The 2021 American Urological Association Annual Meeting had 11 sessions dedicated to Health Services Research. The tenets of Health Services Research, including the delivery of patient-centered, high quality, cost-effective and safe urological care, permeated throughout the entire meeting making this a challenging topic to completely summarize. Therefore, I will focus on several recurrent themes and highlight these topics.

The sessions began with a focus on racial disparities of urological care. Dr. Hayden from Lahey Clinic presented his work on the impact of race on the emergency care of patients with stone disease (PD03-01). Analysis of the Healthcare Cost and Utilization Project revealed that 7% of patients seen in the emergency department for symptomatic stones had an emergency department re-visit within 30 days. Black and Hispanic patients were less likely to re-present compared to White patients, which was an unexpected finding. Possible explanations discussed included a disparity of up-front surgical care and differential pain medication management. Dr. Bernstein from Fox Chase Cancer Center evaluated the differential impact of the COVID-19 pandemic pertaining to race on patients with localized prostate cancer (PD03-02). A retrospective review of a multi-institutional collaborative found that Black men were significantly less likely to undergo prostatectomy during the early COVID-19 pandemic despite similar COVID-19 risk factors, similar Gleason Grade Group, and higher prostate specific antigen values. Bashir Al Hussein Al Awanlh reported on the impact of race on the utilization of active surveillance for prostate cancer using the Surveillance, Epidemiology, and End Results database from 2010–2015 (PD03-03). A predictive model was developed and found that the intensity of active surveillance (prostate specific antigen testing, magnetic resonance imaging scans, surveillance biopsies) was significantly less for Black men compared to nonBlack men. Dr. Michel from the University of Pennsylvania looked at the impact of race on involvement in urologic oncologic clinical trials using the National Cancer Database and ClinicalTrials.gov (PD28-01). Only half of the clinical trials had any data on race/ethnicity despite a 1993 mandate to report this data. They found that Black and Hispanic patients were underrepresented compared to White and Asian groups. This discrepancy impacts not only the availability of clinical care but also the ability to generate relevant conclusions to all patient groups from these clinical trials. Dr. Inoyatov from Albany Medical Center similarly used the ClinicalTrials.gov site and found that the majority of clinical trials failed to report enrollment information regarding minority groups, and those that did had a <3% enrollment (MP34-11). Lastly, Dr. Bernstein found that while the discussion of race and health disparities in the urological literature has increased over time, racial health disparities relating to structural biases and the impact of social inequities are rarely named (MP58-02).

The next area to explore involved social determinants of urological care as social factors are known to impact health outcomes. Dr. Miller from UPMC examined the association of socioeconomic status, rural-urban location, and insurance type with overall and cancer specific mortality in muscle invasive bladder cancer using the Pennsylvania Cancer Registry (PD03-04). Lower socioeconomic status and Medicare/Medicaid insurance type were associated with overall mortality while rural location was not, suggesting a need for public health programs to focus on these at-risk populations. Dr. Lundon from Mount Sinai Hospital looked at a diverse group of patients from New York City diagnosed with both COVID-19 and urological cancers (PD03-06). COVID-19 outcomes (positive test, hospitalization, intubation, and death) were found to be related to factors including zip code, race/ethnicity, smoking status, and English as preferred language. Emily Roebuck from Atrium Health described a pilot project to screen for social determinants of health in 2 outpatient urology clinics; 30% of the participants identified a resource need with food and housing being the most common highlighting the pervasive social needs of urological patients and the opportunity to address such needs in this setting (MP34-10).

Next, disease specific quality of life (QOL) was highlighted. Dr. Penniston from the University of Wisconsin discussed the importance of QOL in kidney stone patients (MP19-01). She described the creation of a shortened version of the Wisconsin Stone Quality of Life scale that can more easily be used for repeated collection of QOL measures. The Wisconsin Stone Quality of Life scale has previously shown that certain stone forming groups have lower QOL scores including those with multiple stone events/procedures/complications, women, obese, cystine stone formers, lower socioeconomic status and others. QOL related to urological cancers was explored by Dr. Maciejewski from the Ottawa Hospital (MP19-02). He described outcomes in patients undergoing radical cystectomy. Emotional distress was often found before cystectomy while physical and social concerns were frequently identified after surgery, highlighting the importance of assessing QOL factors pre and post-radical cystectomy. Patient-reported QOL has been independently associated with survival for many disease states, per Dr. Alam from Johns Hopkins (MP19-04). His group examined the differential effects of a cancer diagnosis on QOL. Using the Surveillance, Epidemiology, and End Results–Medicare Health Outcomes Survey, they found that both mental and physical health declined after cancer diagnosis for all urological cancers except testicular cancer. The greatest decline in mental health occurred in those with a diagnosis of ureteral cancer while the greatest decline in physical health occurred in those with a penile cancer diagnosis.

A recurrent topic in the sessions related to cost and outcome measures was the 2021 changes made by Centers for Medicare & Medicaid Services to the physician fee schedules. Drs. Mikula and Williams from the Smith Institute described these changes, which involve increased payments for outpatient evaluation and management services and subsequent decreases in compensation for in-office and inpatient procedures (MP17-12).

Several abstracts focused on the limited use of palliative care (PC) in urological patients. Dr. Filippou from the University of Washington and Dr. Hugar from Moffitt reported on patients with bladder cancer where only 4% utilize these services (MP19-07). Using the Bladder Cancer Advocacy Network Patient Survey Network, it was shown that PC is infrequently discussed by providers. Both patients and caregivers, however, were receptive to PC and would like it introduced earlier and more frequently in their care. Most patients had accurate knowledge and positive beliefs about PC. Using the National Cancer Database, Dr. Patel from Rutgers showed that PC was also infrequently used in patients with metastatic RCC (17%–20%) and that its use was influenced by several socioeconomic and clinical variables (PD38-09).

There were many presentations on opioid limitation and predictors of persistent use. In addition to urology-specific improvements in prescribing, Eric Macdonald from Albert Einstein reported that opioid prescriptions for patients with urolithiasis seen in the emergency department have steadily decreased in all U.S. regions except the Midwest (MP23-19). Another common topic explored was evaluating the safety and feasibility of same day discharges for procedures traditionally kept in the hospital in the postoperative setting including percutaneous nephrolithotomy and robotic-assisted prostate and kidney surgeries.

There were many other impactful projects that did not necessarily fall into a grouping. I strongly recommend going through these sessions on-demand to review the important work that I could not highlight in this short review, and congratulations to everyone for doing such great work!