Effect of Postcystectomy Infectious Complications on Cost, Length of Stay, and Mortality

Incidence and predictors of deep incisional and organ/space surgical site infection following radical cystectomy

OBJECTIVE

To investigate clinical risk factors associated with postoperative deep incisional or organ/space surgical site infections (SSI) following radical cystectomy (RC) in a well characterized and large contemporary cohort.

METHODS

We used the American College of Surgeons National Surgical Quality Improvement Program database to identify adult patients who underwent RC for bladder cancer between 2015 and 2020 (n = 13,081). We conducted multivariable-adjusted logistic regression and Cox adjusted proportional hazards regression analysis to identify clinical predictors of deep incisional or organ/space SSI in the 30-day postoperative-period following RC.

RESULTS

Deep incisional or organ/space SSI risk increased with continent urinary diversion (HR = 1.61, 95% CI: 1.38-1.88; P < 0.001), obesity (HR = 1.60, 95% CI: 1.35-1.90; P < 0.001), diabetes mellitus (HR = 1.30, 95% CI: 1.13-1.51; P < 0.001), and being functionally dependent before surgery (HR = 2.09, 95% CI: 1.44-3.03; P < 0.001).

CONCLUSIONS

Postoperative deep incisional or organ/space SSIs following RC occur more frequently in patients who were obese, diabetic, functionally dependent before surgery, and those who underwent continent urinary diversion. These findings may assist urologists in preoperative counseling, medical optimization, and choice of urinary diversion approach, as well as improved patient monitoring and identification of candidates for intervention postoperatively.

Novel Antibiotic-Irrigating Wound Protector Reduces Infectious Complications in Robot-Assisted Radical Cystectomy with Extracorporeal Urinary Diversion

OBJECTIVE

To determine whether use of an antibiotic-irrigating wound protector (AWP) reduces infectious complications after robotic radical cystectomy with extracorporeal urinary diversion (RCUD).

METHODS

A prospectively maintained bladder cancer database was queried for patients undergoing robotic RCUD at a tertiary referral center one year prior to implementing an AWP and one year after (2018-2020). All diversions were performed extra-corporally. 92 patients total. 46 consecutive patients using a traditional wound protector (TWP) and 46 consecutive with an AWP. Infections were classified as symptomatic urinary tract infection, blood stream infection, and surgical site infection. The incidence of infectious complications at 30- and 90-days were compared.

RESULTS

Baseline patient characteristics between the 2 groups showed no statistically significant differences. The overall complication rate was 65.2% in the TWP group and 26.1% in the AWP group at 30-days, and 67.4% vs 30.4% at 90-days. Focusing on infections, the 30-day complication rate was 30.4% in the TWP group compared to 6.5% in the AWP group (P =.003). This pattern persisted at 90-days with 37.0% in the TWP group compared to 6.5% in the AWP group (P =.004). Most complications were symptomatic UTI and blood stream infections, 14/24 (58%), requiring parenteral antibiotic treatment.

CONCLUSION

We provide preliminary data showing use of an AWP can reduce infectious complications after RCUD. While larger prospective studies are warranted, our findings are a significant step towards decreasing morbidity of an already highly morbid procedure.

Cost of cystectomy-related complications in patients with bladder cancer in the United States

Aims: To describe healthcare utilization and cost associated with the short-term and long-term complications of cystectomy among commercially insured bladder cancer patients in the United States.Materials and methods: This retrospective, observational cohort study evaluated adults with bladder cancer receiving a transurethral resection of bladder tumor followed by a partial or radical cystectomy procedure using U.S. administrative claims from the 2005-2015 IBM MarketScan Commercial and Medicare Supplemental databases. Bladder cancer patients were classified into two cohorts: partial cystectomy or radical cystectomy. Cystectomy complications were identified during the cystectomy admission, short-term period, and long-term period. Complication-related utilization and cost outcomes were reported in aggregate during the cystectomy admission and per patient per month (PPPM) during the short-term and long-term follow-up periods.Results: Of 5136 patients who received a cystectomy, 488 (9.5%) received partial cystectomy and 4648 (90.5%) received radical cystectomy. The mean (SD) costs of complications during the cystectomy admission were $11,728 ($43,380) for radical cystectomy and $4657 ($25,668) for partial cystectomy. In the short-term period, PPPM complication-related healthcare costs were $638 [$3793] for partial cystectomy and $2681 [$14,705] for radical cystectomy. In the long-term period, PPPM complication-related healthcare costs were $544 [$2580] for partial cystectomy and $1619 [$7874] for radical cystectomy.Conclusions: Cystectomy-related complications, especially with radical cystectomy, present a substantial financial burden to patients and payers immediately after surgery as well as in the long term. Targeted interventions which improve clinical outcomes but reduce substantial costs associated with cystectomy for bladder cancer are needed.

