Introduction

We assessed surgeon knowledge of commonly used instruments and disposable items and described attitudes toward incorporating cost data into daily practice.

Methods

An electronic, e-mail based survey was distributed to faculty and trainees in the University of California San Francisco (UCSF) Department of Urology. The 26-question survey assessed opinions regarding general operating room supply cost information and specific costs of 10 supplies used for laparoscopic nephrectomy. A response was considered accurate when it fell within 50% of the actual cost.

Results

The response rate was 71% among faculty (13) and 90% among trainees (17). Overall 55% of faculty and 82% of trainees considered their knowledge of costs "fair" or "poor." The overall accuracy of cost estimation for 10 commonly used supply items was 27% (SD ± 45%), with no significant difference between trainees and faculty (p=0.70). Accuracy was not associated with self-reported cost knowledge (p=0.25) or number of laparoscopic nephrectomies performed (p=0.47). Of the faculty 33% and of the trainees 41% reported that having more knowledge of costs would motivate them to decrease their operating room supply costs, and 42% of faculty raised the idea of an incentive program. Overall 75% of study participants believe that there is "too little" or "not enough" emphasis placed on cost awareness.

Conclusions

Trainees and faculty generally have poor knowledge of operating room supply costs. In our academic setting we noted an interest among faculty and residents to make cost data more accessible. These data would provide an opportunity for surgeons to act as cost arbiters in the operating room.

INTRODUCTION: Rising health care costs are leading to efforts to minimize costs while maintaining high quality care. Practice variation in the operating room that is not dictated by patient necessity or clinical guidelines presents an opportunity for cost containment. We identified variation in surgical supply costs among urological surgeons performing laparoscopic nephrectomy and evaluated whether this variation was associated with patient outcomes. METHODS: A total of 211 consecutive laparoscopic nephrectomies performed at an academic center between September 1, 2012 and December 31, 2015 were identified and surgical supply costs for each case were determined from the institutional negotiated rate. Patient and surgical factors relevant to case complexity, comorbidity and perioperative outcomes were obtained. Univariate and multivariable analysis of predictors of surgical supply costs and patient outcome as determined by length of stay was conducted. RESULTS: Median supply cost was $2,537, with individual medians ranging from $1,642 to $4,524, representing a significant variation among surgeons (p <0.01). On multivariable analysis, accounting for patient factors and case complexity, most surgeons remained significant predictors of surgical supply costs. Case supply cost was not a significant predictor of patient outcomes as measured by length of stay on univariate or multivariable analysis controlling for surgeon, patient factors and case complexity. CONCLUSIONS: Significant variation in surgeons surgical supply costs for laparoscopic nephrectomy exists and is driven by surgeons, and this does not correlate with length of stay. Targeting variation in surgical supply costs in this setting represents an opportunity for cost savings without adversely impacting patient outcomes.

INTRODUCTION: We assessed surgeon knowledge of commonly used instruments and disposable items and described attitudes toward incorporating cost data into daily practice. METHODS: An electronic, e-mail based survey was distributed to faculty and trainees in the University of California San Francisco (UCSF) Department of Urology. The 26-question survey assessed opinions regarding general operating room supply cost information and specific costs of 10 supplies used for laparoscopic nephrectomy. A response was considered accurate when it fell within 50% of the actual cost. RESULTS: The response rate was 71% among faculty (13) and 90% among trainees (17). Overall 55% of faculty and 82% of trainees considered their knowledge of costs fair or poor. The overall accuracy of cost estimation for 10 commonly used supply items was 27% (SD ± 45%), with no significant difference between trainees and faculty (p=0.70). Accuracy was not associated with self-reported cost knowledge (p=0.25) or number of laparoscopic nephrectomies performed (p=0.47). Of the faculty 33% and of the trainees 41% reported that having more knowledge of costs would motivate them to decrease their operating room supply costs, and 42% of faculty raised the idea of an incentive program. Overall 75% of study participants believe that there is too little or not enough emphasis placed on cost awareness. CONCLUSIONS: Trainees and faculty generally have poor knowledge of operating room supply costs. In our academic setting we noted an interest among faculty and residents to make cost data more accessible. These data would provide an opportunity for surgeons to act as cost arbiters in the operating room.

