomyosis is underestimated due to lack of a specific diagnostic code and diagnostic delays given most diagnoses occur at hysterectomy. OBJECTIVES: To identify women with adenomyosis using indicators derived from natural language processing (NLP) of clinical notes in the Optum Electronic Health Record database (2014-2018), and to estimate the prevalence of potentially undiagnosed adenomyosis. METHODS: An NLP algorithm identified mentions of adenomyosis in clinical notes that were highly likely to represent a diagnosis. The anchor date was date of first affirmed adenomyosis mention; baseline characteristics were assessed in the 12 months prior to this date. Characteristics common to adenomyosis cases were used to select a suitable pool of women from the underlying population, among whom undiagnosed adenomyosis might exist. A random sample of this pool was selected to form the comparator cohort. Logistic regression was used to compare adenomyosis cases to comparators; the predictive probability (PP) of being an adenomyosis case was assessed. Comparators having a PP ≥ 0.1 were considered potentially undiagnosed adenomyosis and were used to calculate the prevalence of potentially undiagnosed adenomyosis in the underlying population. RESULTS: Among 11 456 347 women aged 18-55 years in the underlying population, 19 503 were adenomyosis cases. Among 332 583 comparators, 22 696 women were potentially undiagnosed adenomyosis cases. The prevalence of adenomyosis and potentially undiagnosed adenomyosis was 1.70 and 19.1 per 1000 women aged 18-55 years, respectively. CONCLUSIONS: Considering potentially undiagnosed adenomyosis, the prevalence of adenomyosis may be 10x higher than prior estimates based on histologically confirmed adenomyosis cases only.

A Randomized Cross-Over Trial Focused on Clinical Breast Exam Skill Acquisition Using High Fidelity versus Low Fidelity Simulation Models in Rwanda.

OBJECTIVE: Breast cancer incidence is rising for women in low and middle income country (LMIC)s. Growing the health care workforce trained in clinical breast exam (CBE) is critical to mitigating breast cancer globally. We developed a CBE simulation training course and determined whether training on a low-fidelity (LF) simulation model results in similar skill acquisition as training on high-fidelity (HF) models in Rwanda. DESIGN: A single-center randomized educational crossover trial was implemented. A preintervention baseline exam (exam 1), followed by a lecture series (exam 2), and training sessions with assigned simulation models was implemented (exam 3)-participants then crossed over to their unassigned model (exam 4). The primary outcome of this study determined mean difference in CBE exam scores between HF and LF groups. Secondary outcomes identified any provider level traits and changes in overall scores. SETTING: The study was implemented at the University Teaching Hospital, Kigali (CHUK) in Rwanda, Africa from July 2014 to March 2015 PARTICIPANTS: Medical students, residents in surgery, obstetrics and gynecology, and internal medicine residents participated in a 1-day CBE simulation training course. RESULTS: A total of 107 individuals were analyzed in each arm of the study. Mean difference in exam scores between HF and LF models in exam 1 to 4 was not significantly different (exam 1 0.08 standard error (SE) = 0.47, p = 0.42; exam 2 0.86, SE = 0.69, p = 0.16; exam 3 0.03, SE = 0.38, p = 0.66; exam 4 0.10 SE = 0.37, p = 0.29). Overall exam scores improved from pre- to post-intervention. CONCLUSIONS: Mean difference in exams scores were not significantly different between participants trained with HF versus LF models. LF models can be utilized as cost effective teaching tools for CBE skill acquisition, in resource poor areas.

A Randomized Cross-Over Trial Focused on Breast Core Needle Biopsy Skill Acquisition and Safety Using High Fidelity Versus Low Fidelity Simulation Models in Rwanda.