A novel prevention bundle to reduce incisional infections after radical cystectomy

PURPOSE

Our institution implemented a novel intervention bundle to reduce incisional surgical site infections (SSIs) for patients undergoing radical cystectomy. The primary objective of this study was to evaluate the efficacy of the bundle in reducing incisional SSIs post-cystectomy.

MATERIAL AND METHODS

A before-after cohort study was performed on all patients who underwent radical cystectomy by urologic oncologists at The Ottawa Hospital from January 2016 to March 2019. Thirty-day postoperative incisional SSIs were identified from the medical record and were compared to institutionally collected National Surgical Quality Improvement Program data. The SSI reduction strategy was implemented as of March 1st, 2018. Adjusted associations between the SSI intervention with the risk of incisional SSI were determined. Cystectomy incisional SSI rates were compared to all other National Surgical Quality Improvement Program-collected surgeries at The Ottawa Hospital during the same time period.

RESULTS

One hundred and thirty-two patients were included; 41 following implementation of the SSI reduction bundle. Mean age was 69 years, 104 (79%) were male, and 59 (45%) received neobladders. The risk of incisional SSI decreased from 16.5% preintervention to 2.4% post intervention (risk ratio 0.17; P = 0.004). Intraoperative transfusion and diabetes were independently associated with an increased risk of incisional SSI (P < 0.05). The SSI rate for all other surgical procedures at our institution remained stable during the same time period.

CONCLUSIONS

The risk of SSI after radical cystectomy is high. Use of an SSI reduction bundle was associated with a large reduction in incisional SSIs. Further evaluation of this intervention in other centers is warranted.

Safety of decreasing ureteral stent duration following radical cystectomy

PURPOSE

We aim to assess the safety of decreasing ureteral stenting duration following Radical Cystectomy with Urinary Diversion (RCUD).

MATERIALS AND METHODS

We analyzed a prospectively and retrospectively collected dataset for cystectomy patients at our tertiary center. Adult patient who underwent RCUD for malignancy from January 2013 to February 2018 were included. Patients with a history of abdominal/pelvic radiation and continent diversions were excluded. The patient population was divided to late stent removal group (LSR-POD 14) and early stent removal group (ESR-POD5). Our endpoints were total stent duration, 90-day readmission, 90-day total-UTI, 90-day urinary-readmissions, complications and Ureteroenteric Stricture (UES) rates. Statistical methods included t test, Chi-squared test and multivariate logistic regression.

RESULTS

One hundred and seventy-eight patients were included in the final analysis after inclusion/exclusion criteria were applied. The LSR (n = 74) and ESR (n = 104) groups were similar in preoperative characteristics except higher intracorporeal ileal conduit formation in ESR. The duration of stenting decreased significantly from approximately 15.5-5 days (P < 0.001). The LSR had higher 90-day overall readmission rates (OR = 2.57, 95% CI 1.19-5.53, P = 0.016) and total-UTIs (OR = 2.36, 95%CI 1.11-5.04, P = 0.026). With a median follow-up of 9.8 months, UES was similar between the two groups.

CONCLUSION

Shorter ureteral stent duration is a safe and non-inferior option following RCUD. It allows for stent removal prior to discharge and less outpatient visits. In addition, decreasing stent duration was linked decreased readmissions and total-UTIs without increased risk of UES. However, future studies are needed to establish causality and promote stent duration change.

