Public Policy - Data Quality

Objectives

As the U.S. healthcare system shifts from fee-for-service reimbursement to value-based payment paradigms, pay-for-performance (P4P) models have striven to improve the value of healthcare (i.e., improve quality and lower cost). We developed a prostate cancer (PCa) active surveillance (AS) P4P incentive payment model to improve the appropriate adoption and quality of surveillance or watchful waiting (WW) for men with low-risk PCa. Our pilot study develops and tests quality measures, performance thresholds, technology infrastructure and its cost-effectiveness to support the P4P model.

Methods

In collaboration with the national Prostate Cancer Active Surveillance Project (PCASP) consortium, Genesis Healthcare Partners (GHP), developed 4 quality measures: Utilization of an electronic medical record (EMR)-embedded template to capture physician assessed PCa risk and management strategy, Adoption of AS/WW for low-risk PCa, Quality of surveillance with PSA testing, and Quality of surveillance with biopsy procedures. The GHP WizMD® software platform overlays the EMR allowing it to retrieve, organize and report on clinical/pathology data from the EMR-embedded templates. The templates prompt physicians to assess and document the patient’s PCa risk category and management strategy. We undertook a pilot study at a centralized location within GHP.

Results

Compared to manual chart review data abstraction, automated template data abstraction resulted in a 26-fold decrease in cost (n=450 patients x2 visits per year). Template use has been well received. A physician commented: “The template is intuitively easy to use. It takes no more than 1 minute to input the data. While it is an additional step, it is not onerous and appropriate classification and documentation is what we should be doing all the time.”

Conclusions

Value-based payment models, including pay-for-performance, require quality measures that can be assessed with a high degree of fidelity to support a payment-incentive method. Our pilot study shows that detailed PCa data on risk stratification and patient management selection can be efficiently, reliably and cost-effectively retrieved from the EMR using information technology to avoid the need for manual chart review.

Introduction: Radiation exposure is a significant concern for patients and health care providers. Manufacturers of flat panel C-arms have claimed reduced radiation exposure, however, the dose delivered at the lowest possible settings for each C-arm type hasn't been compared. The purpose of this study was to compare the cumulative radiation dose between the OEC Elite CMOS Flat Detector (FD) and the conventional OEC 9800 Image Intensifier C-Arm (Round) in a cadaver model.

Methods:  Optically stimulated luminescence (OSL) chips were implanted into a cadaver as seen in Figure 1. Five trials were performed at six different C-arm settings: round 1PPS (lowest possible setting) at standard and low dose, round 4PPS at standard and low dose, and FD 4PPS (lowest possible setting) at standard and low dose. All trials used five minutes of fluoroscopy with automatic brightness control. Radiation dose and settings were compared using t-tests, with p<0.05 considered significant.

Results: When comparing the FD and Round C-arms at their lowest possible pulse settings, the FD produced 3-5 times more radiation exposure at all locations using standard dose settings (Table 1). This difference was maintained in all locations at low dose settings (p<0.05 for all, data not shown). When comparing FD and Round C-arms at 4PPS, radiation exposure from the FD was about 2x higher when using standard exposure settings (Table 1). At low dose settings and 4PPS, the FD and Round C-arms produced equivalent radiation exposure at all locations (P>0.05 for all).

Conclusions: While modern flat panel detector C-arm manufacturers advertise lower radiation exposure, when FD machines are utilized at the lowest pulse settings they produce approximately 4x greater radiation exposure than the Round panel at the lowest pulse settings. At both standard and low dose settings, the round C-arm produced significantly less radiation exposure. When it is imperative to have the lowest possible radiation exposure, for example when operating on pregnant patients or in children, older round C-arms should be utilized.

Introduction & Objective: There are significant risks associated with radiation exposure. Recurrent stone formers and the urologists that treat them are exposed to significant intraoperative radiation. Recently, reduced fluoroscopy protocols during ureteroscopy (URS) have been developed. No large previous series have determined whether a minimum fluoroscopic threshold is required to maintain quality of outcome during URS. In this study, the clinical outcomes of URS were compared based upon the amount of fluoroscopy to determine whether a minimum safe fluoroscopic threshold exists.  

Methods: A retrospective review of 520 patients undergoing URS for urolithiasis between January 2015 and June 2019 performed by a single fellowship trained endourologist was conducted. Patients undergoing multiple procedures or URS for entombed stents were excluded. Patient characteristics, operative, and post-operative outcomes were collected and stratified by fluoroscopy time into ‘ultra-low’ (0-1.5 sec) ‘very low’ (1.5-6 sec) and ‘low’ (>6 sec) groups. ANOVA and Chi-square tests were used with p<0.05 considered significant.

Results: Of the 335 patients included in the study, 120 were in the ‘ultra-low,’ 107 were in the ‘very low,’ and 108 were in the ‘low’ fluoroscopy groups. The mean fluoroscopy times were 0.45, 3.4 and 18.0 sec. for the ‘ultra-low’ ‘very low’ and ‘low’ groups, respectively. The mean BMI (30.3; p=0.856), total stone burden (117.7mm2; p=0.252), stone location (p=207), and density (810.9HU; p=0.878) were similar between all groups. Fifty patients had no fluoroscopy used (14.9%). Stone free rate overall was 80.7% and did not differ between groups (p=0.067). Hospital stay (10.9h, 23.6h and 20.1h, p=0.154), re-operation rate (14.9%, 9.3% and 12%, p=0.444), and complication rates (5%, 7.5% and 7.3%, p=0.687) were not different between the ‘ultra-low’ ‘very low’ and ‘low’ groups, respectively.

Conclusions: Our study showed that both ultra-low and very low fluoroscopy times did not compromise clinical outcomes. This suggests that there is no minimum fluoroscopic threshold during uncomplicated URS required to ensure safe and effective surgery. Surgeons should strive to achieve the lowest possible fluoroscopy times to reduce both patient and clinician radiation exposure.

Introduction: Physician burnout is a well-recognized issue in medicine. While there is data to suggest that burnout interventions can be effective, organizational approaches may need to be incorporated as well. Unfortunately, there is little data evaluating the prevalence and effectiveness of specific burnout interventions in urology.

Methods: The Western Section of the American Urological Association created an electronic, 29 question workforce survey. This was distributed to members of the section via e-mail. Several questions focused on assessing the level of urologist burnout, prevalence of work sponsored burnout interventions, and effectiveness of specific interventions. 