OBJECTIVE: Breast cancer is the most common cancer diagnosed in low and middle-income countries. Growing the number of health care personnel trained in diagnostic procedures like breast core needle biopsy (BCNB) is critical. We developed a BCNB simulation-training course that evaluated skill acquisition, confidence, and safety, comparing low-cost low fidelity (LF) models to expensive high fidelity (HF) models. DESIGN: A single-center randomized education crossover trial was implemented. Participants were randomized to HF or LF groups. A preintervention baseline exam followed by lectures and training sessions with a HF or LF model was implemented. A postintervention simulation exam was conducted, and participants crossed over to the other simulation model. SETTING: The study was implemented at the University Teaching Hospital, Kigali (CHUK) in Rwanda, Africa from October 2014 to March 2015. PARTICIPANTS: Residents training in surgery or obstetrics and gynecology participated in a 1-day BCNB training course. RESULTS: A total of 36 residents were analyzed, 19 in the HF arm and 17 in the LF arm. Mean difference in exam scores for HF and LF groups in the baseline exam (exam 1) (0.067, p = 0.94, standard error [SE] of 1.57) postintervention exam (exam 2) (1.85, SE 1.46, p = 0.33), and the crossover exam (exam 3) (4.39, SE = 1.90, p = 0.11) were not significantly different between HF and LF. Overall exam scores improved from pre- to postintervention. CONCLUSIONS: Our results indicate that mean difference in exams scores were not significantly different between residents trained with HF versus LF models. In resources poor areas-LF models can be utilized as effective teaching tools for skill acquisition for diagnostic surgical procedures.

Association between access to social service resources and cardiometabolic risk factors: a machine learning and multilevel modeling analysis.

OBJECTIVES: Interest in linking patients with unmet social needs to area-level resources, such as food pantries and employment centres in one's ZIP code, is growing. However, whether the presence of these resources is associated with better health outcomes is unclear. We sought to determine if area-level resources, defined as organisations that assist individuals with meeting health-related social needs, are associated with lower levels of cardiometabolic risk factors. DESIGN: Cross-sectional. SETTING: Data were collected in a primary care network in eastern Massachusetts in 2015. PARTICIPANTS AND PRIMARY AND SECONDARY OUTCOME MEASURES: 123 355 participants were included. The primary outcome was body mass index (BMI). The secondary outcomes were systolic blood pressure (SBP), low-density lipoprotein (LDL) cholesterol and haemoglobin A1c (HbA1c). All participants were included in BMI analyses. Participants with hypertension were included in SBP analyses. Participants with an indication for cholesterol lowering were included in LDL analyses and participants with diabetes mellitus were included in HbA1c analyses. We used a random forest-based machine-learning algorithm to identify types of resources associated with study outcomes. We then tested the association of ZIP-level selected resource types (three for BMI, two each for SBP and HbA1c analyses and one for LDL analyses) with these outcomes, using multilevel models to account for individual-level, clinic-level and other area-level factors. RESULTS: Resources associated with lower BMI included more food resources (-0.08 kg/m2 per additional resource, 95% CI -0.13 to -0.03 kg/m2), employment resources (-0.05 kg/m2, 95% CI -0.11 to -0.002 kg/m2) and nutrition resources (-0.07 kg/m2, 95% CI -0.13 to -0.01 kg/m2). No area resources were associated with differences in SBP, LDL or HbA1c. CONCLUSIONS: Access to specific local resources is associated with better BMI. Efforts to link patients to area resources, and to improve the resources landscape within communities, may help reduce BMI and improve population health.

PLGA-encapsulation of the Pseudomonas aeruginosa PopB vaccine antigen improves Th17 responses and confers protection against experimental acute pneumonia.

The Pseudomonas aeruginosa type III secretion system protein PopB and its chaperon protein PcrH, when co-administered with the adjuvant curdlan, elicit Th17 responses after intranasal immunization of mice. These PopB/PcrH-curdlan vaccines protect mice against acute lethal pneumonia in an IL-17-dependent fashion involving CD4 helper T cells secreting IL-17 (Th17 cells). In this study, we tested whether encapsulation of PopB/PcrH in poly-lactic-co-glycolic acid (PLGA) nanoparticles could elicit Th17 responses to PopB. Recombinant PopB/PcrH or PcrH alone was encapsulated into PLGA nanoparticles. Mice (FVB/N) were intranasally immunized with the PLGA-PopB/PcrH nanoparticles, PLGA-PcrH nanoparticles, PLGA alone, or PopB/PcrH alone. The protective efficacy was assessed in an acute lung infection model with a lethal dose of an ExoU-producing version of P. aeruginosa strain PAO1. Th17 responses were assayed by intracellular flow cytometry and by ELISA for IL-17 in supernatants of splenocytes co-cultured with purified PopB/PcrH. PLGA-PopB/PcrH-immunized mice showed 3-4-fold higher Th17 responses both in the lung and in the spleen compared to mice immunized with empty PLGA or PopB/PcrH alone. After challenge with P. aeruginosa, PLGA-PopB/PcrH-immunized mice showed significantly lower bacterial counts in the lungs and improved survival. In conclusion, encapsulation of PopB/PcrH in PLGA nanoparticles can elicit Th17 responses to intranasal vaccination and protect mice against acute lethal P. aeruginosa pneumonia.

BaTiO3-core Au-shell nanoparticles for photothermal therapy and bimodal imaging.

We report sub-100 nm metal-shell (Au) dielectric-core (BaTiO3) nanoparticles with bimodal imaging abilities and enhanced photothermal effects. The nanoparticles efficiently absorb light in the near infrared range of the spectrum and convert it to heat to ablate tumors. Their BaTiO3 core, a highly ordered non-centrosymmetric material, can be imaged by second harmonic generation, and their Au shell generates two-photon luminescence. The intrinsic dual imaging capability allows investigating the distribution of the nanoparticles in relation to the tumor vasculature morphology during photothermal ablation. Our design enabled in vivo real-time tracking of the BT-Au-NPs and observation of their thermally-induced effect on tumor vessels. STATEMENT OF SIGNIFICANCE: Photothermal therapy induced by plasmonic nanoparticles has emerged as a promising approach to treating cancer. However, the study of the role of intratumoral nanoparticle distribution in mediating tumoricidal activity has been hampered by the lack of suitable imaging techniques. This work describes metal-shell (Au) dielectric-core (BaTiO3) nanoparticles (abbreviated as BT-Au-NP) for photothermal therapy and bimodal imaging. We demonstrated that sub-100 nm BT-Au-NP can efficiently absorb near infrared light and convert it to heat to ablate tumors. The intrinsic dual imaging capability allowed us to investigate the distribution of the nanoparticles in relation to the tumor vasculature morphology during photothermal ablation, enabling in vivo real-time tracking of the BT-Au-NPs and observation of their thermally-induced effect on tumor vessels.

Do Transferred Patients Increase the Risk of Venous Thromboembolism in Trauma Centers?

Trauma patients often require initial stabilization followed by transfer for ongoing trauma care. Thus, the administration of VTE prophylaxis is often delayed until admission to the receiving hospital. It is unclear if transfer status is a risk factor for VTE. The National Trauma Database v6.2 was used to identify patients admitted to Level I and II trauma centers. Exclusions included patients on anticoagulation, <18 years, known VTE before trauma, or pregnant. Patients transferred were compared with nontransferred patients. Analysis included 736,374 patients with 189,166 (25.69%) transferred patients within 24 hours of injury. Using weighted measures, VTE was identified in 11,619 (1.50%) patients. The VTE rate was significantly higher in the transferred group compared with the nontransferred group (1.73% vs 1.42%, P = 0.002) including deep venous thrombosis (1.39% vs 1.14%, P = 0.004) and pulmonary embolism (0.45% vs 0.39%, P = 0.003). Multivariable analyses adjusting for patient-level risk factors demonstrated that transfer was associated with a higher likelihood of VTE (aOR 1.18; 95% CI: 1.09-1.28, P ≤ 0.001), pulmonary embolism (aOR 1.21; 95% CI: 1.11-1.33, P ≤ 0.001), and deep venous thrombosis (aOR 1.17; 95% CI: 1.07-1.28, P = 0.0004). Transfer status of trauma patients is a risk factor for VTE. Accepting a transferred patient results in an increased VTE risk and may not be reflective of the quality of care at the receiving facility.

Association between androgen deprivation therapy and anxiety among 78 000 patients with localized prostate cancer.

