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Significant Management Variability of Urethral stricture Disease in United States: Data from the AUA Quality (AQUA) Registry

  • Andrew J. Cohen
    Correspondence
    Address correspondence to: Andrew Cohen, MD, Assistant Professor, Department of Urology, Johns Hopkins University, The Brady Urological Institute at JHBMC, 4940 Eastern Avenue, 301 Building, Suite 3100, Baltimore, MD 21224. Office: 410-550-7739; Fax: 410-550-3341
    Affiliations
    Department of Urology, Johns Hopkins University, Baltimore, MD
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  • Nnenaya Agochukwu-Mmonu
    Affiliations
    Department of Urology, University of California, San Francisco, California
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  • Danil V. Makarov
    Affiliations
    VA New York Harbor Healthcare System and Department of Urology, New York University Langone Medical Center, NY, NY
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  • William Meeks
    Affiliations
    American Urological Association Education & Research, Department of Data Management & Statistical Analysis, Linthicum, MD
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  • John Murphy
    Affiliations
    American Urological Association Education & Research, Department of Data Management & Statistical Analysis, Linthicum, MD
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  • Raymond Fang
    Affiliations
    American Urological Association Education & Research, Department of Data Management & Statistical Analysis, Linthicum, MD
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  • Author Footnotes
    ⁎ Authors Contributed Equally to Senior Authorship
    Matthew R. Cooperberg
    Footnotes
    ⁎ Authors Contributed Equally to Senior Authorship
    Affiliations
    Department of Urology, University of California, San Francisco, California

    Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
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  • Author Footnotes
    ⁎ Authors Contributed Equally to Senior Authorship
    Benjamin N. Breyer
    Footnotes
    ⁎ Authors Contributed Equally to Senior Authorship
    Affiliations
    Department of Urology, University of California, San Francisco, California

    Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
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  • Author Footnotes
    ⁎ Authors Contributed Equally to Senior Authorship

      Abstract

      Objective

      To determine the degree of contemporary practice variation for the treatment of urethral stricture disease (USD) given repeated endoscopic management yields poor long-term success.

      Materials and Methods

      The AUA Quality (AQUA) Registry collects data from participating urologists across practice settings by direct interface with local electronic health record systems. We identified procedures used for USD using Current Procedural Terminology (CPT) and International Statistical Classification of Diseases (ICD-9/-10) codes. We assessed the association between patient and provider factors and repeated endoscopic treatment using generalized linear models. Provider details were derived from AUA Census.

      Results

      We identified 20,640 male patients with USD treated surgically in AQUA from 2014-2018. The patients were cared for by 1343 providers at 171 practices, 95% of these community-based. Among patients with USD who had treatment, 20,101(97.9%) underwent endoscopic management. 6218(31%) underwent repeated endoscopic treatment during the study period. Urethroplasty was performed in 539(2.6%) patients.  Median patient age at first procedure for endoscopic surgery vs. urethroplasty was 73 vs. 39 years old, respectively (p<0.001). At the practice level, significant variation in rates of repeated endoscopic management was noted. Patients of older age (OR=1.08, 95%CI: 1.06-1.11 for ages ≥80) and patients with a bladder cancer diagnosis (OR=1.17, 95%CI: 1.15-1.20) had higher odds of receiving repeated endoscopic management. Increasing practitioner age was also associated with increased odds of repeated endoscopic management. (OR=1.13, 95%CI: 1.11- 1.16, for practitioners ≥64).

      Conclusions

      Repeated endoscopic management for USD is overused. The utilization of endoscopic management is variable across practices and frequently guideline-discordant, presenting an opportunity for quality improvement.
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