Results: A total of 440 responses were received for a 25.9% response rate. 352 were male (82.2%). The majority of urologists noted some level of burnout (n = 349/439, 79.5%). There was no statistically significant difference between those who reported no burnout versus some level of burnout (p = 0.30). The most commonly tried interventions to reduce or prevent burnout were participating in regular physical exercise (n = 337), reading non-medical literature (n = 295), and decreasing or modifying work hours (n = 233). The interventions most frequently cited as “very effective” were hiring a scribe (n = 30/48, 62.5%), regular exercise (n = 189/337, 56.1%), and participating in 1-on-1 gatherings with colleagues outside of work (n = 58/130, 44.6%). There were no significant differences noted when comparing “very effective” interventions by gender. The interventions most frequently cited as not effective were stress or burnout seminars (n = 14/52, 26.9%) and meditation/mindfulness training (n = 14/122, 11.5%). Unfortunately, only 42.5% noted workplace interventions to help prevent or reduce burnout. 

Conclusion: Certain practice changing and personal burnout interventions were noted to be very effective in decreasing or preventing burnout. Less than half of survey responders noted workplace sponsorship of interventions. Organizational support may lead to increased participation and effectiveness of burnout interventions. 

Objectives

The U.S. health care system is undergoing a major paradigm shift away from compensating for the volume of care delivered to its value (outcomes relative to cost). This shift to value and evidence-based medical practice poses a prodigious challenge to our health care system. We examine the goals of recent health care legislation and propose a Pay-for-Performance (P4P) payment incentive model for conservatively managing low-risk prostate cancer (PCa) that aligns with the Quality Payment Program’s (QPP) Alternative Payment Model (APM).

Methods

Genesis Healthcare Partners (GHP), in collaboration with The Prostate Cancer Active Surveillance Project (PCASP), a national consortium of academic and community urologists, has developed quality measures and thresholds determined by expert opinion to improve adoption and quality of conservative management of men with low-risk PCa, thus fulfilling the promise of value-based care. GHP, PCASP and UnitedHealthcare (the largest US payer) have developed a payment incentive model currently being tested as a demonstration project at GHP.

Results

The P4P model includes the following measures:

1. Use of electronic medical record (EMR)-embedded templates, prompting physicians to risk assess and select a management strategy at the point of care.
2.  Adoption of AS or WW for low-risk PCa. Both AS and watchful waiting (WW) are included to promote conservative management, and appropriately reduce the intensity of surveillance when indicated.
3. Surveillance quality with PSA testing biannually. Excluded from this measure are WW patients.
4. Surveillance quality based on confirmatory biopsy within 18 months for AS patients. Excluded from this measure are WW patients.

A pilot study has confirmed the cost-effectiveness of the EMR-embedded templates to acquire structured data for reporting, 26 fold less expensive than manual chart review.

Conclusions

The described P4P payment incentive model represents a novel approach to improve conservative management of men with low-risk PCa. If successful, we believe this approach could be scaled within Urology and be applied to other urological conditions (low-risk bladder and renal tumors), other medical conditions, and be considered a basis for developing APMs. These efforts support the goal of achieving the highest value of health care delivery for our patients.

Introduction: Underserved patients in the community often do not receive guideline concordant care for a variety of urologic conditions. Although prostate cancer has been well-studied in urologic academic settings, less is known about the quality of prostate cancer screening provided to underserved community patients. In an effort to optimize urologic referrals and improve quality of care throughout Southern California, the Inland Empire Health Plan (IEHP) has mandated eConsult implementation for all ambulatory specialty care for its 1.2 million Medicare-Medicaid patients. We hypothesize that eConsult reveals guideline discordant community-based urologic care and provides an opportunity to improve the quality of care for the early detection of prostate cancer in the safety-net.

Methods: Patients referred via eConsult for elevated PSA were retrospectively identified from 2018-2020. The study compared quality of care and referral concordance according to the 2018 American Urological Association guideline for early detection of prostate cancer. Chi-square / Fisher’s exact tests and T-test were used to compare categorical and continuous variables respectively.

Results: From 5/2018-8/2020, 121 patients were referred for elevated PSA. Median age was 63 (IQR: 59,71). In total, 6 (5%) were within the 40-54 age bracket, 81 (67%) were between 55-69 years of age. There were 33 (27%) patients referred over the age of 70, of which none had a documented provider assessment of life expectancy. Regarding high risk indicators, among all providers, 38% asked for family history, 21% asked about race, and 0% asked about BRCA (breast cancer gene). Furthermore, advanced practice providers (NP/PA) assessed for smoking (p<0.001), free/total PSA (p=0.04), and shared decision making (p=0.005) more often than physicians (MD/DO).

Conclusion: The eConsult system provides an avenue to explore community-based data and reveals low rates of appropriate evaluation for high risk indicators associated with PSA screening, high rates of guideline discordant referrals, and better quality assessment by PA/NP’s in various categories. There is an opportunity to educate and optimize provider referrals.

Objectives: A diagnosis of cancer is a life-changing event for patients and their families. Caring for a family member with cancer can be a psychologically stressful experience for caregivers, specifically spouses and family members. The purpose of our study is to investigate the relationship between a genitourinary (GU) cancer diagnosis within the family and the post-diagnosis psychological health of first-degree relatives (FDR) and spouses.    

Methods: GU cancer patients were identified and linked to family members using the Utah Population Database (UPDB). The primary outcome was the onset of depression, anxiety, drug dependence/abuse, mood disorders, and adjustment disorders in family members, after the GU cancer diagnosis of a relative. The secondary outcome was to investigate factors associated with the diagnosis of mental health disorders among caregivers, specifically the type of relationship. Cox proportional hazard models were used to examine the risk of each event in FDR and spouses of individuals with cancer, relative to population controls. All models were adjusted for age, sex, and cancer relative age/sex.

Results: We identified 136,807 individuals diagnosed with GU cancer (1958-2008). In addition, 6,136 family members (spouses/FDR) of individuals with cancer were identified with a mental health disorder diagnosis following the diagnosis of GU cancer within the family. The risks of developing a mental health disorder for FDR and spouses were 1.11 (1.02-1.2) at 1 year, 1.07 (1.02-1.12) at 3 years, and 1.05 (1.01-1.09) at 5 years following the diagnosis of cancer, when compared to the control population.   Parents of children diagnosed with GU cancer were 4.89 (4.12-5.81) times more likely to develop a mental health disorder within 1 year, compared to the diagnosis of cancer in other family members.

Conclusions: FDR and spousal caregivers of cancer patients are at increased risks of developing mental health disorders. These psychological diagnoses may persist over time. There is need for possible policy change to help curtail these risks in family members of cancer patients.