OBJECTIVES: To examine whether any androgen deprivation therapy use or longer duration is associated with an increased risk of anxiety in patients with prostate cancer. METHODS: We identified 78 552 men aged ≥66 years with stage I-III prostate cancer using the Surveillance, Epidemiology, and End Results-Medicare linked database from 1992 to 2006, excluding patients with psychiatric diagnoses within the year prior or 6 months after prostate cancer diagnosis. Multivariable Cox regression was used to examine the association between pharmacological androgen deprivation therapy and diagnosis of anxiety. RESULTS: The 43.1% (33 882) of patients who received androgen deprivation therapy experienced a higher 3-year cumulative incidence of anxiety compared with men who did not (4.1% vs 3.5%, P < 0.001). Any androgen deprivation therapy use was associated with a nearly significant increased risk of anxiety (adjusted hazard ratio 1.08, 95% confidence interval 1.00-1.17, P = 0.054). There was a significant trend between a longer duration of therapy and increased risk of anxiety (P-trend = 0.012), with a 16% higher risk for ≥12 months (adjusted hazard ratio 1.16, 95% confidence interval 1.04-1.29, P = 0.010). CONCLUSIONS: Androgen deprivation therapy was associated with an elevated risk of anxiety in this cohort of elderly men with localized prostate cancer, with the risk higher with a longer duration of treatment. Anxiety should be considered among the possible psychiatric effects of androgen deprivation therapy and discussed before initiating treatment, particularly if a long course is anticipated.

Morbidity and Mortality of Locally Advanced Prostate Cancer: A Population Based Analysis Comparing Radical Prostatectomy versus External Beam Radiation.

PURPOSE: The management of locally advanced prostate cancer remains controversial. We compared the effect of primary external beam radiation therapy vs radical prostatectomy for locally advanced prostate cancer. MATERIALS AND METHODS: We retrospectively analyzed the records of 2,935 elderly men 65 years old or older in the SEER (Surveillance, Epidemiology and End Results)-Medicare linked database who underwent external beam radiation therapy or radical prostatectomy for locally advanced prostate cancer. Propensity adjusted Cox proportional hazard and regression models were fit to examine urinary and gastrointestinal toxicities, the use of androgen deprivation therapy, and overall and prostate cancer specific mortality. RESULTS: A total of 1,429 men (48.69%) underwent radical prostatectomy and had a median followup of 11.47 years (IQR 6.17-17.17) years. A total of 1,506 men (51.31%) received external beam radiation therapy and had a median followup of 7.04 years (IQR 4.11-10.51, p <0.001). Patients treated with radical prostatectomy were at significantly higher risk for urinary and sexual toxicities (HR 1.93, 95% CI 1.66-2.24 and HR 5.50, 95% CI 3.59-8.42, respectively). However, they were at lower risk for gastrointestinal toxicities (HR 0.75, 95% CI 0.65-0.86) than those treated with external beam radiation therapy. Radical prostatectomy was associated with lower odds of androgen deprivation therapy 5 years after primary treatment (OR 0.53, 95% CI 0.41-0.69, p <0.001). External beam radiation therapy was associated with higher overall and prostate specific mortality (HR 1.41, 95% CI 1.09-1.82 and HR 2.35, 95% CI 1.85-2.98, respectively). CONCLUSIONS: We found significant toxicity and survival differences in elderly men who underwent primary external beam radiation therapy vs radical prostatectomy for locally advanced prostate cancer. While our findings must be interpreted within the limitations of studies that rely on administrative claims, they may yet help tailor individual therapies for elderly men who present with locally advanced prostate cancer.

A Nationwide Survey of Prostate Specific Antigen Based Screening and Counseling for Prostate Cancer.

