Social Factors Impact Urethral Stricture Surgery Outcomes - Hiren Patel
November 5, 2024
Ruchika Talwar hosts Hiren Patel to discuss a multi-institutional study examining the impact of social deprivation on anterior urethral stricture recurrence after urethroplasty. Using the TURNS database of over 1,400 patients, the research reveals that higher social deprivation scores correlate with increased stricture recurrence rates and shorter recurrence-free intervals following surgery. The conversation explores how social determinants of health influence surgical outcomes, with findings showing an 8% increase in stricture recurrence for every 10-point increase in social deprivation index. Dr. Patel discusses practical applications of these findings, including the use of zip code-based social deprivation calculators to inform preoperative counseling and postoperative surveillance protocols. The conversation concludes with insights into incorporating social determinants of health assessment into clinical practice and the potential for future EMR integration of these tools.
Biographies:
Hiren Patel, MD, PhD, Reconstructive Urologist, Assistant Professor of Urology, Ohio State Medical Center, Columbus, Ohio
Ruchika Talwar, MD, Assistant Professor of Urology, Urologic Oncologist, and Associate Medical Director in Population Health, Vanderbilt University Medical Center, Nashville, TN
Biographies:
Hiren Patel, MD, PhD, Reconstructive Urologist, Assistant Professor of Urology, Ohio State Medical Center, Columbus, Ohio
Ruchika Talwar, MD, Assistant Professor of Urology, Urologic Oncologist, and Associate Medical Director in Population Health, Vanderbilt University Medical Center, Nashville, TN
Read the Full Video Transcript
Ruchika Talwar: Hi everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar and I'm a urologic oncologist at Vanderbilt in Nashville, Tennessee. Today I'm really excited to be joined by Dr. Hiren Patel, who's an assistant professor of urology at OSU. He'll be joining us today discussing some recent work he published exploring the impact of social deprivation on anterior urethral stricture recurrence after urethroplasty. We really appreciate you taking the time to chat with us today.
Hiren Patel: Hi, Ruchika. Thank you so much for inviting me to discuss my recent findings. I'm happy to talk to you and I'm honored that you UroToday was able to provide that opportunity.
My work is exploring the impact of social deprivation on anterior urethral stricture recurrence after urethroplasty. This is a study that was done in collaboration with the TURNS network of surgeons and is a multi-institutional study. It was mainly led with my efforts during fellowship at UCSF under the tutelage of Dr. Benjamin Breyer.
Urethral stricture disease occurs because of many reasons, it's multifactorial. There's been several patient and clinical factors that have been related to urethral stricture occurrence and the gold standard of treatment has been urethroplasty for many years. However, after urethroplasty, there are patients that have recurrence of their stricture disease and in the literature there have been many clinical and patient-related factors that have been associated with stricture recurrence after urethroplasty, and these recurrence rates can be as high as 20%. So it really begs the question, despite knowing these clinical factors and patient factors and optimizing for these different disease factors, why is the recurrence rate so high? Is there another non-observed factor that's related to stricture recurrence after urethroplasty?
We were interested in looking at social determinants of health. Particularly these are conditions in the environment that affect a wide range of health functioning as well as quality of life outcomes. It also contributes to health disparities and inequities and can inform policies and aid in the implementation of specialized care. In this project, we were looking at social deprivation, which is a composite measure that assesses social disadvantage in a neighborhood that a patient lives in.
So like I had mentioned, our study was looking at the impact of social deprivation on stricture recurrence after urethroplasty, and we hypothesized that patients that were in more disadvantaged environments were at a higher risk of observing urethral stricture recurrence. We used the TURNS database, which is a multi-institutional collaboration among 10 institutions. We identified patients that underwent anterior urethroplasty and we accounted for about close to a little bit over 1400 patients that had urethral repair. We collected different variables and the outcome was looking at functional stricture recurrence, which is any stricture that required re-treatment after it was identified.
What we immediately found was that patients that were in the worst SDI or social deprivation index quartile, so quartile four had a higher recurrence rate and they also had a shorter recurrence-free interval after urethroplasty. You can see that over here where at year one they're very similar, and at year five you can see that there's starting to be separation among the quartiles and the recurrence rate is also commensurate of this, where quartile one has a 15% recurrence rate, whereas in quartile four it's close to 27%. These were all statistically significant.