Objectives: Despite clinical guidelines against advanced imaging in men with newly diagnosed low-risk prostate cancer, the use of low-value imaging persists. Previous studies show significant regional variation exists in the use of low-value imaging. The type of health care market in which a provider practices may provide some explanation for this variation. The objective of our study is to examine the relationship between the health care markets in which providers practice, and the use of low-value imaging in prostate cancer.

Methods: Men diagnosed with incident, localized, or locally advanced prostate cancer between 2007-2016 were identified from the Surveillance, Epidemiology, and End Results (SEER) Medicare database. Patients identified with incident, low-risk prostate cancer were assigned to diagnosing urologist or radiation oncologist. Using Medicare claims data from 2007-2016 and the Dartmouth Atlas Hospital Referral Region (HRR), we were able to identify relevant provider claims and associated practice regions. We created count data to show the number of claims for each provider per HRR per year. We evaluated providers health care markets by calculating the Herfindahl-Hirschman index (HHI) for each HRR. Poisson regression models were used to assess the relationship between market competition (HHI) and counts of low-value imaging performed by diagnosing providers. Models were adjusted for patient age group, CCI, and race.

Results: We identified 23,777 patients with low-risk prostate cancer, 4,127 urologists, and 1,197 radiation oncologists between 2007-2016. Our analysis shows the rate of low-value imaging by providers was significantly influenced by health care markets HHI (p<0.001). In overly competitive markets, those with low HHI, diagnosing providers use low value imaging at higher rates. When comparing markets with HHIs between 0-799 (very competitive), to markets with HHIs between 1300 1899 (average competition), providers in very competitive markets use low-value imaging at a rate 1.272 times higher than in average competitive markets. Providers in more monopolistic markets, HHIs between 1900-2899 (lower competition), use low-value imaging at a rate 1.103 times higher than in average competitive markets.

Conclusions: Urologists and radiation oncologists practicing in average competitive health care markets provide less low-value imaging than those practicing in more competitive or more monopolistic markets.

Introduction and Objective: Quality improvement and patient safety (QIPS) have grown increasingly important in medicine. Little research has been done to quantify QIPS participation within urology and to differentiate participants from nonparticipants. We describe QIPS engagement in urology and factors related to non-participation.

Methods: We used the 2018 American Urologic Association census data to assess urology participation in various QIPS programs. QIPS participants and non-participants were compared using univariate and multivariate analyses to explore factors predictive of QIPS non-participation.

Results: Stratified weighted analysis was performed to represent 12,660 practicing urologists in the United States. Most urologists were Caucasian (80.1%), non-Hispanic (93.8%), males (90.8%) working in metropolitan (88.9%) private practice settings (56.9%) with a median age of 56 and 21.7 (SE 0.53) years of practice. 90.5% of urologists reported participation in QIPS initiatives. QIPS participants and non-participants significantly differed in distributions of age (p < .05), gender (p < .01), practice setting (p < .001), employment status (p < .001), and fellowship training (p < .001). Participants reported fewer years in practice (21.3 vs. 25.9, p < .05) and higher clinical (45.2 vs. 39.2, p < .05) and non-clinical hours (8.76 vs. 5.28, p < 0.01) working per week. Non-participation was predicted by male gender (OR = 2.68, 95% CI 1.03-6.95) (Table 1) and Asian race (OR = 2.59, 95% CI 1.27-5.29) for quality and private practice setting (ORs range from 8.72-27.8) (Table 2) for safety. Quality and safety participation were mutually predictive.

Conclusions: QIPS participation was associated with academic settings. Interventions to increase rates of quality and safety participation should target individual and system-level factors, respectively. Future work should discern barriers to QIPS engagement and quantify the clinical benefits of QIPS engagement.

Introduction: Healthcare providers are one of the leading contributors to the current opioid epidemic.Understanding opioid prescribing practices and patients’ narcotic requirements while not over-prescribing opioids is a public health priority. In this study, we aim to better understand the pain needs of our urologic patients. 

Methods: We conducted a prospective study to examine opioid consumption among adult patients who presented for outpatient urologic surgery at the University of California San Francisco (UCSF) and Zuckerberg San Francisco General (ZSFG) hospitals. We administered a Pre-Operative Pain Requirement Assessment Tool (POPRAT) 3 days prior to surgery to identify objective factors that may predict post-operative pain and opioid requirements.

Results: 263 participants were eligible for the study and 211 completed the study. Urology patients undergoing outpatient elective procedures used a mean of 5 morphine milligram equivalents (MME) (SD=14.9) in a 7-day period. Women and patients less than 45 years of age had the highest opioid use. Based on the POPRAT, major predictors of post-operative pain were pre-operative anxiety (0.34 estimate, p value < 0.001) and anticipated pain (0.34 estimate, p value < 0.001). Anticipated opioid use, however, did not predict actual opioid use. 

Conclusions: Urologic outpatient surgeries require minimal opioids for pain management. The POPRAT may help identify which patients may experience more pain after surgery. Certain factors such as age and gender may need to be considered when prescribing opioids. 

OBJECTIVE: Robotic assisted laparoscopic radical prostatectomy (RALP) is a standard of care for localized prostate cancer. Buprenorphine is an FDA approved opioid for acute pain but is also used for management of opioid addiction. It has unique mu receptor agonist-antagonist properties with potentially lower opioid side effects in surgical patients. The purpose of this multidisciplinary study (urologists, anesthesia/pain specialists) is to examine perioperative outcomes in patients who received standard mu opioid agonists versus buprenorphine for perioperative pain.

METHODS: Two perioperative analgesic pathways were designed for patients undergoing RALP. A retrospective study in a single institution over a 10-month period was performed. The conventional group (n=45) used standard mu opioid agonists and the intervention group (n=40) used buprenorphine. Five patients from each group were excluded due to loss of follow-up. The patients were surveyed on postoperative day five. The primary endpoint was adequate pain control. The secondary endpoints were length of stay, opioid-related side effects and patient satisfaction. Statistical analysis was performed using Mann- Whitney U for nominal variables and Chi-square for categorical variables, with p<0.05 considered significant.

RESULTS: There was a significant reduction in the number of patients using mu opioid agonists in the buprenorphine group compared to the conventional group (tramadol 3.3% vs 37.5%, p=0.001 and hydrocodone/acetaminophen 0% vs 20%, p=0.009). There was no difference between the buprenorphine group and the conventional group in length of stay (1.1 vs 1.3 days, p=0.18), pain control (0-10 scale) at the time of discharge (5.2 vs 5.7, p=0.4) and overall patient satisfaction (p=0.1). Patients in the intervention group had similar duration to return of bowel function compared to the conventional group (2.6 vs 2.7 days, p=0.7). There were more patients reporting subjective constipation in the conventional group vs intervention group, although not statistically significant (35% vs 30%, p=0.19).