Relation of CHA2DS2VASC Score With Hemorrhagic Stroke and Mortality in Patients Undergoing Fibrinolytic Therapy for ST Elevation Myocardial Infarction

Hemorrhagic stroke (HS) is a feared complication of Fibrinolytic therapy (FT). Risk assessment scores may help in risk stratification to reduce this complication. Patients (admissions) ≥18 years with a primary diagnosis of ST-elevation myocardial infarction (STEMI) who received systemic thrombolysis were extracted from Nationwide Inpatient Sample database and stratified and compared based on CHA₂DS₂VASC score 0 to 3, 4 to 6, and 7 to 9 as low, intermediate and high risk, respectively. The primary outcomes of interest were HS and mortality. We performed logistic regression analysis with a composite of HS and mortality as the primary end point. Of the 917,307 admissions with a primary diagnosis of STEMI, 39,579 (4.3%) underwent FT. The median score was 3 (interquartile range 1 to 5). The rate of HS significantly increased in the risk category compared with the low and intermediate groups (0.5% and 0.6% vs 4.1%; p <0.001). Mortality increased with increasing risk category (3.8% vs 10.5% vs 20.7%; p <0.001). Compared with the low-risk group patients in the intermediate (odds ratio 2.11 95% confidence interval [CI] 1.56 to 2.85; p <0.001) and high risk groups (odds ratio 3.47 95% CI 1.68 to 7.2; p <0.001) were more likely to experience the composite end point of HS or inpatient mortality. CHA₂DS₂VASC score performed better at predicting mortality (area under curve 0.67, 95% CI 0.64 to 0.7; p = 0.014) than HS (area under curve 0.6 95% CI 0.52 to 0.69; p = 0.021). In conclusion, patients with high CHA₂DS₂VASC score (7 to 9) are at a higher risk of hemorrhagic stroke and death after FT for STEMI. CHA₂DS₂VASC score performed better at predicting mortality than hemorrhagic stroke in this cohort.

Antibiotic prophylaxis is not associated with reduced urinary tract infection-related complications after cystectomy and ileal conduit

OBJECTIVES

Majority of complications after ileal conduit urinary diversion with cystectomy are related to urinary tract infections (UTIs). Controversy exists regarding use of prophylactic antibiotics after surgery. We determined if prophylactic antibiotic use during ureteral stent placement after ileal conduit urinary diversion decreased incidence of UTI-related complications.

METHODS

We retrospectively identified 75 consecutive patients who underwent ileal conduit urinary diversion with cystectomy at our institution from 2010 to 2016. Patients were stratified based on presence or absence of a UTI-related complication in the 90-day postoperative period. Means were compared with independent t-test and proportions with chi-square analysis. Multivariate logistic regression was performed to determine independent predictors of UTI-related complications.

RESULTS

Forty-five patients (60%) were prescribed prophylactic antibiotics after surgery. Mean duration of antibiotic use was 15 d, and mean duration of ureteral stenting was 25 d. Most common antibiotics used included fluoroquinolones (n = 23, 30.7%) followed by sulfamethoxazole-trimethoprim (n = 14, 18.7%). Rate of 90-day UTI-related complications was 36% (n = 27), and 90-day UTI-related readmission rate was 14.7% (n = 11). On bivariate and multivariate analysis, prophylactic antibiotic use was not associated with reduced 90-day UTI-related complications (P > 0.05). Patients prescribed prophylactic antibiotics had increased incidence of Clostridium difficile infections in the 90-day postoperative period compared to controls (20% vs. 3.3%; P = 0.038).

CONCLUSIONS

Prophylactic antibiotic use after ileal conduit urinary diversion with cystectomy was not associated with reduced UTI-related complications, and rate of Clostridium difficile infections was higher in this patient cohort. The effect of early removal of ureteral stents on UTI risk still has to be elucidated.

Early versus delayed coronary artery bypass graft surgery for patients with non-ST elevation myocardial infarction

BACKGROUND

Although coronary artery bypass graft surgery (CABG) has been proven to have mortality and morbidity benefits in patients with non-ST elevation myocardial infarction and multivessel disease, the appropriate timing of this procedure remains unclear. Therefore, we proposed a propensity score-matched analysis comparing the clinical outcomes between patients who underwent CABG within the first 48 h of admission (early CABG) and patients who underwent CABG after 48 h of admission (delayed CABG).