INTRODUCTION: Controversy surrounds prostate specific antigen screening following the 2012 U.S. Preventive Services Task Force grade D recommendation. There is limited evidence evaluating patterns of prostate specific antigen counseling and patient perceptions of the prostate specific antigen test since 2012. We evaluated the association between prostate cancer screening counseling and patient sociodemographic factors in a nationally representative sample. METHODS: Using data from the 2013 Health Information National Trends Survey we identified 768 male respondents age 40 to 75 years without a prior prostate cancer diagnosis. Using logistical regression we assessed trends in prostate cancer screening, counseling and prostate specific antigen use. RESULTS: Overall 54.1% of respondents reported ever having a prostate specific antigen test. Men undergoing prostate specific antigen testing were more likely to have had a prior cancer diagnosis other than prostate cancer (OR 3.93, 95% CI 1.19-12.94) and to have had at least some college education (OR 11.35, 95% CI 3.29-39.04). Men 40 to 49 years old had decreased odds of undergoing prostate specific antigen testing compared to men 50 to 69 years old (OR 0.20, 95% CI 0.10-0.39). History of cancer (OR 2.50, 95% CI 1.19-5.26) was associated with greater odds of being counseled on the potential adverse effects of prostate cancer treatment. Younger men (age 40 to 49 years) had decreased odds of discussing the prostate specific antigen test with a health care professional (OR 0.32, 95% CI 0.16-0.62) and being informed of the controversy surrounding prostate specific antigen screening (OR 0.35, 95% CI 0.13-0.95). CONCLUSIONS: We show that certain men receive substantially different prostate specific antigen screening counseling, which may impact shared patient-provider decision making before prostate specific antigen counseling.

Addressing Unmet Basic Resource Needs as Part of Chronic Cardiometabolic Disease Management.

Importance: It is unclear if helping patients meet resource needs, such as difficulty affording food, housing, or medications, improves clinical outcomes. Objective: To determine the effectiveness of the Health Leads program on improvement in systolic and diastolic blood pressure (SBP and DBP, respectively), low-density lipoprotein cholesterol (LDL-C) level, and hemoglobin A1c (HbA1c) level. Design, Setting, and Participants: A difference-in-difference evaluation of the Health Leads program was conducted from October 1, 2012, through September 30, 2015, at 3 academic primary care practices. Health Leads consists of screening for unmet needs at clinic visits, and offering those who screen positive to meet with an advocate to help obtain resources, or receive brief information provision. Main Outcomes and Measures: Changes in SBP, DBP, LDL-C level, and HbA1c level. We compared those who screened positive for unmet basic needs (Health Leads group) with those who screened negative, using intention-to-treat, and, secondarily, between those who did and did not enroll in Health Leads, using linear mixed modeling, examining the period before and after screening. Results: A total of 5125 people were screened, using a standardized form, for unmet basic resource needs; 3351 screened negative and 1774 screened positive. For those who screened positive, the mean age was 57.6 years and 1811 (56%) were women. For those who screened negative, the mean age was 56.7 years and 909 (57%) were women. Of 5125 people screened, 1774 (35%) reported at least 1 unmet need, and 1021 (58%) of those enrolled in Health Leads. Median follow-up for those who screened positive and negative was 34 and 32 months, respectively. In unadjusted intention-to-treat analyses of 1998 participants with hypertension, the Health Leads group experienced greater reduction in SBP (differential change, -1.2; 95% CI, -2.1 to -0.4) and DBP (differential change, -1.0; 95% CI, -1.5 to -0.5). For 2281 individuals with an indication for LDL-C level lowering, results also favored the Health Leads group (differential change, -3.7; 95% CI -6.7 to -0.6). For 774 individuals with diabetes, the Health Leads group did not show HbA1c level improvement (differential change, -0.04%; 95% CI, -0.17% to 0.10%). Results adjusted for baseline demographic and clinical differences were not qualitatively different. Among those who enrolled in Health Leads program, there were greater BP and LDL-C level improvements than for those who declined (SBP differential change -2.6; 95% CI,-3.5 to -1.7; SBP differential change, -1.4; 95% CI, -1.9 to -0.9; LDL-C level differential change, -6.3; 95% CI, -9.7 to -2.8). Conclusions and Relevance: Screening for and attempting to address unmet basic resource needs in primary care was associated with modest improvements in blood pressure and lipid, but not blood glucose, levels.

Preoperative assessment of surgical risk: creation of a scoring tool to estimate 1-year mortality after emergency abdominal surgery in the elderly patient.