CONCLUSIONS: The use of buprenorphine in a multimodal perioperative analgesic pathway for RALP was found to significantly reduce the use of standard mu opioid agonists. This was achieved while maintaining patient satisfaction and pain control between the two groups. This novel pathway can greatly reduce opioid use in patients undergoing RALP.

Introduction

Robotic surgical performance, in particular suturing, has been linked to post-operative clinical outcomes. Prior to attempting live surgery, virtual reality (VR) simulators afford opportunities for training surgeons to learn fundamental technical skills. Herein, we evaluate the ability to transfer suturing technical skill assessments between VR simulation, live surgery, and functional clinical outcomes.  

Methods

20 surgeons completed a VR suturing exercise on the Mimic^TM Flex VR simulator. Videos of the same surgeons performing the anterior vesicourethral anastomosis during robot-assisted radical prostatectomy (RARP) were also obtained. Three independent and blinded graders (DS, RM, AG) received standardized training and provided technical skill scores using the validated assessment tool Robotic Anastomosis Competency Evaluation (RARP). Discrepant scores were discussed until group consensus was reached. Correlations between VR and live scores were assessed by Spearman’s correlation coefficients (𝛒). A Generalized Linear Mixed Model was used to test the association between technical skill and urinary continence recovery while adjusting for the clustering of data. 

Results

Training (n=6, median caseload 18 [IQR 2-45]) and expert (n=14, 400 [150-725]) surgeons participated. Statistically significant correlations for scores provided between VR simulation and live surgery were found for Overall and Needle Driving scores (𝛒 = 0.555, p = 0.011; 𝛒 = 0.570, p = 0.009, respectively) (Figure 1A). A sub-analysis performed on training surgeons found significant correlations for overall scores between VR simulation and live surgery (𝛒 = 0.828, p = 0.042) (Figure 1B). High VR needle driving scores had significantly greater continence recovery rate 24 months following RARP compared to low scores (98.5% vs. 84.9%, p=0.028).

Discussion

Our study found that Overall and Needle Driving technical skill scores provided in VR and live surgery were significantly correlated. Training surgeons had a particularly strong association. Additionally, we found that VR needle driving scores were associated with continence recovery following RARP. Our data support the transferability of skills assessments between VR simulation and live surgery and potential implications for clinical outcomes. 

OBJECTIVE: Current evaluations of robotic OR efficiency focus on surgical console time. Fixed OR times are all OR time points other than cut to close surgeon operating time. Our objective was to evaluate fixed OR times for three common robotic urologic procedures: robotic-assisted partial nephrectomy (RAPN), robotic-assisted radical cystectomy (RARC), and robotic-assisted radical prostatectomy (RARP).

METHODS: At our tertiary institution, all urology fixed OR times were prospectively collected for 24 consecutive months. Fixed OR times were defined as: in room time to anesthesia release time (IRAT), anesthesia release time to cut time (ARCT), in room time to cut time (IRCT) (combines IRAT and ARCT), and close time to wheels out time (CTWO). Comparisons between groups were performed using the Fisher exact test for categorical variables and the Kruskal Wallis test for continuous variables. P values less than 0.05 were considered statistically significant in our analysis. All surgeries were performed with the Da Vinci Xi surgical system (Intuitive Surgical Company Sunnyvale, CA, USA).

RESULTS: Over the 24-month period, 77 RARC, 146 RAPN, and 412 RARP were performed. The percent of total OR time occupied by median total fixed OR variable time consisted of 15.1% for RARC (range: 8.9%-49.3%), 26.6% for RAPN (range: 6.6%-87.0%), and 20.1% for RARP (range: 9.0%-39.9%). Median IRAT was longest for RARC (26.0 min, range 1.0-80.0) and shortest for RARP (15.0 min, range 6.0-45.0) (P <0.001). ARCT median time was longest for RAPN (40.0 min, range 7.0-70.0) and shortest for RARP (29.0 min, range 3.0-59.0) (P <0.001). Median IRCT was longest for RAPN (62.0 min, range 6.0-87.0) and shortest for RARP (45.0 min, range 20.0-80.0) (P <0.001). CTWO median time was the same for both RARC (11.0 min, range 1.0-45.0) and RAPN (11.0 min, range 1.0-50.0); it was shortest for RARP (9.0 min, range 1.0-51.0) (P <0.001).

CONCLUSIONS: Fixed OR times made up a significant portion of robotic-assisted surgery total OR time. RARP had the shortest fixed OR times compared to the other robotic urology procedures. These fixed OR times must be taken into account when evaluating OR efficiency in robotic surgery programs.

OBJECTIVE:

Many difficult catheter consultations simply require improved awareness or proper technique. One such example is coude catheter placement. The purpose of this study was to develop an effective and reproducible training curriculum to increase the comfort level of nurses in placing both standard and coude catheters. 

METHODS:

A training workshop was designed and integrated into a nursing skills fair for RN, LPN and nursing students. The urologic training session included an instructional video featuring a demonstration by a staff urologist using a high fidelity male anatomic model and hands-on teaching on commercially available catheter trainers with urologists. Participants completed pre- and post-didactic questionnaires to assess confidence placing catheters independently using a four point Likert scale. Higher scores represented higher degrees of confidence.

RESULTS:

Sixty three nurses completed the training. Thirty eight (60%) were RNs, 5 (8%) were LPNs, and 20 (32%) were students. Mean age was 28.1 years old (SD +/- 7.7 years), and mean time in position was 22.6 months (SD +/- 47.7 months). Twenty two (35%) of the participants had previously placed a coude catheter. Seventeen (27%) participants reported being asked to place a coude but not being comfortable doing so, with 7 (41%) placed by other floor RNs,  7 (41%) placed by urology staff, and 3 (18%) placed by a member of the primary team. There was a significant difference in mean baseline confidence placing standard versus coude catheters (3.03 vs 2.49, p=0.0025, 95% CI -0.89 to -0.19). Following the instructional video, mean level of comfort with standard and coude catheterization increased from 3.03 to 3.51 (P=0.0022, 95% CI 0.18 to 0.8) and 2.49 to 3.38 (P=0.0001, 95% CI 0.32 to 0.96), respectively.  Only 1 participant reported being unable to successfully place a coude catheter independently after the training. Sixty three (100%) participants reported the video increased their understanding of catheter insertion. 

DISCUSSION:

Comfort in coude catheter insertion among nurses is comparatively lower at baseline than standard catheterization at our institution. A dedicated video-based increased nursing confidence and competence in performing this task.

Background: As healthcare systems examine the increasing expenses for graduate medical education (GME), there remains a question of whether graduates trained internally have measurable differences when compared to hires trained elsewhere.

Objectives: We examine the difference between physicians trained within our GME programs versus physicians trained elsewhere. Our large integrated healthcare system is unique in addressing this objective due to its large physician labor hiring needs and its large GME programs.

Methods: A retrospective review was performed from Jan 2000 to August 2020 of all Kaiser Permanente Southern California (KPSC) physicians who were hired: KPSC GME trained versus non-KPSC GME trained. We examined five variables: retention, leadership (current or historical), physician relations cases, member appraisal of physician and provider services survey (MAPPS) scores, and rate of board certification. Chi-square test of proportions was used for comparison, p<0.05 was considered significant.

Results: From Jan 2000 to August 2020, 2,940 residents and fellows graduated from KPSC GME programs, of which 1,127 (38%) were hired on at KPSC as full time attendings. Across all five metrics (Retention, Leadership [current or historical], Physician Relations, MAPPS, and Board Certification), those who had trained at a KPSC GME program outperformed non-KPSC GME trained physicians to a statistically significant degree.

Conclusions: We have shown that an internally sponsored GME program can represent an opportunity for recruitment of physicians that may have higher retention rates, higher probability of being physician leaders, decreased likelihood of physician relations issues, improved patient satisfaction, and increased rates of board certification.

Introduction and Objective: The American Urological Association (AUA) guidelines are widely used to inform urologic standards of care. We sought to study patterns and factors associated with female representation in the American Urological Association (AUA) guidelines. We also examined the proportion of female panelists in European Association of Urology and National Comprehensive Cancer Network urology guidelines.

Methods: We gathered publicly available information about the AUA panelists, including AUA section, practice setting, academic rank, fellowship training, years in practice, and H-index. The factors associated with the proportion of female panelists and trends were investigated. We also examined the proportion of female panelists in the EAU and NCCN urology guidelines.

Results: There were 483 non-unique panelists in AUA guidelines. Of all panelists, 76% (369/483) were urologists, and 17% (82/483) were female. Non-urologist female panelists in AUA guidelines represented a higher proportion than female urologists (30% [34/114] vs. 13% [48/369], p<0.0001). Compared with male panelists, females had lower H-indices (23 [IQR 16-41] vs. 35 [IQR 22-55], p<0.0001), and fewer were fellowship-trained (77% [51/66] vs. 87% [318/366]; X² = 4.15; p=0.042). On multivariate analysis, female representation was associated with being a non-urologist (OR 5.2 [CI 2.2-12.2], p<0.0001) and lower H-indices (OR 0.96 [CI 0.94-0.99], p=0.0024). There was no association with guideline specialties, academic ranking, geographic section, years in practice, and fellowship training with increased female authorship. Over time, the proportion of female participation in guidelines remained stable. In the EAU and NCCN guidelines, 12.2% (22/180) and 10.7% (16/150) of the panelists were female, respectively. 

Conclusions: Female representation among major urologic guidelines authors is low, without significant change over time. The proportion of female urologists in the AUA guidelines is proportional to overall representation in the urology workforce. Being a non-urologist and having lower H-indices were associated with female authorship in guideline panels. As more women enter the urology workforce, additional studies are needed to assess trend in representation over time.

Introduction:   While cystoscopy is a commonly performed procedure for urologists, patients may not know what to expect. Patients want to be treated as an individual and not another “procedure to do.”  For women it is an invasive, personal, and fear-inducing experience. The objective of this study was to re-examine and improve the cystoscopy process for women based on patient input.

Methods:    Women’s perspectives on cystoscopy were collected using experience-based design.  Observations and timings, emotion word lists, debrief forms, patient surveys, simulation, and interviews were used. A structured 2-day quality improvement event was utilized, including both in person and virtual patient participation to gain a deeper understanding of the patient perspective in their own words, using open-ended questions. Ideas for actionable changes were generated using brainstorming, creativity exercises, and prioritization. These changes were implemented and refined using an iterative process based on staff and patient feedback.

Results:    This process improvement work was grounded in the patient perspective. Patients who reported feeling grateful for the positive impact of their care tended to minimize wait times, inconvenience, and discomfort associated with the procedure. Women in the evaluation phase of their treatment and those who were unhappy with their symptoms tended to magnify the negative emotions associated with their procedure. Patient feedback and areas for improvement specific to women’s needs were identified.   Actionable changes were implemented including engaging clinic staff, updating the cystoscopy workflow, and physical changes to enhance patient privacy.

Conclusion:    Identifying and addressing the needs of women undergoing cystoscopy improves satisfaction as their emotional, physical, and knowledge-based needs are being addressed. Active participation in the health care process empowers patients to have a voice in their care.  An extraordinary experience with cystoscopy may decrease anxiety of the unknown and helps patients have control over the experience. 

Source of Funding:   None

Objectives: Having a family member diagnosed with cancer and the following care requirements can serve as a significant source of stress for the entire family. Unfortunately, there is scarce information on the effects this stress has on caregivers’ cardiovascular health. Our study aims to investigate the impact of a family member’s genitourinary cancer (GU) diagnosis on the cardiovascular health of first-degree relatives (FDR) and spouses.

Methods: Utilizing data drawn from the Utah Population Database (UPDB), we linked GU cancer patients to their corresponding family members. We determined the cardiovascular health of FDR/spouses by the onset of myocardial infarction, cerebrovascular disease, heart failure, or hypertensive disease following the GU cancer diagnosis of a relative. We further investigated the impact of GU cancer on the cardiovascular health of family members concerning the type of relation to the patient. Cox proportional hazard models were used to examine the risk of each event in FDR and spouses of individuals with cancer, relative to population controls. All models were adjusted for age, sex, and cancer relative age/sex.

Results: We classified 136,694 persons with GU cancer, and 6,709 family members with a cardiovascular health event following their relative’s cancer diagnosis. The risks of having a cardiovascular condition for spouses/FDR were 26% higher (1.26; 1.15-1.38) at 1-year, 15% higher (1.15; 1.09-1.2) at 3-years, and 13% higher (1.13; 1.08-1.17) at 5-years when compared to the control group. Parents of children diagnosed with a GU cancer were also at increased risk of having a cardiovascular event: 4.82 (4.02-5.77) at 1-year, 4.19 (3.78-4.65) at 3-years, and 3.95 (3.65-4.27) at 5-years, when compared to other caregiver relationships. 