Additionally, we then looked at, we modeled whether there were factors that were associated with stricture recurrence, and what we identified was that for every 10 point increase in social deprivation index, there was an 8% increase in stricture recurrence after urethroplasty. There were additional factors that we looked at as well, and those were not significant. The only ones that were significant were whether substitutions or a graft was used during the procedure and whether smoking status, so whether they were a former smoker or never smoked. When we looked at the interaction between smoking and STI, there was no significant evidence that there was interaction between the two, suggesting that smoking status may have some alternate factors that might be leading to stricture recurrence.
In conclusion, what we found was that higher social deprivation was associated with a higher risk of recurrence after urethroplasty. Social determinants of health in addition to clinical and patient factors play an important role in the success after urethroplasty, and this has implications for clinical care when we think about preoperative counseling, risk stratifying and postoperative surveillance protocols.
Ruchika Talwar: Thanks, Dr. Patel, really interesting findings. This is obviously an expensive, complex disease state and recurrence is of significant financial burden to the patient and to the overall health system. So I think your findings are very relevant and shed light on some potential areas where we as urologists can focus on in our counseling and evaluation of these patients. Can you share with me a little bit about how this has potentially affected the way you think about these patients?
Hiren Patel: Absolutely. These findings, when we identify that social deprivation was associated with an increased risk of recurrence, made me think about how we would change our practice moving forward. For me specifically, I would counsel patients differently depending on their socio-demographic factors. It also may lead to different post-operative surveillance protocols. So bringing in patients sooner to come in for surveillance, maybe to see if they have symptoms or require other endoscopic treatments might be a different way of doing surveillance in the future for them.
Ruchika Talwar: And how do you suggest we tease out some of those social deprivation factors during our visits? It's not always something that we're able to, or I should say it's not always something that we proactively ask about. So what are some suggestions you have to the urologic community on how to incorporate that into office visits?
Hiren Patel: Absolutely. The social deprivation index that we used, it required us to punch in the zip code into a SDI index calculator. It's very simple to use. You can find there are many resources online that are available, and so that can give you a whole lot of information without asking the patient a lot of specific information about what is their smoking status, do they have food that's available to them? It gets a rough estimate about what kind of environment that the patient lives in and can give you a lot of information about what's available and what kind of access they have to a lot of other resources in the community. That being said, if you forget to ask it, it's always available. Their zip code is always available in the EMR, and so you can backtrack it and figure that out as well. And that allows us to kind of tease out some of these access to care issues post-hoc as well.
Ruchika Talwar: Absolutely. Really interesting stuff, and I certainly can imagine a day in which these algorithms are built into our EMR, and so hopefully we'll be able to proactively identify patients who are potentially at risk and try to mitigate some of this. But until then, I applaud you on this important work, and thank you for sharing some time this afternoon to talk with us.
Hiren Patel: Absolutely. It was an honor to talk to you, Dr. Talwar.
Ruchika Talwar: And to our audience, thank you so much for tuning in. We'll see you next time.
Ruchika Talwar: Hi everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar and I'm a urologic oncologist at Vanderbilt in Nashville, Tennessee. Today I'm really excited to be joined by Dr. Hiren Patel, who's an assistant professor of urology at OSU. He'll be joining us today discussing some recent work he published exploring the impact of social deprivation on anterior urethral stricture recurrence after urethroplasty. We really appreciate you taking the time to chat with us today.
Hiren Patel: Hi, Ruchika. Thank you so much for inviting me to discuss my recent findings. I'm happy to talk to you and I'm honored that you UroToday was able to provide that opportunity.
My work is exploring the impact of social deprivation on anterior urethral stricture recurrence after urethroplasty. This is a study that was done in collaboration with the TURNS network of surgeons and is a multi-institutional study. It was mainly led with my efforts during fellowship at UCSF under the tutelage of Dr. Benjamin Breyer.
Urethral stricture disease occurs because of many reasons, it's multifactorial. There's been several patient and clinical factors that have been related to urethral stricture occurrence and the gold standard of treatment has been urethroplasty for many years. However, after urethroplasty, there are patients that have recurrence of their stricture disease and in the literature there have been many clinical and patient-related factors that have been associated with stricture recurrence after urethroplasty, and these recurrence rates can be as high as 20%. So it really begs the question, despite knowing these clinical factors and patient factors and optimizing for these different disease factors, why is the recurrence rate so high? Is there another non-observed factor that's related to stricture recurrence after urethroplasty?