BACKGROUND: The risk of mortality after emergency general surgery (EGS) in elderly patients is prolonged beyond initial hospitalization. Our objective was to develop a preoperative scoring tool to quantify risk of 1-year mortality. METHODS: Three hundred ninety EGS patients aged 70 years or more were analyzed. Risk factors for 1-year mortality were identified using stepwise-forward logistic multivariate regression and weights assigned using natural logarithm of odds ratios. A geriatric emergency surgery mortality (GEM) score was derived from the aggregate of weighted scores. Leave-one-out cross-validation was performed. RESULTS: One-year mortality was 32%. Risk factors and their weights were: acute kidney injury (2), American Society of Anesthesiology class greater than or equal to 4 (2), Charlson Comorbidity Index greater than or equal to 4 (1), albumin less than 3.5 mg/dL (1), and body mass index (less than 18.5 kg/m2 [1]; 18.5 to 29.9 kg/m2 [0]; ≥30 kg/m2 [-1]). One-year mortality was: GEM 0 to 1 (0% to 7%); GEM 2 to 5 (32% to 68%); GEM 6 to 8 (94% to 100%). C-statistics were .82 and .75 in training and validation data sets, respectively. CONCLUSIONS: A simple score using 5 clinical variables predicts 1-year mortality after EGS with reasonable accuracy and assists in preoperative counseling.

Risk of Small Bowel Obstruction After Robot-Assisted vs Open Radical Prostatectomy.

BACKGROUND AND PURPOSE: Whereas open radical prostatectomy is performed extraperitoneally, minimally invasive radical prostatectomy is typically performed within the peritoneal cavity. Our objective was to determine whether minimally invasive radical prostatectomy is associated with an increased risk of small bowel obstruction compared with open radical prostatectomy. PATIENTS AND METHODS: In the U.S. Surveillance, Epidemiology and End Results (SEER)-Medicare database, we identified 14,147 men found to have prostate cancer from 2000 to 2008 treated by open (n = 10,954) or minimally invasive (n = 3193) radical prostatectomy. Multivariable Cox proportional hazard models were used to examine the impact of surgical approach on the diagnosis of small bowel obstruction, as well as the need for lysis of adhesions and exploratory laparotomy. RESULTS: During a median follow-up of 45 and 76 months, respectively, the cumulative incidence of small bowel obstruction was 3.7% for minimally invasive and 5.3% for open radical prostatectomy (p = 0.0005). Lysis of adhesions occurred in 1.1% of minimally invasive and 2.0% of open prostatectomy patients (p = 0.0003). On multivariable analysis, there was no significant difference between minimally invasive and open prostatectomy with respect to small bowel obstruction (HR 1.17, 95% CI 0.90, 1.52, p = 0.25) or lysis of adhesions (HR 0.87, 95% CI 0.50, 1.40, p = 0.57). Limitations of the study include the retrospective design and use of administrative claims data. CONCLUSIONS: Relative to open radical prostatectomy, minimally invasive radical prostatectomy is not associated with an increased risk of postoperative small bowel obstruction and lysis of adhesions.

Determinants of cancer screening in Asian-Americans.

PURPOSE: Recent data suggest that Asian-Americans (AsAs) are more likely to present with advanced disease when diagnosed with cancer. We sought to determine whether AsAs are under-utilizing recommended cancer screening. METHODS: Cross-sectional analysis of the 2012 Behavioral Risk Factor Surveillance System comprising of AsAs and non-Hispanic White (NHW) community-dwelling individuals (English and Spanish speaking) eligible for colorectal, breast, cervical, or prostate cancer screening according to the United States Preventive Services Task Force recommendations. Age, education and income level, residence location, marital status, health insurance, regular access to healthcare provider, and screening were extracted. Complex samples logistic regression models quantified the effect of race on odds of undergoing appropriate screening. Data were analyzed in 2015. RESULTS: Weighted samples of 63.3, 33.3, 47.9, and 30.3 million individuals eligible for colorectal, breast, cervical, and prostate cancer screening identified, respectively. In general, AsAs were more educated, more often married, had higher levels of income, and lived in urban/suburban residencies as compared to NHWs (all p < 0.05). In multivariable analyses, AsAs had lower odds of undergoing colorectal (odds ratio [OR] 0.78, 95 % confidence interval [CI] 0.63-0.96), cervical (OR 0.45, 95 % CI 0.36-0.55), and prostate cancer (OR 0.55, 95 % CI 0.39-0.78) screening and similar odds of undergoing breast cancer (OR 1.29, 95 % CI 0.92-1.82) screening as compared to NHWs. CONCLUSIONS: AsAs are less likely to undergo appropriate screening for colorectal, cervical, and prostate cancer. Contributing reasons include limitations in healthcare access, differing cultural beliefs on cancer screening and treatment, and potential physician biases. Interventions such as increasing healthcare access and literacy may improve screening rates.