Conclusions: Our study suggests that FDR/spousal caregivers of GU cancer patients experience significant stress. This stress leads to persistent increases in risks of cardiovascular diseases after the diagnosis of cancer within the family. Increased clinical attention and support are needed for caregivers of cancer patients.

Introduction: While operating room efficiency is important for patient safety and minimizing time costs, excessive pre-emptive opening of surgical supplies generates financial and environmental waste. In our current culture, there is rarely opportunity for feedback regarding unused opened items at the end of a case, as the OR team rapidly transitions to delivering an efficient turnover. We hypothesized that real-time feedback to both the surgical and the OR team could significantly decrease the number of wasted items in the OR.

Methods: In a resident-led effort at our safety-net public hospital, we instituted a paper checklist to track unused opened items, completed by a trainee or OR staff at the end of each elective cystoscopic and percutaneous case while other members of the team repositioned the patient. The checklist was pre-populated with a list of commonly opened supplies and included standard costs of disposable items to bolster cost awareness. Participation was incentivized through an institutional quality improvement program and the data reviewed at our monthly huddle. Multivariate sandwich-adjusted Poisson and log link generalized linear models were fit to determine predictors of wasted item counts and costs. 

Results: Over 8 months of implementation, the checklist was completed for 84% of qualifying cases (n=152). The average number of disposable and reusable items wasted per case decreased significantly over time (z<0.001). The average wasted cost decreased from a “baseline” of $29 (+/- $93) per case in the first month to $11 (+/- $88) in the subsequent months of the intervention. Simple cystoscopy predicted fewer wasted items (z<0.001) while PCNL predicted increased waste counts (z=0.001).

Conclusions: With incentivized engagement, a simple postoperative checklist progressively and significantly reduced surgical supply waste in cystoscopic and percutaneous urology cases over only a few months of implementation. We next plan to formalize the checklist as part of the postoperative debrief in order to preserve lasting change in the setting of trainee and OR team turnover.

INTRODUCTION: Our objective was to analyze COVID-19’s effect on fixed OR times for urology robotic-assisted procedures in a negative testing environment.  We divided operations into fixed and variable times, fixed times being all time besides surgeon operating time. 

METHODS: All patients undergoing robotic surgery are confirmed negative for COVID-19 viral RNA with polymerase chain reaction (PCR) testing within 48 hours of their OR time. Fixed OR times were defined as: in room time to anesthesia release time (IRAT), anesthesia release to cut time (ARCT), in room time to cut time (IRCT) (IRAT + ARCT), and close time to wheels out time (CTWO). All of 2019 (January 1-December 31) was classified as pre-COVID-19 and April 1, 2020-December 31, 2020 was classified as post-COVID-19. The procedures evaluated were robotic-assisted partial nephrectomy (RAPN), robotic-assisted radical cystectomy (RARC), and robotic-assisted radical prostatectomy (RARP). When comparing groups, we utilized the Fisher exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. 

RESULTS: 566 robotic-assisted procedures were evaluated, 338 pre-COVID-19 and 228 post-COVID-19. COVID-19 did not significantly affect IRAT (RARC: P=0.11, RAPN: P=0.84, RARP: P=0.91). ARCT was faster post-COVID-19 for RARC (median pre-: 36.0 min, range: 10.0-65.0 vs. median post-: 27.0 min, range:15.0-56.0, P=0.009) and RARP (median pre-: 30.0 min, range: 11.0-59.0 vs. median post-: 27.0 min, range: 3.0-51.0, P<0.001); RAPN was not significantly affected (P=0.44). IRCT was faster post-COVID-19 for RARC (median pre-: 64.0 min, range: 40.0-100.0 vs. median post-: 57.0, range: 32.0-92.0, P<0.001) and RARP (median pre-: 45.5 min, range: 21.0-80.0 vs. median post-: 43.0 min, range: 25.0-80.0, P=0.002); RAPN was not significantly affected (P=0.88). COVID-19 did not significantly affect CTWO for RARC (P=0.27), was the same pre- and post-COVID-19 for RARP (median pre-: 9.0 min, range: 1.0-39.0 vs. median post-: 9.0 min, range: 1.0-51.0, P=0.029), and was faster post-COVID-19 for RAPN (median pre-: 11.0 min, range: 1.0-38.0 vs. median post-: 9.5 min, range: 1.0-50.0, P=0.027).

CONCLUSIONS: COVID-19 did not have a negative impact on fixed OR times for robotic-assisted urology procedures. High OR efficiency for robotic urologic surgery can be maintained post COVID-19 in a negative testing environment.

OBJECTIVE: We aimed to evaluate the effect of number of frontline anesthesia personnel per robotic-assisted surgery case on fixed OR times. All times except surgeon operating time were defined as fixed OR times. 

METHODS: We evaluated fixed OR times for three urology robotic-assisted procedures over a 24-month period (2019-2020). The procedures were: robotic-assisted partial nephrectomy (RAPN), robotic-assisted radical cystectomy (RARC), and robotic-assisted radical prostatectomy (RARP). Fixed OR times were: in room time to anesthesia release time (IRAT), anesthesia release to cut time (ARCT), in room time to cut time (IRCT) (IRAT + ARCT), and close time to wheels out time (CTWO). Number of certified registered nurse anesthetists (CRNA) per procedure was collected and compared between RAPN, RARC, and RARP. We evaluated the impact of CRNA count per case on fixed OR times. Group comparisons were made using the Fisher exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. 

RESULTS: 635 consecutive robotic-assisted procedures were evaluated. CRNA count was highest for RARC, with a median of 3.0 CRNAs per procedure (range: 0.0-7.0, P<0.001). 92.2% (71/77) of RARCs had ≥2 CRNAs present. RAPN and RARP had a median CRNA count of 2.0 (RAPN and RARP range: 0.0-5.0). 81.5% (119/146) of RAPNs had ≥2 CRNAs. 82.8% (341/412) of RARP procedures had ≥2 CRNAs. Number of anesthesia personnel did not significantly impact IRAT for any procedure (RARC: P=0.56, RAPN: P=0.39, RARP: P=0.18). ARCT was faster when ≥2 CRNAs were involved for RARP (median ≤1 CRNA:31.0, range 17.0-59.0) (median ≥2 CRNA: 29.0, range 3.0-54.0) (P=0.004); however, this was not statistically significant for RARC or RAPN (P=0.84 and P=0.80, respectively). There was no significant association between IRCT and the number of CRNAs for any of the three procedures (RARC: P=0.80, RAPN: P=0.62, RARP: P=0.051). CTWO was also not significantly impacted by CRNA count for any of the procedures (RARC: P=0.61, RAPN: P=0.14, RARP: P=0.24).

