title: Patient Function and the Value of Surgical Care for Kidney Cancer.
abstract: Frailty and functional status have emerged as significant predictors of morbidity and mortality for patients undergoing cancer surgery. To articulate the impact on value (ie quality per cost), we compared perioperative outcomes and expenditures according to patient function for older adults undergoing kidney cancer surgery.
  
  
  
  Using linked SEER (Surveillance, Epidemiology and End Results)-Medicare data, we identified 19,129 elderly patients with kidney cancer treated with nonablative surgery from 2000 to 2009. We quantified patient function using function related indicators (claims indicative of dysfunction and disability) and measured 30-day morbidity, mortality, resource use and cost. Using multivariable, mixed effects models to adjust for patient and hospital characteristics, we estimated the relationship of patient functionality with both treatment outcomes and expenditures.
  
  
  
  Of 19,129 patients we identified 5,509 (28.8%) and 3,127 (16.4%) with a function related indicator count of 1 and 2 or greater, respectively. While surgical complications did not vary (OR 0.95, 95% CI 0.86-1.05), patients with 2 or more indicators more often experienced a medical event (OR 1.22, 95% CI 1.10-1.36) or a geriatric event (OR 1.55, 95% CI 1.33-1.81), or died within 30 days of surgery (OR 1.43, 95% CI 1.10-1.86) compared with patients with no baseline dysfunction. These patients utilized significantly more medical resources and amassed higher acute care expenditures (p <0.001).
  
  
  
  During kidney cancer surgery, patients in poor functional health can face a more eventful medical recovery at elevated cost, indicating lower value care. Greater consideration of frailty and functional status during treatment planning and transitions may represent areas for value enhancement in kidney cancer and urology care.
authors.affiliation: Department of Urology, University of North Carolina, Chapel Hill, North Carolina. Electronic address: hjtan@med.unc.edu.
authors.forename: Hung-Jui
authors.initials: HJ
authors.lastname: Tan
authors.affiliation: Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California.
authors.forename: Joseph D
authors.initials: JD
authors.lastname: Shirk
authors.affiliation: Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California.
authors.forename: Karim
authors.initials: K
authors.lastname: Chamie
authors.affiliation: Department of Health Policy and Management, UCLA Fielding School of Public Health and UCLA School of Nursing, Los Angeles, California.
authors.forename: Mark S
authors.initials: MS
authors.lastname: Litwin
authors.affiliation: Department of Urology, Weill Cornell School of Medicine, New York, New York.
authors.forename: Jim C
authors.initials: JC
authors.lastname: Hu
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003362:Cost-Benefit Analysis / Q000706:statistics & numerical data*; D018588:Fee-for-Service Plans / Q000706:statistics & numerical data; D005260:Female; D016330:Frail Elderly / Q000706:statistics & numerical data; D000073496:Frailty / Q000150:complications / Q000191:economics; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006801:Humans; D007680:Kidney Neoplasms / Q000191:economics / Q000401:mortality / Q000601:surgery*; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D009392:Nephrectomy / Q000009:adverse effects / Q000191:economics*; D011183:Postoperative Complications / Q000191:economics / Q000453:epidemiology* / Q000209:etiology / Q000628:therapy; D018426:SEER Program / Q000706:statistics & numerical data; D016896:Treatment Outcome; D014481:United States
keywords: SEER Program; health care costs; kidney neoplasms; nephrectomy; perioperative period