THE IMPACT OF SURGEON VOLUME ON THE MORBIDITY AND COSTS OF RADICAL CYSTECTOMY IN THE UNITED STATES: A CONTEMPORARY POPULATION-BASED ANALYSIS

   Purpose: Radical cystectomy (RC), the gold standard treatment for invasive bladder cancer, is a morbid procedure associated with high costs. Numerous volume-outcomes studies focused on postoperative mortality suggest that centralization of care can reduce the economic burden of disease. This study evaluates the relationship between surgeon volume and RC morbidity outcomes as well as costs in the United States.

   Methods: We captured all who underwent a RC (ICD-9 code 57.71) from 2003 to 2010, from a nationally representative discharge database. Patient (age, gender, race, marital status, insurance status, Charlson comorbidity), hospital (bed size, teaching status, location, region), and surgical characteristics (year of procedure, type of approach and urinary diversion, receipt of pelvic lymphandectomy) were evaluated. Annual volume, defined as the total number of cystectomies performed by a surgeon in the year the procedure was performed on a patient, was divided into quintiles. Multivariable logistic and linear regression analyses were performed with clustering by hospitals and survey weighting to ensure nationally representative estimates. Outcomes include 90-day major complications (Clavien 3-5) as defined by ICD-9 diagnosis codes, and direct patient costs.

   Results: The weighted cohort included 49792 RC patients with an overall major complication rate of 16.2%. Compared to very low volume surgeons (1/year), very high surgeons (³7/year) had 44% decreased odds of major complications (OR: 0.56, 95% CI: 0.41-0.76, p<0.001). Compared to patients who did not have any complications, those who suffered a major or minor complication had significantly higher 90-day median direct hospital costs ($59283 and $54149 vs. $36550, both p<0.0001).

   Conclusions: Our contemporary evaluation of radical cystectomy in the United States suggests an inverse relationship between surgeon volume and postoperative 90-day major complication rates as well as 90-day direct hospital costs. Preventing major complication via centralization of care may reduce the burden of disease. Primary mechanisms underlying this effect, such as peri-operative process of care variables, need to be investigated.