CONCLUSIONS: RARC had more CRNAs per case than any other robotic procedure evaluated. The number of frontline anesthesia personnel per case did not significantly impact the efficiency of fixed operating room time points in robotic-assisted urology procedures.

OBJECTIVE: The purpose of our study was to analyze the effect COVID-19 had on fixed OR times for urology implant surgeries in a negative testing environment. OR efficiency is frequently analyzed by surgeon operating time (variable OR time). We defined “fixed OR times” as all time points except cut to close time.

METHODS: All surgical patients were tested for COVID-19 viral RNA within 48 hours of their OR time with polymerase chain reaction (PCR) testing. Fixed OR times were defined as: in room time to anesthesia release time (IRAT), anesthesia release to cut time (ARCT), in room time to cut time (IRCT) (a combination of IRAT and ARCT), and close time to wheels out time (CTWO). Procedures performed from January 1, 2019-December 31, 2019 were considered pre-COVID-19 and April 1, 2020-December 31, 2020 procedures were considered post-COVID-19. We excluded procedures from January 1, 2020-March 31, 2020. The implant procedures evaluated were: male sling, correction Peyronie's, implantation inflatable penile prosthesis (IPP), artificial genitourinary sphincter (AGS), pubovaginal sling, placement Spaceoar, penile plication, removal procedures (AGS, prosthetic material/mesh), revision/replacement procedures (AGS, IPP), and urethroplasty with/without buccal graft. To compare groups for categorical variables the Fisher exact test was utilized and to compare groups for continuous variables the Wilcoxon rank sum test was utilized. In our analysis, P values less than 0.05 were statistically significant.

RESULTS: We evaluated a total of 343 implant procedures, 192 pre-COVID-19 and 151 post-COVID-19. IRAT median time was slightly longer pre-COVID-19 (12.0 minutes (min), range: 4.0-41.0) than it was post-COVID-19 (11.0 min, range: 3.0-28.0) (P=0.40). Median ARCT was the same both pre-COVID-19 (30.0 min, range: 2.0-61.0) and post-COVID-19 (30.0 min, range: 6.0-57.0) (P=0.36). IRCT median time pre-COVID-19 (42.0 min, range: 13.0-75.0) was similar to IRCT median time post-COVID-19 (41.0 min, range: 17.0-69.0) (P=0.20). CTWO median time was the same both pre-COVID-19 (8.0 min, range: 1.0-31.0) and post-COVID-19 (8.0 min, range: 1.0-29.0) (P=0.91).

CONCLUSIONS: For urology implant procedures, COVID-19 did not have a statistically significant impact on fixed OR times. In a negative testing environment, OR efficiency can be expected to continue at its pre-COVID-19 levels.

Purpose: Urologists provide opioids post-operatively for a wide variety of procedures. Understanding patient utilization of opioids post-operatively allows us to minimize the risk of overprescribing. Our objective was to evaluate the effectiveness of standardized multimodal pain therapy post-operatively for gender affirming orchiectomy (GAO).

Materials and Methods: A standardized discharge pain pathway for GAO was created in May 2020 (Table 1). We evaluated all patients who underwent this procedure between May 2020- March 2021 from a single surgeon. Patients were asked 5 questions about their discharge pain management at the 3-week outpatient follow-up.

Results: 39 patients were included in the study. Of these, three patients underwent a concurrent procedure (n=2 for scrotectomy, n=1 for testicular prostheses). The patient with testicular implants was prescribed 8 tablets of oxycodone.

The mean age was 33.8 years (SD ± 9.7; range 21-68) with a mean BMI of 26.7 (SD ± 7.8; range 17- 45). No patients were taking pre-operative narcotics.  The mean number of oxycodone tablets taken by GAO patients without concurrent procedures was 4.3 tablets (SD ± 3.3; range 0-8) with 19 patients (48.7%) taking < 4 tablets. Seven of these patients (17%) required no narcotics. Four patients (10%) requested an additional narcotic prescription, none of whom underwent a concurrent procedure.  Figure 1 shows the “most effective” patient reported therapies that were used post-operatively.

Conclusions: A standardized pain pathway incorporating non-opioid analgesics and limited narcotics for GAO revealed that most patients achieved adequate post-operative pain control as the number seeking an additional narcotic prescription was low. In addition, almost half of patients used < 4 tablets and most patients employed multiple alternative non-opioid analgesics for pain control. Based on these findings, we plan to decrease the quantity of opioids on discharge.  

Source of Funding: none

Objective: To analyze the factors associated with non-attendance at a urology telehealth clinic in a large urban safety-net hospital after institutional-mandated transition to telehealth due to COVID-19.

Methods: We identified all encounters scheduled for telehealth after March 17, 2020 and in the subsequent 8 weeks. Logistic regression was used to identify factors associated with attendance.

Results: In total there were 322 telehealth encounters, 228 (70.8%) of which were attended and 94 (29.2%) that were not attended. Racial/ethnic minorities accounted for 175 (77.0%) of attended and 73 (76.7%) of non-attended encounters. On multivariable regression, single/divorced/widowed (odds ratio [OR] 2.36, 95% confidence interval [CI] 1.26-4.43), current substance use disorder (OR 5.33, 95% CI 2.04-13.98), and being scheduled for a new patient appointment (OR 1.81, 95% CI 1.04-3.13) were associated with higher odds of not attending a telehealth encounter. Race/ethnicity, primary language, and country of birth were not associated with odds of attendance.

Conclusions: Our findings identify several social factors (social support, substance use) associated with non-attendance at outpatient telehealth urology encounters at an urban safety-net hospital during the early stages of the COVID-19 pandemic. These barriers may have a greater impact specifically within a safety-net healthcare system and will inform equitable provision of urology telehealth programs in the future.

Introduction

Prostatitis is a common clinical condition accounting for nearly 8% of urological visits. The proper diagnosis and treatment of chronic bacterial prostatitis (CBP), as opposed to nonbacterial chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), relies on the accurate detection of urogenital pathogens; the traditional culture assays can fail to detect bacteria in a subset of prostatitis cases due to their inadequate sensitivity. Herein, we explore the significance of using a PCR-based assay and a genital culture test in parallel with the traditional culture methods to more accurately diagnose and classify patients with chronic prostatitis. 

