OBJECTIVE To determine the incremental hospital cost and mortality associated with the development of postoperative acute kidney injury (AKI) and with other associated postoperative complications. SUMMARY BACKGROUND DATA Each year 1.5 million patients develop a major complication after surgery. Postoperative AKI is one of the most common postoperative complications and is associated with an increase in hospital mortality and decreased survival for up to 15 years after surgery. METHODS In a single-center cohort of 50,314 adult surgical patients undergoing major inpatient surgery we applied risk-adjusted regression models for cost and mortality using postoperative AKI and other complications as the main independent predictors. We defined AKI using consensus RIFLE criteria. RESULTS The prevalence of AKI was 39% among 50,314 patients with available serum creatinine. Patients with AKI were more likely to have postoperative complications and had longer lengths of stay in the intensive care unit and the hospital. The risk-adjusted average cost of care for patients undergoing surgery was $42,600 for patients with any AKI compared to $26,700 for patients without AKI. The risk-adjusted 90-day mortality was 6.5% for patients with any AKI compared to 4.4% for patients without AKI. Serious postoperative complications resulted in increased cost of care and mortality for all patients, but the increase was much larger for those patients with any degree of AKI. CONCLUSIONS Hospital costs and mortality are strongly associated with postoperative AKI, are correlated with the severity of AKI, and are much higher for patients with other postoperative complications in addition to AKI.

Introduction Benign prostatic hyperplasia is a prevalent chronic condition with expenditures exceeding $1 billion each year. Little is known about management of patients by primary care physicians compared to urologists. We assessed changes in management after medication initiation in these two settings. Methods From the Chronic Condition Warehouse 5% sample of Medicare beneficiaries linked to Medicare Part D data, we defined a cohort of men, 66 to 90 years old, with initial prescriptions for alpha-blocker, 5-alpha reductase inhibitor (5-ARI), or both. We assessed the initial change in therapy for up to four years after medication initiation: add a medication, switch medication, stop medication, or have surgery/retention. We estimated the cumulative incidence functions from competing risks data, and tested equality across groups (primary care physician vs. urologist). Results 5714 men started medication with a primary care physician, 1970 with a urologist. The most common change in treatment after medication initiation across all groups was medication discontinuation (55% alpha blocker; 46% 5-ARI; 30% combination therapy cumulative incidence at 3 years). Patients who started with primary care physicians were more likely to discontinue BPH-related medications, than patients with urologists (HR 1.19; 95% CI 1.09 – 1.29). The majority of patients who stopped alpha blocker therapy did not have further BPH therapy. Conclusions Men given combination therapy are most likely to have continued medication use. Surgical therapy and retention are relatively rare events. Patients who initiate care with urologists are more likely to continue medical therapy than patients with care initiated by primary care providers.

PurposeTo evaluate a physician's impression of a urinary stone patient's dietary intake and whether it was dependent on the medium through which the nutritional data were obtained. Furthermore, we sought to determine if using an electronic food frequency questionnaire (FFQ) impacted dietary recommendations for these patients.Materials and MethodsSeventy-six patients attended the Stone Clinic over a period of 6 weeks. Seventy-five gave consent for enrollment in our study. Patients completed an office-based interview with a fellowship-trained endourologist, and a FFQ administered on an iPad. The FFQ assessed intake of various dietary components related to stone development, such as oxalate and calcium. The urologists were blinded to the identity of patients' FFQ results. Based on the office-based interview and the FFQ results, the urologists provided separate assessments of the impact of nutrition and hydration on the patient's stone disease (nutrition impact score and hydration impact score, respectively) and treatment recommendations. Multivariate logistic regressions were used to compare pre-FFQ data to post-FFQ data.ResultsHigher FFQ scores for sodium (odds ratio [OR], 1.02; p=0.02) and fluids (OR, 1.03, p=0.04) were associated with a higher nutritional impact score. None of the FFQ parameters impacted hydration impact score. A higher FFQ score for oxalate (OR, 1.07; p=0.02) was associated with the addition of at least one treatment recommendation.ConclusionsInformation derived from a FFQ can yield a significant impact on a physician's assessment of stone risks and decision for management of stone disease.

OBJECTIVES To evaluate the utilization of follow-up imaging after nephrectomy for renal cell carcinoma (RCC) in nationally representative data. PATIENTS AND METHODS Using Surveillance, Epidemiology, End Results (SEER) data linked to Medicare records, we identified patients with RCC who received nephrectomy from 1991 to 2007. Patients were stratified by tumor stage. Postoperative chest and abdominal imaging (including chest x-ray, CT scan, and MRI; abdominal ultrasound, CT scan, and MRI) was assessed. Observed surveillance imaging frequency was compared to published protocols. Predictors of initial and continued yearly surveillance imaging were identified. RESULTS Agreement between observed imaging frequency and evidence-based surveillance protocols was low, particularly for patients with T2-T4 disease. For patients who were not censored prior to 13 months, initial abdominal and chest surveillance imaging was obtained in 69% and 78% of patients, respectively. By year five, 28% and 39% of patients with high risk disease (T3 or T4), as compared to 21% and 25% of patients with low to moderate risk disease (T1 and T2) , received yearly surveillance abdominal and chest imaging, respectively. High risk disease was predictive of initial chest (OR 1.38) and abdominal (OR 1.6) imaging, as well as continued yearly chest (HR 0.73) and abdominal (HR 0.74) imaging surveillance. For abdominal imaging, more contemporary year of surgery was predictive of initial (1997–2001, OR 1.6; 2002–2007, OR 2.4) and continued yearly surveillance (1997–2001, HR 0.82; 2002–2007; HR 0.67). CONCLUSIONS In the Medicare population, surveillance imaging is performed in a limited number of patients following nephrectomy for RCC. However, increasing tumor stage is predictive of both increased chest and abdominal imaging surveillance.

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