PATIENTS AND METHODS

Using the largest inpatient care database in the USA, the Nationwide Inpatient Sample, we identified patients with a primary diagnosis of acute myocardial infarction using the ICD 9-DM diagnosis codes. We then performed propensity score-matching analysis to control for 24 possible confounders.

RESULTS

We identified 31 969 patients in the Nationwide Inpatient Sample database with a primary diagnosis of acute myocardial infarction who underwent CABG. The mean age of the cohort was 64.5±11.5 years and 33.4% were female. After performing propensity-matching analysis, we obtained a subset of 1555 patients in each group, with a mean age of 64.7±10.1 years; the male to female ratio was ~4 : 1. The incidence of hemorrhage, shock, and cardiac, pulmonary, and renal complications was comparable between the two groups. The incidence of mortality was not statistically significant between the two groups (2% in the early CABG vs. 1.8% in the delayed CABG, P=0.695). The mortality risk factors were as follows: age more than 70 years [odds ratio (OR): 3.42, 95% confidence interval (CI): 1.85-6.34, P<0.001]; cardiogenic shock (OR: 3.22, 95% CI: 1.35-7.67, P=0.008); and mechanical circulatory support with balloon counterpulsation (OR: 2.93, 95% CI: 1.45-5.90, P=0.003).

CONCLUSION

CABG performed within 48 h of admission does not significantly increase the risk for in-hospital mortality compared with undergoing the procedure after 48 h of admission in propensity-matched patients.

Incidence, predictors, and outcomes associated with pneumothorax during cardiac electronic device implantation: A 16-year review in over 3.7 million patients

BACKGROUND

Pneumothorax (PTX) is a potential complication of vascular access during cardiac implantable electronic device (CIED) procedures and is being scrutinized as a health care-acquired condition.

OBJECTIVE

The purpose of this study was to determine the trends in PTX incidence in the United Stated over a 16-year period and to determine whether PTX is associated with increased mortality after adjustment for other factors.

METHODS

Using weighted sampling in the largest inpatient health database in the United States (National Inpatient Sample), we evaluated data from patients with a primary procedure of CIED implantation from 1998 to 2013 who had at least 1 new vascular access (new or upgrade of prior CIED). The unadjusted and adjusted associations of PTX with mortality and other parameters were examined.

RESULTS

Among 3,764,703 CIED procedures, PTX occurred in 47,839 cases (1.3%). The apparent incidence of PTX peaked at 1.6% in 2012 and 2013, although this result may have been affected by a concomitant decrease of inpatient (vs outpatient) CIED. PTX was significantly associated with pulmonary complications, chest tube insertion, length of stay, and costs. Mortality was statistically higher in patients with PTX (1.2% vs 0.7%; P <.001), a relationship that remained significant in a multivariate logistic regression analysis (odds ratio 1.50, 95% confidence interval 1.36-1.65; P <.001). Age >80 years, female gender, Caucasian race, chronic obstructive pulmonary disease, and dual-chamber (vs single-chamber) device were all associated with higher odds for PTX occurrence. Placement of a chest tube was a major determinant of worse outcomes and higher costs.

CONCLUSION

PTX remains an important complication of CIED procedures and is associated with increased morbidity, mortality, and costs.

Health care services utilization during the last 6 months of life among patients with bladder cancer who underwent radical cystectomy in Quebec, Canada

INTRODUCTION AND OBJECTIVES

Management of bladder cancer imposes a great economic challenge on the health care system; with the greatest share of this burden attributed to radical cystectomy (RC) and prolonged postoperative follow-up. Our aim was to characterize health care services utilization and evaluate associated cost predictors during the last 6 months of life in patients who had RC.

METHODS

We conducted a retrospective study within a cohort of 2,988 patients who had RC from 2000 to 2009. Data were obtained from the Quebec health insurance medical services database. We included patients who deceased during the study period, and survived at least 6 months after the first 90 postoperative days. Services billing codes were used to retrieve hospital, outpatient and imaging services. Linear regression models were used to assess predictors of costs.