Methods

Retrospectively, we analyzed test results for 31 patients who presented with CP/CPPS-associated symptoms from 12/1/2020 to 2/12/2021. Samples of expressed prostatic secretion (EPS) or post-prostate-massage urine (VB3) were obtained from the patients. We used the Urine-ID™ test, a PCR-based assay from VikorScientific, as well as the genital culture and urine culture tests (Quest Diagnostics™) to analyze the same samples from each patient.

Results

The traditional urine culture test failed to specify pathogens in all 29 patients (23 had no growth, and 6 had less than 10,000 CFU/mL of unspecified organism). The Urine-ID test was the only test that detected pathogens in 9 patients out of those 31 patients (31%). Either the Urine-ID™ test or the genital culture test was able to identify some pathogen in 13 patients (42%), while the traditional culture tests failed to do so (Table 1).

Conclusion

We found that the Urine-ID™ and genital culture tests were able to detect bacteria in a notable (n=13, 42%) subset of chronic prostatitis patients that could have traditionally been classified as CP/CPPS. Therefore, supplementing the traditional urine culture test with PCR-based and genital culture tests can potentially help avoid false-negative results and allow clinicians to better treat this particular subset of patients. Larger studies need to be performed to validate these results as well as to assess patient outcomes.

Introduction: The Abdominal Organ Transplant Service rotation is an important part of the urology residency at our institution. It is a historically high-volume open surgical experience that provides training in vascular control and urinary tract reconstruction, management of critically ill surgical patients, and daily working as a member of a multi-specialty care team. The COVID-19 pandemic changed many aspects of residency training, and we sought to define the impact on our transplant experience.  

Materials and Methods. We reviewed urology resident surgical logs for kidney transplant cases during the 2-month urology resident transplant rotations of 2020 and 2021. Organ retrievals from deceased donors, living donor nephrectomies, native nephrectomies, allograft nephrectomies, liver transplants, and pancreas transplants were not included.

Results: Kidney transplant case numbers for urology residents at our institution decreased significantly during the beginning of the COVID-19 pandemic (Table 1). The virus arrived in Oregon on February 28^th, 2020, and our institution modified its operations dramatically on March 23^rd, and living donor transplants were discontinued. We began offering living donor transplant surgeries again in May 2020, but limited outpatient testing and donor reticence slowed the return of these cases. Transplant cases have now returned to pre-pandemic levels. 

Discussion. The kidney transplant rotation is an important component of our urology residency, and it was negatively impacted by COVID-19. This effect has since resolved in spite of continued high case counts in our state. 

Conclusions. As COVID surgical precautions, rapid testing, and vaccination protocols were developed, solid organ transplantation increased and the surgical experience of the urology residents returned to baseline. 

Introduction

Ureteropelvic junction (UPJ) obstruction is a common cause of upper tract obstruction often driven by intrinsic narrowing or fibrosis in children and crossing vessels in adults, for which surgical repair is often indicated. We sought to examine our own institution’s patterns of sending the UPJ for pathology and the results of that analysis for pediatric and adult cases.

Methods

IRB approved chart review of Current Procedural Terminology (CPT) codes was used to identify UPJ surgeries from February 2012 to May 2020 at our pediatric and adult university hospitals.

Clinical variables were extracted from the operative and pathology reports. Pathology results were dichotomously classified as “benign” or “malignant,” and further assigned to four themes (inflammation, fibrosis, muscular hyperplasia, no atypical findings). The Pathology department was queried regarding the cost of tissue analysis for these specimens.

Results

269 pyeloplasties were performed over the eight years reviewed, 68% of which were pediatric cases. The majority of patients were female (65% of pediatric, 61% of adults), and adults underwent robotic surgery much more often than children (85% vs 22%, respectively). A crossing vessel was identified in 62% of the adult cases and 20% of the pediatric cases. Pathology was sent in 91% of cases (94% adult, 90% pediatric), and was benign in every case. The most common descriptions were “normal”(38%), followed by “inflammation” (27%) and “fibrosis”(13%). The pathologic analysis for each UPJ specimen costs $205.

Discussion

The vast majority of both adult and pediatric pyeloplasty cases at our institution have pathologic analysis of the UPJ specimen requested, with no clinically useful results found in the last 8 years. These specimens should not be sent unless there is high clinical concern for adverse pathology, as the chance of finding occult malignancy is exceptionally low and the current practice is a poor use of healthcare resources.

Introduction/Background 

In this retrospective study, we evaluate the association between technical skills using the Global Evaluative Assessment of Robotic Skills (GEARS) criteria, as well as assessment of objective errors/outcomes during robotic surgery skills exercises. 

Methods

Participants were selected to create three groups based on robotic surgical expertise: novice (no prior experience; n = 7), intermediate (< 100 cases; n = 9), and experts (≥ 100 cases; n = 6). Each participant completed ten tasks on a da Vinci XI Surgical System (Intuitive Surgical, Inc.), each representing a surgical skill type: EndoWrist® manipulation, needle targeting, suturing/knot tying, and excision/dissection of an orange. Technical skills were retrospectively evaluated for each task using the GEARS criteria comprising five domains: Depth Perception, Bimanual Dexterity, Efficiency, Force Sensitivity, and Robotic Control. Errors during excision tasks were distinguished as either active if the surgeon made an error during intentional movements, or passive if the error occurred during unintentional movements, namely “Through Skin Puncture” (TS), “Passive Puncture” (PP) and “Skin Tear” (ST). Poisson or Negative Binomial model was used to compare the risk of errors (number of errors/100 seconds) at different skill assessment scores. 

Results

Analysis showed statistically significant associations between depth perception and TS with relative risk (RR) of 0.28 95% CI: (0.14, 0.571) P_adj<0.01; between force sensitivity and PP with RR of 0.20 95% CI: (0.10, 0.39) P_adj<0.01; between robotic control and TS with RR of 0.42 95% CI: (0.25, 0.711) P_adj<0.01. For example, a 5/5 (perfect) GEARS score for robotic control was associated with an estimated risk of 0.04/100 seconds for TS, with 3/5 score the risk elevated to 0.20/100 seconds. Additionally, “expert” level of experience was not significantly associated with a lower number of errors. 

Conclusions

Technical Skills evaluations using the GEARS criteria can be used to predict outcomes of robotic surgical skills exercises. Higher scores in certain domains of the GEARS criteria were associated with lower risk of committing unintentional passive errors.