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We sought to analyze trends in male urethral stricture management through the use of 1992–2001 Medicare claims data, and to determine whether certain racial and ethnic groups bear a disproportionate burden of urethral stricture disease.
We analyzed Medicare claims for fiscal years 1992, 1995, 1998, and 2001. ICD-9 diagnosis codes were used to identify men with urethral stricture. Demographic characteristics assessed included patient age, race, and comorbidities as measured by the Charlson index. Treatments were identified by CPT-4 procedure codes and stratified into four treatment types: (1) urethral dilation, (2) direct vision internal urethrotomy (DVIU), (3) urethral stent/steroid injection, and (4) urethroplasty.
Overall rates of stricture diagnosis decreased from 10,088 per 100,000 population in 1992 to 6,897 in 2001 (1.4% to 0.9%). Stricture prevalence was highest among African American and Hispanic men, although urethroplasty rates were highest among Caucasians. DVIU was the most common treatment, followed by urethral dilation, urethral stent/steroid injection, and urethroplasty. Urethroplasty rates remained stable, but quite low (0.6–0.8%), over the period of study.
Overall rates of stricture diagnosis decreased from 1992 to 2001. Despite the poor overall efficacy of urethrotomy and urethral dilation relative to urethroplasty, and despite the known complications of stent placement in this setting, urethroplasty rates were the lowest of all treatments. Although we cannot determine treatment success with these data, these findings suggest an underuse of the most efficacious treatment for urethral stricture disease, urethroplasty.
The demographics of urethral stricture disease are poorly understood and sparsely reported in the literature. The 2003 Urologic Diseases of America Project (UDA) compendium produced the first description of the incidence of urethral stricture in the United States1. This report provided perspective on the burden of male urethral stricture disease in the US, a medical problem responsible for more physician office visits than urolithiasis. The annual economic burden of stricture disease exceeds $200 million (year 2000) 1. However, little is known about practice patterns for this entity.
Management of urethral stricture includes urethral dilation, internal urethrotomy, urethral stent placement, and open reconstruction or urethroplasty. Urethral dilation is the oldest and simplest treatment for urethral stricture disease, and may be curative only for some men with very short, uncomplicated strictures. The goal of this treatment is to stretch the scar without producing more scarring. Internal urethrotomy refers to any procedure that opens the stricture by incising or ablating it transurethrally. The goal is to incise through scar and into healthy tissue to allow the scar to expand (release of scar contracture) and the lumen to heal enlarged through secondary intention.
Unfortunately, both urethral dilation and internal urethrotomy have a very high failure rate. The overall success rate of urethrotomy for anterior urethral strictures is 32–40% with long-term (>24 month) follow-up2–5. Risk factors for failure include penile urethral strictures (vs. bulbar) and long strictures. Success rates can be as high as 77% in bulbar strictures less than 1cm in length and as low as 18% in penile strictures greater than 1 centimeter2–5. Finally, urethral stents placed in the anterior urethra are known to have complication rates up to 58%6, 7. Experts have abandoned the use of urethral stents for anterior urethral strictures other than bladder neck contractures.
The literature is clear that repeat urethrotomy or dilation for urethral stricture is neither curative2, 4, 5 nor cost-effective8, 9. Yet, most urologists do not perform urethroplasty10, and most patients with urethral stricture undergo multiple dilations and/or urethrotomies before being offered urethroplasty11. Often, they are never offered formal reconstruction. To date, no study has evaluated patterns of care for urethral stricture disease. Whether there is underutilization of urethroplasty or overuse of urethral dilation and internal urethrotomy is presently unknown.
In this study we sought to assess the overall burden of stricture disease using a national dataset. We hypothesized that there exists an overuse of less effective modalities such as urethrotomy and dilation and an underuse of urethroplasty. We also sought to understand the demographics of patients diagnosed with stricture disease, including age, race, and region in the United States.
We analyzed claims data for 1992, 1995, 1998, and 2001 from the Centers for Medicare and Medicaid Services (CMS) to estimate utilization of care for the male Medicare population aged 65 and over diagnosed with urethral stricture disease.
Data from the three Medicare Standard Analytic files were linked to determine utilization in the inpatient, ambulatory surgery center, hospital outpatient, physician office, and emergency room settings, as previously described11. A 5% national random sample of Medicare records, which has been shown to be adequate for detecting meaningful differences in demographics, was queried. National estimates of service use were obtained by multiplying counts by a constant weight of 2012.
