Kim, Simon

Introduction: Testing healthcare delivery interventions in rigorous clinical trials is a critical step in improving patient care, but conducting multisite randomized clinical trials to test the effect of care delivery interventions has unique challenges and requires foresight and planning. Methods: We conducted the first care delivery trial (A191402CD) in the Alliance for Clinical Trials in Oncology, a National Cancer Institute Community Oncology Research Program research base, which tested the effectiveness of two different decision aids for supporting shared decision-making about prostate cancer treatment. Our experience illustrates the kind of challenges that confront care delivery researchers as they seek to test interventions to improve the experiences of patients. Results: Lessons learned include the following: cluster-randomized designs introduce complexity; workflow disruption can discourage site participation; evidence-based methods may not always be sufficient. Conclusion: We conclude with the following recommendations: assessing feasibility requires special rigor; relationships and interpersonal dynamics must be leveraged. Our experiences may inform future care delivery research.

503 Background: We evaluated temporal patterns in the utilization of systemic therapy among patients undergoing cytoreductive nephrectomy (CN) for metastatic Renal Cell Carcinoma (mRCC) from a large national cancer registry and assessed patient characteristics associated with receipt of systemic treatment. Methods: We reviewed the National Cancer Database to identify patients with stage IV RCC who underwent CN between 1998-2010. Systemic therapy was defined as any treatment with immunotherapy and/or chemotherapy (including targeted agents). We evaluated the association between clinicopathologic features and receipt of systemic therapy using multivariable logistic regression with generalized estimating equations, and assessed the interaction of treatment with time, stratified as immunotherapy (1998-2004) versus targeted-therapy (2005-2010) eras. Results: Of 22,409 patients with mRCC undergoing CN, 8,830 (39%) received systemic therapy. Receipt of systemic therapy increased from 32% in 1998 to 49% in 2010 (p<0.001), largely due to increased utilization of chemotherapy (13.9% vs. 46.7%; p<0.001). Following adjustment, increasing patient age (51-60 years: OR 0.82 [CI 0.73-0.92]; 61-70 years: OR 0.67 [CI 0.59-0.76]; ≥71 years: OR 0.36 [CI 0.31-0.43]), as well as coverage with Medicaid (OR 0.61 [CI 0.5-0.74]), Medicare (OR 0.70 [CI 0.62-0.79]), or no insurance (OR 0.75 [CI 0.63-0.91]) were associated with decreased utilization of systemic therapy. Although use of systemic therapy in the elderly (≥71 years) and in patients with Medicare/Medicaid remained lower throughout the study period, each of these cohorts was significantly more likely to receive systemic treatment in the targeted versus immunotherapy era (all p values <0.05). Conclusions: Utilization of systemic therapy among patients undergoing CN has increased over time, coinciding with the introduction of targeted therapies. Nevertheless, still less than half of such patients receive systemic treatment. While the etiology for lack of treatment is likely multifactorial, the potential health policy implications of continued disparities in care warrant further investigation.

167 Background: Physicians have a variety of resources available about the treatment of localized prostate cancer. Yet, it is largely unknown what resources and evidence radiation oncologists and urologists commonly use to inform patients and possibly alter clinical practice. In this national survey study, we assessed the types of resources prostate cancer specialists’ use and the level of evidence needed to change treatment recommendations in localized prostate cancer. Methods: From a random sample, 1,422 physicians were sent a mail survey assessing what type of information was used to guide prostate cancer treatment. The survey also queried what level of evidence could alter recommendations. Multivariable logistic regression models were used to identify for differences in physician characteristics for each outcome. Results: Survey response rates were similar for radiation oncologists and urologists (44% vs. 46%; p=0.46). Specialty-specific journals represented the most commonly used resource to inform the clinical practice for radiation oncologists (65%) and urologists (70%). Relative to radiation oncologists, urologists were less likely to utilize medical journals (25% vs. 38.7%, OR: 0.50; p=0.01), cancer journals (21.7% vs. 50.8%, OR: 0.50; p<0.001), but more likely to rely on clinical guidelines (46.3% vs. 37.7%,OR: 1.6; p=0.006). Radiation oncologists and urologists both viewed RCT’s as the most likely source of evidence needed to change treatment recommendations (85% vs. 77%). Conclusions: Both specialties most commonly rely on their specialty-specific journals to inform their clinical practice and view RCT’s as the level of evidence needed to change treatment recommendations for localized prostate cancer. Radiation oncologists embraced greater diversity in literature, while urologists were more likely to use clinical guidelines. Utilizing this information may overcome barriers to the dissemination and adoption of new treatment paradigms for localized prostate cancer.

Objective To describe the extent of use and in‐hospital outcomes of open and laparoscopic pyeloplasty for paediatric pelvi‐ureteric junction ( PUJ ) obstruction in the USA . Patients and Methods Using the 2004–2008 N ationwide I npatient S ample, we identified 4590 paediatric patients (≤18 years old) who underwent open or laparoscopic pyeloplasty for PUJ obstruction at 195 hospitals. Multivariable regression models were used to test the associations between hospital and patient covariates (age, gender, race, primary health insurance), type of admission (emergent vs elective), and hospital characteristics (teaching vs non‐teaching status; rural vs urban location) with complications, length of stay ( LOS ), and total hospitalization costs. Results During the 5‐year study interval, 4426 (96.4%) and 164 (3.6%) paediatric patients diagnosed with PUJ obstruction underwent open and laparoscopic pyeloplasty, respectively. The proportion of patients undergoing laparoscopic pyeloplasty gradually increased from 2.4% in 2004 to 4.4% in 2008, but this increase was not significant ( P = 0.22 for trend). On multivariable analysis, laparoscopic pyeloplasty was observed to have rates of postoperative complications (2.51 vs 5.00; P = 0.67), LOS (2.42 vs 2.75; P = 0.33) and total hospitalization cost ($9755 vs $8537; P = 0.24) similar to those of open pyeloplasty. Conclusions While laparoscopic pyeloplasty was generally an infrequent operation performed for paediatric PUJ obstruction during the period studied, this minimally invasive surgery provided similar outcomes in terms of in‐hospital complications, LOS and total hospitalization costs. The results of this study inform policymakers about the comparative effectiveness of laparoscopic and open pyeloplasty.