Significant Management Variability of Urethral stricture Disease in United States: Data from the AUA Quality (AQUA) Registry.

To determine the degree of contemporary practice variation for the treatment of urethral stricture disease (USD) given repeated endoscopic management yields poor long-term success.

The AUA Quality (AQUA) Registry collects data from participating urologists across practice settings by direct interface with local electronic health record systems. We identified procedures used for USD using Current Procedural Terminology (CPT) and International Statistical Classification of Diseases (ICD-9/-10) codes. We assessed the association between patient and provider factors and repeated endoscopic treatment using generalized linear models. Provider details were derived from AUA Census.

We identified 20,640 male patients with USD treated surgically in AQUA from 2014-2018. The patients were cared for by 1343 providers at 171 practices, 95% of these community-based. Among patients with USD who had treatment, 20,101(97.9%) underwent endoscopic management. 6218(31%) underwent repeated endoscopic treatment during the study period. Urethroplasty was performed in 539(2.6%) patients.  Median patient age at first procedure for endoscopic surgery vs. urethroplasty was 73 vs. 39 years old, respectively (p<0.001). At the practice level, significant variation in rates of repeated endoscopic management was noted. Patients of older age (OR=1.08, 95%CI: 1.06-1.11 for ages ≥80) and patients with a bladder cancer diagnosis (OR=1.17, 95%CI: 1.15-1.20) had higher odds of receiving repeated endoscopic management. Increasing practitioner age was also associated with increased odds of repeated endoscopic management. (OR=1.13, 95%CI: 1.11- 1.16, for practitioners ≥64).

Repeated endoscopic management for USD is overused. The utilization of endoscopic management is variable across practices and frequently guideline-discordant, presenting an opportunity for quality improvement.

Urology. 2020 Aug 07 [Epub ahead of print]

Andrew J Cohen, Nnenaya Agochukwu-Mmonu, Danil V Makarov, William Meeks, John Murphy, Raymond Fang, Matthew R Cooperberg, Benjamin N Breyer

Department of Urology, Johns Hopkins University, Baltimore, MD. Electronic address: ., Department of Urology, University of California, San Francisco, California., VA New York Harbor Healthcare System and Department of Urology, New York University Langone Medical Center., American Urological Association Education & Research, Department of Data Management & Statistical Analysis., Department of Urology, University of California, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA.