Tag Archive for: BAUS

Posts

Best Practice Tariffs: could they be the solution to compliance with British Association of Urological Surgeons ureteric stone targets?

In January 2019, the National Institute for Clinical Excellence (NICE) and British Association of Urological Surgeons (BAUS) published new guidance on the management of Acute Ureteric Stones. This guidance suggests that primary definitive treatment should be the goal for all symptomatic ureteric stones, via either ureteroscopy (URS) or extra-corporeal shock wave lithotripsy (EWSL), and should be undertaken within 48 hours of acute presentation.

This is in stark contrast to current practice in the UK: Getting It Right First Time evidence suggests 20% (2-49%) of acute stones are currently treated in this way with only 8% treated primarily with URS and just 2% with primary ESWL.

It has been shown that primary definitive treatment of acute stones within 48 hours has superior outcomes to secondary definitive treatment after stenting; including a higher chance of achieving a stone free state, lower chance of needing retreatment, reduced exposure to general anaesthetic and associated complications, and avoidance of stent-associated symptoms.

However, due to the nature of current emergency surgery provision in UK NHS Trusts, primary definitive treatment is often impossible. Procedures are performed on pressured CEPOD lists which may not be set up for laser treatment (lacking suitable equipment and trained scrub staff) and are often incredibly time-pressured, necessitating ureteric stenting as a faster and simpler option.

Whilst the upfront investment required to provide sufficient resources and training is expected to be recovered downstream by reducing costs associated with stent use and the need for multiple procedures, NHS Trusts are reluctant to make these upfront investments unless incentivised.

We propose a potential solution in the form of Best Practice Tariffs (BPTs).

Traditionally, NHS Trusts receive their income from Clinical Commissioning Groups (CCGs) on the basis of a ‘Payment by Results’ (PbR) system. Under this system, tariffs are calculated based on the national average cost for clinically similar treatments (grouped together into healthcare resource groups; HRGs) and Trusts can retain additional income by keeping costs below this national average.  However, this can lead to wide variations in the standards of care. Lord Darzi’s 2008 ‘High Quality Care For All – NHS Next Stage Review’ report suggested that a revised payment system be used, where payment depended on compliance with best-known practice; a best-practice tariff (BPT).

BPTs have now been rolled out across more than 50 diseases and procedures including cholecystectomies, strokes/TIA and NSTEMIs and are recognised as an effective tool for changing practice in an acute setting.

One of the earliest examples was in the management of fractured neck of femurs (NOFs). The base tariff was halved and an additional BPT of £1,335 was made available if seven key ‘best practice’ criteria were met. A dramatic improvement in adherence to national guidelines for management of NOF fractures was seen after introduction of this BPT as shown in Figure 1 (Royal College of Physicians; 2014).

Of particular relevance here was the BPT criteria that required a ‘time to surgery within 36 hours from arrival in A&E to the start of anaesthesia’. The overall median time reduced from 44 hours pre-BPT to 23 hours post-BPT (p<0.005) and the proportion of patients being operated on within 36 hours of admission increased from 36% pre-BPT to 84% post-BPT (p<0.005).

BPTs have the most potential utility for high volume procedures with large variations in national practice and where there is a strong evidence base regarding what constitutes best practice. Renal stones are high volume, affecting 12.5% of the population and resulting in 18,000 URS  procedures a year. There is significant national variation in management and there is strong evidence on best practice.

Therefore, if we truly believe that the BAUS and NICE guidelines are in the best interests of patients, BPTs should be considered as a tool to prompt a rapid paradigm shift and make the gold standard, of primary definitive treatment within 48 hours, the new norm.

Further details available here.

by Sam Folkard, Richard Menzies-Wilson, Charlotte Burford, Paula Pal and James Green

Twitter: @FolkardSam

BJUI Annual Awards

Trainees who have a paper accepted for publication in the BJU International Journal are eligible for one of the following three BJUI Journal Prizes, which are awarded annually, based on the authors’ geographical location when they conducted the research.

The BJUI Global prize

This is awarded to authors who are trainees based anywhere in the world other than the Americas and Europe. The prize is presented at the USANZ annual meeting. In 2019 the BJUI Global prize was presented to Dr Amila Siriwardana from St Vincent’s Prostate Cancer Centre in Sydney, Australia for his article: Initial multicentre experience of 68gallium‐PSMA PET/CT guided robot‐assisted salvage lymphadenectomy: acceptable safety profile but oncological benefit appears limited.