Surgeon and Hospital Level Variation in the Costs of Robot-Assisted Radical Prostatectomy.

PURPOSE: We assessed surgeon and hospital level variation in robot-assisted radical prostatectomy costs and predictors of high and low cost surgery. MATERIALS AND METHODS: The study population consisted of a weighted sample of 291,015 men who underwent robot-assisted radical prostatectomy for prostate cancer by 667 surgeons at 197 U.S. hospitals from 2003 to 2013. We evaluated 90-day direct hospital costs (2014 USD) in the Premier Hospital Database. High costs per robot-assisted radical prostatectomy were those above the 90th percentile and low costs were those below the 10th percentile. RESULTS: Mean hospital cost per robot-assisted radical prostatectomy was $11,878 (95% CI $11,804-$11,952). Mean cost was $2,837 (95% CI $2,805-$2,869) in the low cost group vs $25,906 (95% CI $24,702-$25,490) in the high cost group. Nearly a third of the variation in robot-assisted radical prostatectomy cost was attributable to hospital characteristics and more than a fifth was attributable to surgeon characteristics (R-squared 30.43% and 21.25%, respectively). High volume surgeons and hospitals (90th percentile or greater) had decreased odds of high cost surgery (surgeons: OR 0.24, 95% CI 0.11-0.54; hospitals: OR 0.105, 95% CI 0.02-0.46). The performance of robot-assisted radical prostatectomy at a high volume hospital was associated with increased odds of low cost robot-assisted radical prostatectomy (OR 839, 95% CI 122-greater than 999). CONCLUSIONS: This study provides insight into the role of surgeons and hospitals in robot-assisted radical prostatectomy costs. Given the substantial variability, identifying and remedying the root cause of outlier costs may yield substantial benefits.

Data on Medicare eligibility and cancer screening utilization.

Health insurance is associated with increased utilization of cancer screening services. Data on breast, prostate and colorectal cancer screening were abstracted from the 2012 Behavioral Risk Factor and Surveillance System. This data in brief includes two sets of analyses: (i) the use of cancer screening in individuals within the low-income bracket and (ii) determinants for each of the three approaches to colorectal cancer screening (fecal occult blood test, colonoscopy and sigmoidoscopy+fecal occult blood test). Covariates included education attainment, residency, and access to health care provider. The data supplement our original research article on the effect of Medicare eligibility on cancer screening utilization "The impact of Medicare eligibility on cancer screening behaviors" [1].

Variation in National Use of Long-Term ADT by Disease Aggressiveness Among Men With Unfavorable-Risk Prostate Cancer.

BACKGROUND: The current NCCN Clinical Practice Guidelines in Oncology for Prostate Cancer recommend long-term androgen deprivation therapy (ADT) for all men with high-risk prostate cancer treated with external-beam radiation therapy (EBRT). We determined whether the use of long-term ADT varied by the recently defined subcategories of high-risk disease (favorable, other, and very high) versus unfavorable intermediate-risk disease. METHODS: We identified 5,524 patients with unfavorable-risk prostate cancer diagnosed from 2004 to 2007 and managed with EBRT using the SEER-Medicare linked database. Patients were stratified by risk group: unfavorable intermediate-risk, favorable high-risk (previously defined and validated as clinical stage T1c, Gleason score of 4 + 4 = 8, and prostate-specific antigen [PSA] level <10 ng/mL, or clinical stage T1c, Gleason score of 6, and PSA level >20 ng/mL), very-high-risk (clinical stage T3b-T4 or primary Gleason pattern 5), or other high risk (ie, neither favorable nor very high). We used multivariable competing risks regression to estimate the rates of long-term (≥2 years) ADT by group. RESULTS: Men with favorable high-risk prostate cancer were significantly less likely to receive long-term ADT than those with other high-risk disease (15.4% vs 24.6%, adjusted hazard ratio [AHR], 0.68; 95% CI, 0.60-0.76;P<.001), and similarly likely as those with unfavorable intermediate-risk disease (AHR, 1.10; 95% CI, 0.99-1.23;P=.087). Other high-risk disease was less likely to receive long-term ADT than very high-risk cancer (24.6% vs 30.8%; AHR, 0.83; 95% CI, 0.74-0.93;P=.002). CONCLUSIONS: Despite current guidelines, patients with EBRT-managed high-risk prostate cancer received significantly different rates of long-course ADT based on subclassification. Our results suggest that oncologists view these patients as a heterogeneous group with favorable high-risk cancer warranting less aggressive therapy than other high-risk or very high-risk disease.