We were interested in looking at social determinants of health. Particularly these are conditions in the environment that affect a wide range of health functioning as well as quality of life outcomes. It also contributes to health disparities and inequities and can inform policies and aid in the implementation of specialized care. In this project, we were looking at social deprivation, which is a composite measure that assesses social disadvantage in a neighborhood that a patient lives in.
So like I had mentioned, our study was looking at the impact of social deprivation on stricture recurrence after urethroplasty, and we hypothesized that patients that were in more disadvantaged environments were at a higher risk of observing urethral stricture recurrence. We used the TURNS database, which is a multi-institutional collaboration among 10 institutions. We identified patients that underwent anterior urethroplasty and we accounted for about close to a little bit over 1400 patients that had urethral repair. We collected different variables and the outcome was looking at functional stricture recurrence, which is any stricture that required re-treatment after it was identified.
What we immediately found was that patients that were in the worst SDI or social deprivation index quartile, so quartile four had a higher recurrence rate and they also had a shorter recurrence-free interval after urethroplasty. You can see that over here where at year one they're very similar, and at year five you can see that there's starting to be separation among the quartiles and the recurrence rate is also commensurate of this, where quartile one has a 15% recurrence rate, whereas in quartile four it's close to 27%. These were all statistically significant.
Additionally, we then looked at, we modeled whether there were factors that were associated with stricture recurrence, and what we identified was that for every 10 point increase in social deprivation index, there was an 8% increase in stricture recurrence after urethroplasty. There were additional factors that we looked at as well, and those were not significant. The only ones that were significant were whether substitutions or a graft was used during the procedure and whether smoking status, so whether they were a former smoker or never smoked. When we looked at the interaction between smoking and STI, there was no significant evidence that there was interaction between the two, suggesting that smoking status may have some alternate factors that might be leading to stricture recurrence.
In conclusion, what we found was that higher social deprivation was associated with a higher risk of recurrence after urethroplasty. Social determinants of health in addition to clinical and patient factors play an important role in the success after urethroplasty, and this has implications for clinical care when we think about preoperative counseling, risk stratifying and postoperative surveillance protocols.
Ruchika Talwar: Thanks, Dr. Patel, really interesting findings. This is obviously an expensive, complex disease state and recurrence is of significant financial burden to the patient and to the overall health system. So I think your findings are very relevant and shed light on some potential areas where we as urologists can focus on in our counseling and evaluation of these patients. Can you share with me a little bit about how this has potentially affected the way you think about these patients?
Hiren Patel: Absolutely. These findings, when we identify that social deprivation was associated with an increased risk of recurrence, made me think about how we would change our practice moving forward. For me specifically, I would counsel patients differently depending on their socio-demographic factors. It also may lead to different post-operative surveillance protocols. So bringing in patients sooner to come in for surveillance, maybe to see if they have symptoms or require other endoscopic treatments might be a different way of doing surveillance in the future for them.
Ruchika Talwar: And how do you suggest we tease out some of those social deprivation factors during our visits? It's not always something that we're able to, or I should say it's not always something that we proactively ask about. So what are some suggestions you have to the urologic community on how to incorporate that into office visits?
Hiren Patel: Absolutely. The social deprivation index that we used, it required us to punch in the zip code into a SDI index calculator. It's very simple to use. You can find there are many resources online that are available, and so that can give you a whole lot of information without asking the patient a lot of specific information about what is their smoking status, do they have food that's available to them? It gets a rough estimate about what kind of environment that the patient lives in and can give you a lot of information about what's available and what kind of access they have to a lot of other resources in the community. That being said, if you forget to ask it, it's always available. Their zip code is always available in the EMR, and so you can backtrack it and figure that out as well. And that allows us to kind of tease out some of these access to care issues post-hoc as well.
Ruchika Talwar: Absolutely. Really interesting stuff, and I certainly can imagine a day in which these algorithms are built into our EMR, and so hopefully we'll be able to proactively identify patients who are potentially at risk and try to mitigate some of this. But until then, I applaud you on this important work, and thank you for sharing some time this afternoon to talk with us.
Hiren Patel: Absolutely. It was an honor to talk to you, Dr. Talwar.
Ruchika Talwar: And to our audience, thank you so much for tuning in. We'll see you next time.