RESULTS

From the 1,355 patients who deceased during the study period, we analyzed data of 799 subjects. Men formed 77.3% and 52.8% of patients were between 60 and 75 years of age at the time of RC. In their last 6 months of life, 17.2% of patients had surgery for major urinary tract complications, 25% had chemotherapy whereas 27.6% had radiotherapy. Also, 3.5% of patients had hemodialysis. Imaging was performed in 94.6% of patients. Urologist (specialist) visits ranked first where 72.3% of patients had 3,481 visits (average = 6 visits/pt) followed by medical subspecialist where 69% of patients had 10,010 visits (average = 18 visits/pt). For supportive care, 97% of patients had 25,560 family physician visits (average = 31 visits/pt) whereas only 16% of them had highly specialized care. Services utilization kept increasing with time especially during the last 2 months before death. Post-RC complications were significant predictor associated with increased costs at all assessed services (P<0.0001).

CONCLUSION

Our study results suggest that health care services utilization varies in the assessed period. Urologists involvement in the process of care tends to decrease over time, in favor of other medical specialties, however, some health care services, such as highly specialized supportive care, may be underutilized.

Total Psoas Area Predicts Complications following Radical Cystectomy

Purpose. To determine whether total psoas area (TPA), a simple estimate of muscle mass, is associated with complications after radical cystectomy. Materials and Methods. Patients who underwent radical cystectomy at our institution from 2011 to 2012 were retrospectively identified. Total psoas area was measured on preoperative CT scans and normalized for patient height. Multivariable logistic regression was used to determine whether TPA was a predictor of 90-day postoperative complications. Overall survival was compared between TPA quartiles. Results. 135 patients were identified for analysis. Median follow-up was 24 months (IQR: 6–37 months). Overall 90-day complication rate was 56% (75/135). TPA was significantly lower for patients who experienced any complication (7.8 cm²/m² versus 8.8 cm²/m², P = 0.023) and an infectious complication (7.0 cm²/m² versus 8.7 cm²/m², P = 0.032) than those who did not. On multivariable analysis, TPA (adjusted OR 0.70 (95% CI 0.56–0.89), P = 0.003) and Charlson comorbidity index (adjusted OR 1.34 (95% CI 1.01–1.79), P = 0.045) were independently associated with 90-day complications. TPA was not a predictor of overall survival. Conclusions. Low TPA is associated with infectious complications and is an independent predictor of experiencing a postoperative complication following radical cystectomy.

Health-care services utilization and costs associated with radical cystectomy for bladder cancer: a descriptive population-based study in the province of Quebec, Canada

Background

Bladder cancer (BC) has the highest lifetime treatment costs per patient of all cancers. The objective of this study was to characterize the use of health-care services and costs associated with BC among patients who underwent radical cystectomy (RC) in the province of Quebec.

Methods

We conducted a descriptive study in a retrospective cohort of patients who underwent RC for BC between 2000 and 2009. Data was obtained from two health administrative databases (RAMQ and ISQ). We calculated average costs per patient and total costs in 2014 Canadian dollars for the following components of costs: 1) Pre-surgery costs (pre and post-urologist consultations, urologist consultations, cystoscopies, TURBTs, imaging procedures); 2) Costs of radical cystectomy and 3) Post-surgery costs (urologist consultations, post-operative consultations, medical oncologist consultations, imaging procedures and post-operative complication management). ARIMA models were used to evaluate trends in average costs per patient over the study period.

Results

Among 2759 patients included in the study (75 % men), average pre-surgery costs, RC costs, and post-surgery costs were estimated at 3762$, 18979$ and 4770$, respectively. RC cost was responsible for 69 % of total costs, followed by post-operative consultations (7.8 %), post-operative complications and TURBTs (6 % of total costs, each). Academic hospitals performed RC at a lower average cost, compared to community hospitals (difference of $1000, p < .0001). A decreased trend in post-surgery costs was detected in the year 2009.