The Coffey-Krane prize

The Coffey-Krane prize is awarded to authors who are trainees based in The Americas and it is presented at the AUA annual conference, which was held this year in Chicago. There were two winners this year: Jeffrey J. Tosoian and Meera R. Chappidi from the Johns Hopkins University School of Medicine in Baltimore, USA for their work on: Prognostic utility of biopsy‐derived cell cycle progression score in patients with National Comprehensive Cancer Network low‐risk prostate cancer undergoing radical prostatectomy: implications for treatment guidance.

The John Blandy prize

The John Blandy prize is awarded to authors who are trainees based in Europe. The prize is presented at the BAUS annual conference and the winner gives a presentation. The 2019 award was given to Isabel Rauscher from the Technical University of Munich in Germany, who gave a talk at the conference in Glasgow in June. Her article is entitled: Value of 111In‐prostate‐specific membrane antigen (PSMA)‐radioguided surgery for salvage lymphadenectomy in recurrent prostate cancer: correlation with histopathology and clinical follow‐up.

BJUI Vattikuti Foundation Robotics prize

This prize is a one-off prize awarded for the best robotics paper recently published in the BJU International Journal. The prize is sponsored by the Vattikuti Foundation and voted for by an independent panel. The research was carried out by a team from the Yonsei University College of Medicine in Seoul, South Korea on: Does robot‐assisted radical prostatectomy benefit patients with prostate cancer and bone oligometastases?

Encouraging future urologists: BAUS Section of Trainees (BSoT) goes to ASiT Conference

The Association of Surgeons in Training (ASiT) is a trainee-led, pan-specialty, independent body that aims to promote the highest standards of surgical training. The highlight of their calendar is the ASiT Conference, this year held at the ICC Belfast from 22nd to 24th March 2019. It attracted over 700 delegates of all grades.

ASiT invites representatives of all surgical specialty groups to be part of their council. It is a reciprocal relationship as many surgical training issues affect us all and together we have a great influence. Urology’s BAUS Section of Trainees ‘BSoT’ (formerly SURG) Representative, Clare Jelley (ST5, Oxford Deanery), has done an incredible job over the last 3 years and it is these shoes that I now attempt to fill as the new BSoT/ASiT Rep.

The ASiT Conference weekend included pre-conference courses run by surgical specialty groups, plenary lectures with notable speakers, breakout sessions and an impressive exhibition hall.  Unsurprisingly the plenary session on curricula, credentialing and regulation was full; Charlie Massey and Prof Colin Melville (GMC) were put under fierce questioning by the ASiT Committee and the audience. The plenary talks also included a range of topics: innovation, leadership, burnout, fatigue and overcoming adversity. The latter was poignantly given by John Peter, RAF pilot and POW in Iraq (pictured).

The scientific programme included research and audit project presentations. Successful abstract submissions were invited for poster presentation (grouped and marked by specialty) and the highest scoring, prize-worthy abstracts were invited for oral presentation. Accepted abstracts are published in the British Journal of Surgery. There were also social events including a 5km charity run, welcome drinks and the inaugural black-tie Gala Dinner held at the stunning Belfast City Hall.

 

Clare and I flew the flag for Urology during the conference! The pre-conference course ‘Basic Urology Skills’ was full; we taught 16 very keen delegates interested in a career in urology from all over the UK (pictured). We included practical stations to teach skills such as: cystoscopy, ureteric stenting, scrotal exploration (using medical meat), circumcision and supra-pubic catheter insertion. We are very grateful for reps from Cook, Stryker and Coloplast for providing the equipment and to our urological trainee faculty which included  Mr Trevor Thompson, urological consultant and Head of the School of Surgery in Belfast, UK.

The ‘Specialty Fair’ was another opportunity to showcase urology (and promote it as the best career choice!). The room was packed. Delegates met speciality representatives and trainees, enabling conversations and questions about their surgical specialty in an informal manner. Special thanks to urology registrars Tharani Mahesan and Katie Chan who helped spread the positive message (pictured).

 

The abstract presentations were of a high standard; there were over 50 urology-themed posters showcased. Of particular note there were at least 4 oral presentations reflecting projects within urology – including IDENTIFY preliminary results presented by Tara Sibartie on behalf of all the collaborators, which won the Society of Academic and Research Surgery (SARS) prize. Another urological highlight was the Edinburgh Surgical Sciences Qualification prize being awarded to Katie Chan for her presentation of the #DontPayToStay campaign. This Freedom of Information request exposed that 18% of English hospitals charge for non-resident on call accommodation at a median rate of £25/night. i.e. trainees are left with a financial burden in order to maintain a safe emergency practice. By highlighting this issue and gaining support from ASiT and the Junior Doctors Committee it is hoped that these charges can conclusively be removed during the renegotiation of the junior doctor contract. Katie also brought along the youngest Conference delegate, baby Orla, who enjoyed the use of the ASiT crèche (free of charge!).

