Impact of surgeon volume on the morbidity and costs of radical cystectomy in the USA: a contemporary population‐based analysis

Abstract

ObjectivesTo evaluate the relationship between surgeon volume of radical cystectomy (RC) and postoperative morbidity, and to assess the economic burden of bladder cancer in the USA. MethodsWe captured all patients who underwent RC (International Classification of Diseases, ninth revision, code 57.71) between 2003 and 2010, using a nationwide hospital discharge database. Patient, hospital and surgical characteristics were evaluated. The annual volume of RCs performed by the surgeons was divided into quintiles. Multivariable regression models were developed, adjusting for clustering and survey weighting, to evaluate the outcomes, including 90-day major complications (Clavien grade III-V) and direct patient costs. We adjusted for clustering and weighting to achieve a nationally representative analysis. ResultsThe weighted cohort included 49 792 patients who underwent RC, with an overall 90-day major complication rate of 16.2%. Compared with surgeons performing one RC annually, surgeons performing ≥7 RCs each year had 45% lower odds of major complications (odds ratio [OR] 0.55; P < 0.001) and lower costs by $1690 (P = 0.02). Results were consistent when we analysed surgeon volume as a continuous variable and when we examined the surgeons with the highest volumes (≥28 cases annually), which showed markedly lower odds of major complications compared with the surgeons with the lowest volumes (OR 0.45, 95% CI 0.31-0.67; P < 0.001). Compared with patients who did not have any complications, those who had a major complication were associated with significantly higher 90-day median direct hospital costs ($43 965 vs $24 341; P < 0.001). ConclusionsWe showed that there was an inverse relationship between surgeon volume and the development of postoperative 90-day major complication rates as well as direct hospital costs. Centralisation of RC to surgeons with higher volumes may reduce the development of postoperative major complications, thereby decreasing the burden of bladder cancer on the healthcare system.

Population-based assessment of racial/ethnic differences in utilization of radical cystectomy for patients diagnosed with bladder cancer

“…4 These factors have contributed to the centralization of care to high-volume providers for a number of complex procedures. 14 Our study demonstrated that when radical cystectomy was performed, greater than 90% of patients also underwent a pelvic lymph node dissection. This suggests that if a radical cystectomy is performed, then the vast majority of patients are appropriately undergoing a pelvic lymph node dissection.…”

Open Conversion during Minimally Invasive Radical Prostatectomy: Impact on Perioperative Complications and Predictors from National Data

“…17,18 Multivariate regression modeling was used to compare rates of each complication across the 3 groups after adjusting for age and comorbidities. The Elixhauser method was chosen to adjust for patient comorbidities 19 as it is incorporated into the NIS and performs favorably compared to other indices.…”

How to lower postoperative complications after radical cystectomy - a review

“…It has been shown, that in centres where RC is performed less frequently than 50/year, the complication rate is statistically higher than in centers where RC is performed routinely [36]. It has been demonstrated in another paper, that when compared with surgeons performing one RC annually, surgeons performing ≥7 RCs each year had 45% lower odds of major complications [37]. Likewise, significantly improved RC results are observed in residency teaching institutions and in large centers specializing in oncology compared with other centers [38].…”