Descriptive tables were generated using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes for urethral stricture disease (Appendix 1). Treatments were identified by Physician Current Procedural Terminology Coding System (4th edition, CPT-4) procedure codes and stratified into four treatment types: Urethral dilation, urethrotomy, urethral stent placement/injection of steroid, and urethroplasty. Because of the rarity of stent placement and transurethral steroid injection, these two procedures were categorized together. Demographic characteristics (patient age, race, and comorbidities) were obtained by linking encrypted beneficiary identification numbers from the Medicare Standard Analytic Files. Patient comorbidity burden was measured with the Charlson Index, which represents the sum of weighted diagnosis codes for each comorbid condition13.
Exclusion criteria included Medicare beneficiaries younger than age 65, who represent a disabled population that is unlikely to be representative of most patients with urethral stricture disease, and men with an ICD-9 diagnosis of prostate cancer (ICD-9 code 185), whose strictures are often bladder neck contractures or membranous urethral strictures, rather than true anterior urethral strictures. Men with a diagnosis of BPH or previous TURP were not excluded.
In 1992, 10,088 men were diagnosed with a stricture, which extrapolates to 201,760 Medicare beneficiaries. Overall rates of stricture diagnoses decreased from 1992 to 2001 (1.4 to 0.9%). In 2001, 6,897 men were diagnosed with a stricture (137,940 Medicare beneficiaries, Table 1). The frequency of stricture diagnoses increased with age, from 0.6% at age 65–69 to 1.9% at age 85+ (2001 data). The majority of stricture cases occurred among Caucasian men in all years studied. However, the rate of diagnosis of stricture per 100,000 male Medicare beneficiaries was more common among African Americans and Hispanics than among Caucasians and Asians. A diagnosis of stricture was more common in the South and Midwest than in the West and Northeast. Thirty percent of stricture patients were diabetic. Among men with a stricture diagnosis, 27% had a Charlson score of 0, indicating no comorbidities, 35% had a score of 1 or 2, and 8% had a score of 3.
The number and specific type of procedures performed on men with a diagnosis of urethral stricture is presented in Table 2. DVIU was the most common treatment performed in all years studied, and the rate of its use rose from 51% in 1992 to 58% in 2001. The use of urethral dilation decreased over time, from 44% in 1992 to 35% in 2001. Urethral stenting and steroid injection rose from 0.3% to 1.9% over the 1992–2001 time period. Urethroplasty rates remained stable, but very low (0.6–0.8%), over the period of study.
Characteristics of men who underwent urethroplasty during the 1992–2001 time period were also analyzed. Because of the very low numbers, data from the four years analyzed were combined. Urethroplasty rates rose with patient age, from 24 cases per 100,000 male beneficiaries age 65–69 to 40 per 100,000 beneficiaries age 85 and over. Although Caucasian men had the highest number of urethroplasties performed, rates of urethroplasty per 100,000 Medicare beneficiaries were highest among Hispanic and black men (39 and 36 per 100,000 beneficiaries, respectively, vs. 28 per 100,000 among Caucasians). The largest number of urethroplasties were performed in the Southern US.
Our study has several key findings. First we found that the overall rate of stricture diagnosis decreased from 1.4% to 0.9% from 1992 to 2001. The slight decrease in rates of stricture diagnosis may possibly be due to earlier detection and better treatments of sexually transmitted illnesses known to cause strictures, such as gonorrhea. We also found a higher rate of stricture disease among older men, indicating that age may be a risk factor for stricture disease. The age-related increase in stricture diagnosis we identified may be due to the fact that men who age are more likely to undergo instrumentation, such as cystoscopy, endoscopic procedures, and urethral catheter placement, that may result in later stricture development. In addition, aging urethral tissue may be inherently more susceptible to stricture development. Overall diagnosis and treatment rates were highest among Caucasian men, but rates of treatment and diagnosis per 100,000 Medicare beneficiaries were highest among black and Hispanic men. Whether these racial differences in stricture diagnoses are related to the higher rate of sexually transmitted diseases in the black community14 is unknown to date. It should be noted that 42% of men fit in the “other” category, making it difficult to analyze these data with respect to race.
We also found that, among men diagnosed with a stricture, the most common procedure performed was a urethrotomy, followed by urethral dilation. Given that previous series have shown that the efficacy of urethrotomy is similar to urethral dilation, this finding raises several concerns about the quality of care provided to men with stricture disease. Despite the reported higher success rate of urethroplasty over other modalities, the use of urethroplasty was minimal in the Medicare population. The very low urethroplasty rate identified likely represents significant underuse in this population. A previous cost-effectiveness model by Wright et al. indicated that the most cost-effective management algorithm for a bulbar urethral stricture of < 2cm is a single internal urethrotomy followed by urethroplasty if the urethrotomy fails9. In that study, effectiveness of urethroplasty and initial urethrotomy were assumed to be 95% and 50%, based on a review of the relevant literature9. The underutilization of urethroplasty is illustrated as follows: if the estimated 50% success rate for urethrotomy is correct, then there should be no more than two urethrotomies performed for every urethroplasty. As the success rate of urethrotomy decreases, the rates should be more equal (i.e. 20% success rate = 5 urethrotomies for every 4 urethroplasties). Although this estimation is limited by a lack of clinical information provided from claims data, the 50:1 ratio identified in this study certainly represents underutilization of urethroplasty. Urethral stents and steroid injections, procedures that have been abandoned at high volume centers, were performed more often than the definitive urethroplasty. These practice patterns lead us to believe that the quality of care provided to men with urethral stricture disease in the Medicare population is suboptimal.
Although the incidence of urethral stricture is low among this population, the complexity of urethral reconstruction is high and, in general, should be performed by formally trained urethral reconstructionists. The key to providing patients with optimal care for this disease burden is early referral and access to select centers of excellence in urethral reconstruction. There are few such centers in the US, which means that many Americans may have problems accessing specialized centers of care for urethral stricture. This potential access-to-care barrier may decrease the likelihood that patients receive treatment with curative intent (urethroplasty). Instead, they are more likely to receive less effective palliative treatment (repeat urethrotomy or dilation). Another potential barrier to urethroplasty includes a delay in referral to a specialist who performs urethroplasty. Some urologists choose to perform repeated urethrotomy or dilations, rather than referring the patient to a specialist. Repeated endoscopic procedures will not only delay cure, but may also worsen stricture characteristics by increasing the length of the stricture and causing more spongiofibrosis15. This may ultimately result in the need for a more complex urethroplasty that carries a higher failure rate than a straightforward anastomotic repair. Patient preferences for less invasive endoscopic treatments of urethral stricture may also influence treatment patterns. Despite good results of urethroplasty among elderly men16, many older men may not wish to undergo an operation. Surgeons may also consider patient age and co-morbidities in the decision-making process.
Medicare claims data allow for the assessment of medical care for a large, heterogeneous, nationwide sample of the population across various clinical settings. However, claims files are designed primarily to provide billing information, not detailed clinical information, and therefore this type of study has inherent limitations. Medicare claims data are limited by their reliance on administrative coding systems such as the ICD-9-CM to identify disease burden. Coding is often incomplete, and therefore not all patients treated for stricture are correctly identified. This can result in both underestimation and overestimation of utilization, depending on the sensitivity and specificity of the diagnosis and procedure codes. Our estimates are not population-based; we cannot include prevalent cases of stricture disease for which an individual has not sought care. We were also unable to determine treatment success with these data, and were unable to follow individual patients over time. Also, our use of Medicare claims restricts our analyses to beneficiaries age 65 and over. Our findings therefore may not be generalizable to younger men with stricture disease.
Overall rates of stricture diagnosis decreased from 1992 to 2001. Despite data documenting the poor overall efficacy of urethrotomy and urethral dilation, the complications of urethral stent placement for stricture disease, and the superior efficacy of urethroplasty over other treatments, urethroplasty rates remained the lowest of all treatments. Although longitudinal data are needed to follow patterns of care over time, our findings suggest an overuse of endoscopic procedures and an underuse of urethroplasty. Addressing barriers to urethroplasty will allow for improvement in the quality of care provided to men with stricture disease.
Supported by the National Institute of Diabetes and Digestive and Kidney Diseases as part of the Urologic Diseases in America Project
Presented at the Society for Urodynamics and Female Urology Annual Meeting, February 2008
Best Poster Winner at the American Urological Association International Meeting, Trauma/Reconstruction Poster Session, 2008
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