BSoT is committed to representing current urology trainees but also to inspire and mentor medical students, foundation and core trainees who may be interested in a career in urology. Therefore it was a privilege to be able to represent the newly rejuvenated BSoT; perhaps even encouraging some future urologists!

Overall it was an exciting and interesting weekend; ASiT Conference 2020 will be held at the ICC Birmingham from 6th to 8th March; it promises to be bigger and better than ever and BSoT will be there! I’d thoroughly recommend all those interested in a career in surgery (and urology) to submit their projects, attend and get involved with ASiT. BSoT will also be organising events for those interested in a career in urology – so watch this space!

by Sophie Rintoul-Hoad, ST5 Urology trainee in South London Deanery and recently elected ASiT representative for BAUS Section of Trainees Committee (BSoT).

Acknowledgements: Clare Jelley and Luke Forster (BSoT President)

 

BAUS/BJUI/USANZ Joint Session AUA 2019

British Association of Urological Surgeons/BJU International/Urological Society of Australia and New Zealand (BAUS/BJUI/USANZ) Joint Session AUA 2019

Sunday, May 5th 2:00 – 5.00 PM. McCormick Place Convention Center South Building – Room S102 BC

 

Registries /Smart Data /Complications – CHAIR: Duncan Summerton

 

1400-1420 Alan Partin

A contemporary look at biomarkers for diagnosis of Prostate Cancer

1420-1440 Chris Harding (BJUI sponsored BAUS lecture)

The Mesh Story – lessons learned and future plans

1440-1500 Nick Watkin

PROMs in Urology

1500-1520 Stephen Mark

Big Data and Urology – a pilot trial in New Zealand

1520-1540 Afternoon tea
 

Education /Training /Innovation – CHAIR: Prokar Dasgupta

 

1540-1600 Andrew Hung (BJUI sponsored lecture)

The emerging role of Artificial Intelligence in Surgical Science

1600-1620 Jonathan Kam

Zero learning curve Percutaneous Nephrolithotomy Access – Prone endoscopic combined intrarenal surgery and multimedia training aid to teach urology trainees

1620-1640 Madhu Koya (BJUI sponsored USANZ lecture)

Cx bladder reduces flexible cystoscopy in haematura and superficial TCC

1640-1700 Kamran Ahmad

Innovation in healthcare systems

1700-1705 BJUI Coffey-Krane Award for trainees based in The Americas presented by Prokar Dasgupta
1700-1900 BJUI Reception

 

BAUS 2018 Highlights Day Two

BAUS Day 2. The Multidisciplinary Team Debate. Which way are you headed?

BAUS is certainly a UK-centric meeting. But we all share most of the same challenges in healthcare, and as an international urologist in attendance, the learning experience is often gaining insight into how different health systems tackle common problems with solutions and evolutions.

During day 2 prime time, the agenda tackled the current and future situation with MDTs in cancer treatment—multidisciplinary team meetings. For the USA, we might use the term Tumor Board. At MD Anderson we just say, “Urological Multidisciplinary Case Conference.” So yes, MDT is much more efficient.

The goals are straightforward in principle: 1) increase the quality and standardization of care, 2) improve access to expert imaging/pathology, 3) provide a “group” decision which may be more experienced than any 1 person. In the United States, each center is left on its own how to organize and conduct MDTs, although there may be requirements for inclusion as an NIH designated comprehensive cancer center. In the UK, it appears that MDTs are more of a compulsory element. Another key decision is what patients will be presented—all or selected. In the UK, it appears the goal has been to present everyone.

The first speaker was Hashim Ahmed who showed how the “present everything” model has increasingly become impossible, as half of all cases are presented/discussed in < 2 minutes and few go beyond 3 minutes. A national strategy is being discussed and likely piloted in prostate cancer whereby “routine” cases might be listed as a statistic but not discussed; and time reserved for more complicated cases where discussion might be more fruitful. This model will require the MDT chair to spend more pre-meeting time triaging the meeting agenda.

Jo Cresswell expanded the topic by compiling the UK real world experience with MDTs in terms of what has worked well and where it has been lacking.