Association of Androgen Deprivation Therapy With Depression in Localized Prostate Cancer.

PURPOSE: Androgen deprivation therapy (ADT) may contribute to depression, yet several studies have not demonstrated a link. We aimed to determine whether receipt of any ADT or longer duration of ADT for prostate cancer (PCa) is associated with an increased risk of depression. METHODS: We identified 78,552 men older than age 65 years with stage I to III PCa using the SEER-Medicare-linked database from 1992 to 2006, excluding patients with psychiatric diagnoses within the prior year. Our primary analysis was the association between pharmacologic ADT and the diagnosis of depression or receipt of inpatient or outpatient psychiatric treatment using Cox proportional hazards regression. Drug data for treatment of depression were not available. Our secondary analysis investigated the association between duration of ADT and each end point. RESULTS: Overall, 43% of patients (n = 33,882) who received ADT, compared with patients who did not receive ADT, had higher 3-year cumulative incidences of depression (7.1% v 5.2%, respectively), inpatient psychiatric treatment (2.8% v 1.9%, respectively), and outpatient psychiatric treatment (3.4% v 2.5%, respectively; all P < .001). Adjusted Cox analyses demonstrated that patients with ADT had a 23% increased risk of depression (adjusted hazard ratio [AHR], 1.23; 95% CI, 1.15 to 1.31), 29% increased risk of inpatient psychiatric treatment (AHR, 1.29; 95% CI, 1.17 to 1.41), and a nonsignificant 7% increased risk of outpatient psychiatric treatment (AHR, 1.07; 95% CI, 0.97 to 1.17) compared with patients without ADT. The risk of depression increased with duration of ADT, from 12% with ≤ 6 months of treatment, 26% with 7 to 11 months of treatment, to 37% with ≥ 12 months of treatment (P trend < .001). A similar duration effect was seen for inpatient (P trend < .001) and outpatient psychiatric treatment (P trend < .001). CONCLUSION: Pharmacologic ADT increased the risk of depression and inpatient psychiatric treatment in this large study of elderly men with localized PCa. This risk increased with longer duration of ADT. The possible psychiatric effects of ADT should be recognized by physicians and discussed with patients before initiating treatment.

Explaining the excess morbidity of emergency general surgery: packed red blood cell and fresh frozen plasma transfusion practices are associated with major complications in nonmassively transfused patients.

BACKGROUND: Intraoperative blood product transfusions carry risk but are often necessary in emergency general surgery (EGS). METHODS: We queried the American College of Surgery-National Surgical Quality Improvement Program database for EGS patients (2008 to 2012) at 2 tertiary academic hospitals. Outcomes included rates of high packed red blood cell (pRBC) use (estimated blood loss:pRBC < 350:1) and high fresh frozen plasma (FFP) use (FFP:pRBC >1:1.5). Patients were then stratified by exposure to high blood product use. Stepwise logistic regression was performed. RESULTS: Of 992 patients, 33% underwent EGS. Estimated blood loss was similar between EGS and non-EGS (282 vs 250 cc, P = .288). EGS patients were more often exposed to high pRBC use (adjusted odds ratio [OR] = 2.01, 95% confidence interval [CI] = 1.11 to 3.66) and high-FFP use (OR = 2.75, 95% CI: = 1.10 to 6.84). High blood product use was independently associated with major nonbleeding complications (high pRBC: OR = 1.73, 95% CI = 1.04 to 2.91; high FFP: OR = 2.15, 95% CI = 1.15 to 4.02). CONCLUSIONS: Despite similar blood loss, EGS patients received higher rates of intraoperative blood product transfusion, which was independently associated with major complication.