Conclusions

Costs of RC, TURBT, consultations and post-operative complications were the most important economic components of total RC cost per patient in Quebec. Academic hospitals performed RC at a lower cost, compared to community hospitals.

Surgical site infections in patients who undergo radical cystectomy: Excess mortality, stay prolongation and hospital cost overruns

BACKGROUND

The aim of this study was to analyze the impact of surgical site infections (SSI) in patients who underwent radical cystectomy, in terms of excess hospital mortality, stay prolongation and cost overruns.

MATERIAL AND METHODS

A retrospective observational study was conducted on a sample of patients who underwent radical cystectomy as recorded in the basic minimum data sets of 87 Spanish hospitals from 2008-2010.

RESULTS

We studied 4377 patients who underwent radical cystectomy (3904 men and 473 women) of whom 849 (19.4%) experienced an SSI. The patients with SSI were predominantly men, elderly and had a higher prevalence of alcohol-related disorders and more comorbidities. The patients with SSI had significant excess mortality (125.6%), undue stay prolongation (17.8 days) and cost overruns (14,875.70 euros).

CONCLUSIONS

After controlling for demographic variables, hospital type, addiction disorders and comorbidities using multivariate pairing, the onset of SSI in patients who underwent radical cystectomy significantly increased the mortality, stay and cost. Certain preventive measures already established in previous studies could reduce the incidence of SSI and its healthcare and financial impact.

The health economics of bladder cancer: an updated review of the published literature

The purpose of this paper is to provide a current view of the economic burden of bladder cancer, with a focus on the cost effectiveness of available interventions. This review updates a previous systematic review and includes 72 new papers published between 2000 and 2013. Bladder cancer continues to be one of the most common and expensive malignancies. The annual cost of bladder cancer in the USA during 2010 was $US4 billion and is expected to rise to $US5 billion by 2020. Ten years ago, urinary markers held the potential to lower treatment costs of bladder cancer. However, subsequent real-world experiments have demonstrated that further work is necessary to identify situations in which these technologies can be applied in a cost-effective manner. Adjunct cytology remains a part of diagnostic standard of care, but recent research suggests that it is not cost effective due to its low diagnostic yield. Analysis of intravesical chemotherapy after transurethral resection of bladder tumor (TURBT), neo-adjuvant therapy for cystectomy, and robot-assisted laparoscopic cystectomy suggests that these technologies are cost effective and should be implemented more widely for appropriate patients. The existing literature on the cost effectiveness of bladder cancer treatments has improved substantially since 2000. The body of work now includes many new models, registry analyses, and real-world studies. However, there is still a need for new implementation guidelines, new risk modeling tools, and a better understanding of the empirical burden of bladder cancer.

Anticipating the impact of insurance expansion on inpatient urological surgery

PURPOSE

The Affordable Care Act (ACA) is expected to provide coverage for nearly twenty-five million previously uninsured individuals. Because the potential impact of the ACA for urological care remains unknown, we estimated the impact of insurance expansion on the utilization of inpatient urological surgeries using Massachusetts (MA) healthcare reform as a natural experiment.

METHODS

We identified nonelderly patients who underwent inpatient urological surgery from 2003 through 2010 using inpatient databases from MA and two control states. Using July 2007 as the transition point between pre- and post-reform periods, we performed a difference-indifferences (DID) analysis to estimate the effect of insurance expansion on overall and procedure-specific rates of inpatient urological surgery. We also performed subgroup analyses according to race, income and insurance status.

RESULTS

We identified 1.4 million surgeries performed during the study interval. We observed no change in the overall rate of inpatient urological surgery for the MA population as a whole, but an increase in the rate of inpatient urological surgery for non-white and low income patients. Our DID analysis confirmed these results (all 1.0%, p=0.668; non-whites 9.9%, p=0.006; low income 6.6%, p=0.041). At a procedure level, insurance expansion caused increased rates of inpatient BPH procedures, but had no effect on rates of prostatectomy, cystectomy, nephrectomy, pyeloplasty or PCNL.

CONCLUSIONS

Insurance expansion in Massachusetts increased the overall rate of inpatient urological surgery only for non-whites and low income patients. These data inform key stakeholders about the potential impact of national insurance expansion for a large segment of urological care.