The “good” might include:

  • Building working relationships with colleagues
  • Mentorship interactions
  • Challenging old practices—evolving from eminence based to evidence based decisions
  • Calling out bad practice/minimize rouge decision making
  • Comforting patients that their case has been heard by a group—sort of a free 2nd opinion

The “bad” or “Pet Hates” list is interesting:

  • The cost of running the MDTs—actual and effort
  • Reduced ownership of the patient—notes where the plan just reads “refer to MDT”
  • Waiting on the MDT
  • MDT Tennis—i.e. referring back and forth between different MDTs
  • Fatigue—going through 120 cases in a session—is anyone awake at the end? Some providers have to attend multiple MDTs per week
  • Loud voices can overrule others (queue the photo of Trump)
  • Agenda effect—if you always present in the same order then whoever goes last on the agenda probably gets less quality discussion.

What is the best middle ground? Again,the concept of discussion reserved for complex cases, and routine cases are under the MDT but not given time.

The final speaker was Bill Dunsmuir. He started by challenging the assumption that the MDT make up of 10-20 experts in oncology will produce wiser decisions than any single provider. Case and point was the 1996 climbing expedition to Mount Everest where the group decision making of expert climbers led to the deaths of the many. Maybe group thinking is not so wise? Problems might include group thought with the same ideas, hierarchy that minimizes dissent, and false debates.

From the Emperor of All Maladies book, he channeled the similar questions, “What is Cancer, why does cancer kill?” One trainee responded in a survey “A cancer killed because they were unfortunate enough to have their cases discussed at an MDT.”   So why do we have MDTs?

His proposal was to consider MDTs as not only dedicated to group decisions, which may or may not always be right. Rather consider them as multidisciplinary professional education. As an example, if the group encounters a specific problem, there would be a pool of short video clips to review the evidence and guidelines—and then discussion could flow off of these standardized points. Ambitious for sure and would need funding and buy in.

In conclusion, this was a well-done session, and highlights the natural history, so to speak, of compulsory MDTs including all patients.   At MD Anderson, we went the other way: select presentations. Each case takes 10-20 minutes, so we usually only get through 3-5 in an hour session. Attendance is optional and there tends to emerge faculty personalities who like MDT interaction, and some who never go. Cases are nominated by a fellow or faculty and you would probably be criticized for presenting a patient where we already have a treatment protocol in placed, i.e. “put them on the protocol, next case.” As a fellow in 2001-2002 I observed there are 3 popular categories of MDT case presentation that are always worthwhile:

  1. I dare you to operate on this patient (co-morbidity, prior surgery, obesity etc.)
  2. How to manage multiple cancers
  3. Look what they screwed up on the outside. Now what?

Please use our comment section—where do you stand on MDTs at your center and what is in the future?

 

John W. Davis, MD, FACS

Associated Editor, BJUI

 

Figures: Slide highlights on current and future of MDTs

 

BAUS 2018 Highlights Day One

Day one at BAUS gets started with society meetings and the John Blandy Prize and Lecture delivered by Editor Prokar Dasgupta.  The winner was from Pisano et al from Turin, Italy on “The role of re-transurethral resection in the management of high risk NMIBC (PMID 26469362).

But I had to miss this event as I was having my first patient encounter with the NHS.  I have 4 days of severe pain in my left foot after a lot of walking/running around as a tourist on a Baltic Sea cruise.  I went to the nearby NHS walk in clinic—there for an hour and saw the nurse practitioner and left with new scripts for NSAIDs, pain, etc.  And no bill?  Not in the USA!

So now that I can walk (sort of—but only with my running shoes—looks great with a suit) I made it to the teaching course on quality improvement (QI).  I am interested in the topic as I am a Quality Officer for Urology at MD Anderson Cancer Center.  One of our new directives has been to help with fellows organizing a new mandatory “quality improvement” initiative as part of their training.  From the course, I learned that the UK has similar programs but also similar challenges in implementation and standardization.  In the UK, it sounds like medical students are being taught quality improvement in the curriculum.  But if you are like me and finished school > 20 years ago, you likely missed this content.  A consensus opinion was that educational materials on quality improvement science will be created and hopefully will land on the BJUI Knowledge website.  This will help trainees but also trainers catch up on terminology, goals, and how to coach trainees on project development.

The next strong consensus was that quality improvement projects be listed on a website—likely BAUS—so that they could be indexed and searched.  Similar to clinicaltrials.gov or the PROSPERO website that catalog clinical trials and meta-analyses, respectively, the BAUS site could be searchable for projects that were successful as well as those that failed for some reason (perhaps with lessons learned).  Indexing could help with project selection as some QI ideas are unique to urology versus all specialties, and QI projects may emphasize different practice environments such as clinic, operating theatre, or diagnostic departments.

