With over 30 active projects in every stage, from initial drafting and literature research to papers waiting on comments from journal submission, the Urology Health Services Research Division is always looking for ways to improve the delivery, access, and quality of care. Our many projects cover an extensive range of subject areas, including:
- Opioids
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The United States is in the midst of an opioid epidemic that has only worsened over the COVID-19 pandemic. In the US, surgeons are responsible for up to 10% of opioid prescriptions annually. Recent studies of US populations have demonstrated significant risks of persistent opioid use and overdose in opioid-naive patients who receive post-discharge opioid prescriptions after undergoing urological surgeries. Furthermore, opioid prescribing often exceeds patient's needs by 2-7 fold postoperatively and research has demonstrated that >60% of the excess unused opioids prescribed to patients are not stored securely or disposed of properly. As a result, these unused opioids are susceptible to diversion within the greater community, broadening their impact.
Surgeons, specifically, have been subject to scrutiny as 'adequate treatment' of post-surgical pain is poorly defined and data suggest that many patients receive much larger opioid prescriptions than needed. Several solutions to this crisis are currently being enacted with variable success, including Prescription Drug Monitoring Programs, policy level interventions aimed to de-incentivize over prescribing, limiting opioid exposures through Enhanced Recovery After Surgery protocols, and the novel idea of creating surgery and/or procedure specific prescribing guidelines. It remains critical, however, that we as physicians and prescribers find a way to stop the needless over prescribing while still treating postoperative pain appropriately.
- Screening rates in Western PA
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Routine screening for breast, prostate, lung, cervical, and colorectal cancer reduces cancer mortality, yet it is not performed equitably amongst different patient populations. The evaluation of screening patterns within our community provides an opportunity to improve oncological outcomes and advance health equity. Like most of our healthcare system, disparities in cancer screening serve as a significant driver of the morbidity and mortality of these malignancies. These disparities stem from several historical inequities with downstream effects that continue to permeate our society. Not only do these differences often result in worse oncological outcomes, but they also serve to increase the costs on an already burdened healthcare system. Collectively, they are termed social determinants of health and include race, ethnicity, socioeconomic status, education level, healthcare settings (urban vs. rural), access to an established primary care provider, health insurance status, sex, and the presence of pre-existing chronic conditions.
- Centralization of cancer care
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In recent years, cancer treatment has dramatically shifted towards a centralized model of care, whereby patients with cancer selectively receive complex treatment at regional referral centers, which tend to be tertiary cancer centers. Centralization is associated with improved outcomes for the patients who receive care at regional referral centers for a variety of reasons, including better resources and personnel who treat high volumes of patients. However, the broader impact of centralization on outcomes at the population level remains unknown. Of specific concern are the patients who do not receive care at these centers, but instead continue to receive care at non-regional referral centers, which generally treat lower volumes of patients. These “left behind” patients may suffer poor outcomes due to decreased access to high-quality care. Moreover, to the degree these patients represent traditionally underserved patients (i.e., sociodemographic groups that have long experienced health disparities such as racial and ethnic minorities, low-income individuals, and rural residents), the trend towards centralized cancer care may inadvertently widen disparities in outcomes, worsening care for those patients left behind.
- Private equity
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Private equity (PE) acquisition of urology practice has become the predominant mode of consolidation within the specialty in the past decade. After acquisition of a medical practice, PE firms commonly deploy a “buy and build” model, whereby they attempt to increase revenue and decrease costs to grow practice valuation before selling the practice within 3 to 7 years to the next larger private equity firm. Despite the growing proportion of PE-owned urology clinics, the impact of this ownership model on access to outpatient urologic care is not fully understood.
- Rural and urban divides
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Rural residence is associated with poor access to health care and health outcomes across a range of conditions, including cancer. In the realm of cancer surgery, rural patients experience barriers to accessing surgery and have poorer surgical outcomes than patients in urban areas. These disparities arise in part because of the limited supply of health care providers and limited financial resources of rural
hospitals. Efforts to regionalize cancer care in response to evidence of strong volume-outcome relationships for cancer surgery may improve outcomes for some patients but create unintended consequences, including straining the already limited resources of rural hospitals and limiting access for patients who prefer local treatment options. - Antibiotic stewardship
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In June 2019, the AUA published a best practice clinical guideline statement in response to concerns of rising antimicrobial resistance worldwide and need for further antibiotic stewardship. The new best practice clinical guidelines encompass all common urologic procedures.
There is increasing research to support a more judicious use of antibiotics as recommended by the AUA that will benefit the index patient as well as the larger community. Antibiotic prophylaxis requires that antibiotics be prescribed only when necessary, with the narrowest required spectrum of activity and the shortest duration possible. Increased compliance with published antibiotic prophylaxis guidelines has been shown previously to reduce pathogen resistance, antibiotic drug costs, and adverse events related to antibiotics.