BACKGROUND: Financial toxicity of bladder cancer care may influence how patients utilize healthcare resources, from emergency department (ED) encounters to office visits. We aim to examine whether greater household net worth (HHNW) confers differential access to healthcare resources after radical cystectomy (RC). METHODS: This population-based cohort study examined the association between HHNW and healthcare utilization costs in the 90 days post-RC in commercially insured patients with bladder cancer. Costs accrued from the index hospitalization to 90 days after including health plan costs (HPC) and out-of-pocket costs (OPC). Multivariable logistic regression models were generated by encounter (acute inpatient, ED, outpatient, and office visit). RESULTS: A total of 141,903 patients were identified with HHNW categories near evenly distributed. Acute inpatient encounters incurred the greatest HPC and OPC. Office visits conferred the lowest HPC while ED visits had the lowest OPC. Black patients harbored increased odds of an acute inpatient encounter (OR 1.22, 95% CI 1.16-1.29) and ED encounter (OR 1.20, 95% CI 1.14-1.27) while Asian (OR 0.76, 95% CI 0.69-0.85) and Hispanic (OR 0.74, 95% CI 0.69-0.78, p < 0.001) patients had lower odds of an outpatient encounter, compared to White counterpart. Increasing HHNW was associated with decreasing odds of acute inpatient or ED encounters and greater odds of office visits. CONCLUSIONS: Lower HHNW conferred greater risk of costly inpatient encounters while greater HHNW had greater odds of less costly office visits, illustrating how financial flexibility fosters differences in healthcare utilization and lower costs. HHNW may serve as a proxy for financial flexibility and risk of financial hardship than income alone.

A 29-year-old man presenting with a retroperitoneal mass was found to have a testis lesion consistent with mixed germ cell tumor and the RPLND specimen showed teratoma with an area of central nervous system-type primitive neuroectodermal tumor (PNET) not present in the testis. Whether such primitive tumor components represent a de novo tumor component or represent progression from existing neuroepithelial teratomatous elements is unclear. Given the high likelihood of residual tumor and possibility of malignant transformation, post-chemotherapy RPLND remains vital in treating patients with testis cancer. PNET is chemo-resistant and lesions should be resected, without clear evidence for adjuvant chemotherapy.

Introduction

Rising health care costs are leading to efforts to minimize costs while maintaining high quality care. Practice variation in the operating room that is not dictated by patient necessity or clinical guidelines presents an opportunity for cost containment. We identified variation in surgical supply costs among urological surgeons performing laparoscopic nephrectomy and evaluated whether this variation was associated with patient outcomes.

Methods

A total of 211 consecutive laparoscopic nephrectomies performed at an academic center between September 1, 2012 and December 31, 2015 were identified and surgical supply costs for each case were determined from the institutional negotiated rate. Patient and surgical factors relevant to case complexity, comorbidity and perioperative outcomes were obtained. Univariate and multivariable analysis of predictors of surgical supply costs and patient outcome as determined by length of stay was conducted.

Results

Median supply cost was $2,537, with individual medians ranging from $1,642 to $4,524, representing a significant variation among surgeons (p <0.01). On multivariable analysis, accounting for patient factors and case complexity, most surgeons remained significant predictors of surgical supply costs. Case supply cost was not a significant predictor of patient outcomes as measured by length of stay on univariate or multivariable analysis controlling for surgeon, patient factors and case complexity.

Conclusions

Significant variation in surgeons' surgical supply costs for laparoscopic nephrectomy exists and is driven by surgeons, and this does not correlate with length of stay. Targeting variation in surgical supply costs in this setting represents an opportunity for cost savings without adversely impacting patient outcomes.

Purpose

In many patients partial nephrectomy is the preferred alternative to radical nephrectomy for upper urinary tract cancers. We describe the use of laparoscopic nephrectomy, ex vivo excision and reconstruction, and autotransplantation to expand the realm of minimally invasive, nephron sparing surgery to the most complex renal tumors.

Materials and methods

In our cohort undergoing renal surgery 2 patients had a solitary kidney with renal tumors not considered amenable to in situ partial nephrectomy. After transperitoneal laparoscopic nephrectomy ex vivo tumor excision and renorrhaphy were performed. The kidney was transplanted to the ipsilateral iliac vessels through the Gibson extraction incision.

Results

Indications for surgery were high grade urothelial carcinoma within a caliceal diverticulum and a central 5 cm renal cell carcinoma. Mean nephrectomy, cold ischemic and transplantation times were 4.5, 2 and 3.7 hours, respectively. No intraoperative or postoperative complications were noted. Hospitalization was 12 and 6 days, respectively. At 20 and 12 months of followup each patient remained off dialysis without evidence of recurrence.

Conclusions

Despite experience with conventional nephron sparing surgery some cases may be more appropriate for ex vivo excision and reconstruction. In these situations the minimally invasive approach provides a kidney suitable for renal autotransplantation, while simultaneously decreasing patient morbidity. This novel approach to complex renal tumors is feasible when one applies principles of laparoscopic donor nephrectomy and possesses experience with renal transplantation.