Overall, QI is an emerging field and we are struggling with the same barriers on both sides of the Atlantic.  Principle questions include 1) how to differentiate a clinical study from QI, 2) the role of statistics, evidence-based medicine principles, and ethics committees in QI, 3) how QI should be taught in medical school and post graduate programs, and 4) how QI projects can be published.  On the latter point the Journal of Clinical Urology has expressed interest in publishing QI projects.

The course was directed by Mr. James Green from Barts Health, and also taught by Prof. Nick Sevdalis.  Congrats to both on a job well done.  From my perspective, this field will continue to grow and for some young academic minded urologists will develop into a legitimate academic niche to go along with established pathways such as laboratory investigations, health services research, and surgical education.

Figure: My favorite slide—so may sources of inspiration for a Quality Improvement Projects

John W. Davis, Associate Editor.

 

June 2018 – About the Cover

In the month that brings the BAUS annual meeting to Liverpool, the Article of the Month is a BAUS consensus document and so the cover features the sign for the Beatles Story museum in Liverpool.

The Museum contains recreations of The Casbah Coffee ClubThe Cavern Club and Abbey Road Studios among other historical Beatles items, such as John Lennon‘s spectacles, George Harrison‘s first guitar and a detailed history about the British Invasion and the solo careers of every Beatle.

 

 

 

© istock.com/ilbusca

 

The British are coming!

bju13868-fig-0001Historians report that Paul Revere never said these famous words; as Colonial Americans at the time still considered themselves British. Indeed, Americans still consider themselves European. The United States Census reports that 73% of Americans are of European descent, and 62% of these are of English, Scottish, Welsh or Irish ancestry.

These links to our heritage remain strong. With >1100 European members (close to 200 from the UK) and >300 members from Australia and New Zealand, our bonds of friendship and collaboration are tightly intertwined. So if Paul Revere won’t say it, I will!

The British are coming! Each year >2000 Europeans attend our Annual meeting (200 from the UK) and >100 from Australia and New Zealand. They are represented not only in quantity but also in quality. Of the 1700 scientific abstracts submitted from Europe to the 2017 Annual meeting, the acceptance rate was 38% for the UK, compared to an overall acceptance rate of 34%. Important science comes from the UK and Australia, and raises the quality of our meeting.

The BAUS–BJUI–USANZ Joint Session on Sunday 14 May in Boston is a clear example of how the BJUI family, as the official journal of the USANZ and the BAUS ‘raises the bar’ at the AUA Annual Meeting. With focuses on personalised medicine, genomics, systems biology, immunotherapy, and ‘training the brain’, it promises to stimulate and educate. Following this we look forward to toasting our transatlantic brothers and sisters with a Boston Lager at the BJUI reception.

The British are coming! We look forward to welcoming you in Boston in May.

Manoj Monga, AUA Secretary
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA

 

AUA 2017

aua-combined-session-baus-bjui-usanz-2017

BAUS – BJUI – USANZ Joint Session 2017

Sunday, May 14                               2:00 PM                Westin Grand Ballroom CDE

[divider scroll]

Personalised Medicine

CHAIR: Prokar Dasgupta, BJUI Editor-in-Chief, King’s Health Partners, London, UK

1400-1420

Bernard Bochner, Memorial Sloan Kettering Cancer Center, USA

Personalised Medicine for Bladder cancer

1420-1440 Ian Vela, BJUI Sponsored USANZ Lecture, Princess Alexandra Hospital, Brisbane, Australia

Personalised Medicine for Prostate Cancer

1440-1450 Wade Bushman, University of Wisconsin, USA

Personalised Medicine for BPH

1500-1520 John Davis, MD Anderson Cancer Center, USA

Immunotherapy for Urological Cancers

1520-1550 Afternoon tea

[divider scroll]

Urological Training for the Future

CHAIR: Peter Heathcote, President USANZ, Princess Alexandra Hospital, Brisbane, Australia

1550-1610 Kieran O’Flynn, BJUI Sponsored BAUS Lecture, President BAUS, Salford Royal Foundation Trust, UK

Training and Inspiring the Next Generation of Urologists

1610-1630 Khurshid Guru, Roswell Park Cancer Institute, Buffalo, NY, USA

The Role of Cognitive Training in Surgery

1630-1645 BJUI Peer Review prize for best reviewer from The Americas presented by Prokar Dasgupta

Christchurch Medal Presented by Peter Heathcote

BJUI Coffey-Krane Award for trainees based in The Americas presented by Prokar Dasgupta

1700-1900 BJUI Reception

 

 

© 2020 BJU International. All Rights Reserved.