The economics of bladder cancer: costs and considerations of caring for this disease

CONTEXT

Due to high recurrence rates, intensive surveillance strategies, and expensive treatment costs, the management of bladder cancer contributes significantly to medical costs.

OBJECTIVE

To provide a concise evaluation of contemporary cost-related challenges in the care of patients with bladder cancer. An emphasis is placed on the initial diagnosis of bladder cancer and therapy considerations for both non-muscle-invasive bladder cancer (NMIBC) and more advanced disease.

EVIDENCE ACQUISITION

A systematic review of the literature was performed using Medline (1966 to February 2011). Medical Subject Headings (MeSH) terms for search criteria included "bladder cancer, neoplasms" OR "carcinoma, transitional cell" AND all cost-related MeSH search terms. Studies evaluating the costs associated with of various diagnostic or treatment approaches were reviewed.

EVIDENCE SYNTHESIS

Routine use of perioperative chemotherapy following complete transurethral resection of bladder tumor has been estimated to provide a cost savings. Routine office-based fulguration of small low-grade recurrences could decrease costs. Another potential important target for decreasing variation and cost lies in risk-modified surveillance strategies after initial bladder tumor removal to reduce the cost associated with frequent cystoscopic and radiographic procedures. Optimizing postoperative care after radical cystectomy has the potential to decrease length of stay and perioperative morbidity with substantial decreases in perioperative care expenses. The gemcitabine-cisplatin regimen has been estimated to result in a modest increase in cost effectiveness over methotrexate, vinblastine, doxorubicin, and cisplatin. Additional costs of therapies need to be balanced with effectiveness, and there are significant gaps in knowledge regarding optimal surveillance and treatment of both early and advanced bladder cancer.

CONCLUSIONS

Regardless of disease severity, improvements in the efficiency of bladder cancer care to limit unnecessary interventions and optimize effective cancer treatment can reduce overall health care costs. Two scenarios where economic and comparative-effectiveness research is limited but would be most beneficial are (1) the management of NMIBC patients where excessive costs are due to vigilant surveillance strategies and (2) in patients with metastatic disease due to the enormous cost associated with late-stage and end-of-life care.

The implications of hospital acquired adverse events on mortality, length of stay and costs for patients undergoing radical cystectomy for bladder cancer

PURPOSE

The incidence of hospital acquired adverse events in radical cystectomy and their implications for hospital outcomes and costs remain poorly described. We describe the incidence of hospital acquired adverse events in radical cystectomy, and characterize its relationship with in-hospital mortality, length of stay and hospitalization costs.

MATERIALS AND METHODS

We identified 10,856 patients who underwent radical cystectomy for bladder cancer at 1,175 hospitals in the Nationwide Inpatient Sample from 2001 to 2008. We used hospital claims to identify adverse events for accidental puncture, decubitus ulcer, deep vein thrombosis/pulmonary embolus, methicillin-resistant Staphylococcus aureus, Clostridium difficile, surgical site infection and sepsis. Logistic regression and generalized estimating equation models were used to test the associations of hospital acquired adverse events with mortality, predicted prolonged length of stay and total hospitalization costs.

RESULTS

Hospital acquired adverse events occurred in 11.3% of all patients undergoing radical cystectomy (1,228). Adverse events were associated with a higher odds of in-hospital death (OR 8.07, p<0.001), adjusted prolonged length of stay (41.3%) and total costs ($54,242 vs $26,306; p<0.001) compared to no adverse events on multivariate analysis. The incremental total costs attributable to hospital acquired adverse events were $43.8 million. Postoperative sepsis was associated with the highest risk of mortality (OR 17.56, p<0.001), predicted prolonged length of stay (62.22%) and adjusted total cost ($79,613).

CONCLUSIONS

With hospital acquired adverse events occurring in approximately 11% of radical cystectomy cases, they pose a significant risk of in-hospital mortality and higher hospitalization costs. Therefore, increased attention is needed to reduce adverse events by improving patient safety, while understanding the economic implications for tertiary referral centers with possible policy changes such as denial of payment for hospital acquired adverse events.