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Pfail J, Capellan J, Passarelli R, Kaldany A, Chua K, Lichtbroun B, Srivastava A, Golombos D, Jang TL, Pitt HA, Packiam VT, Ghodoussipour S. National Surgical Quality Improvement Program audit of contemporary perioperative care for radical cystectomy. BJU Int 2024. [PMID: 39087422 DOI: 10.1111/bju.16492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
OBJECTIVE To examine the impact of increased compliance to contemporary perioperative care measures, as outlined by enhanced recover after surgery (ERAS) guidelines, among patients undergoing radical cystectomy (RC). PATIENTS AND METHODS From the National Surgical Quality Improvement Program database we captured patients undergoing RC between 2019 and 2021. We identified five perioperative care measures: regional anaesthesia block, thromboembolism prophylaxis, ≤24 h perioperative antibiotic administration, absence of bowel preparation, and early oral diet. We stratified patients by the number of measures utilised (one to five). Statistical endpoints included 30-day complications, hospital length of stay (LOS), readmissions, and optimal RC outcome. Optimal RC outcome was defined as absence of any postoperative complication, re-operation, prolonged LOS (75th percentile, 8 days) with no readmission. Multivariable regressions with Bonferroni correction were performed to assess the association between use of contemporary perioperative care measures and outcomes. RESULTS Of the 3702 patients who underwent RC, 73 (2%), 417 (11%), 1010 (27%), 1454 (39%), and 748 (20%) received one, two, three, four, and five interventions, respectively. On multivariable analysis, increased perioperative care measures were associated with lower odds of any complication (odds ratio [OR] 0.66, 99% confidence interval [CI] 0.6-0.73), and shorter LOS (β -0.82, 99% CI -0.99 to -0.65). Furthermore, patients with increased compliance to contemporary care measures had increased odds of an optimal outcome (OR 1.38, 99% CI 1.26-1.51). CONCLUSIONS Among the measures we assessed, greater adherence yielded improved postoperative outcomes among patients undergoing RC. Our work supports the efficacy of ERAS protocols in reducing the morbidity associated with RC.
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Affiliation(s)
- John Pfail
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Jasmin Capellan
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Rachel Passarelli
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Alain Kaldany
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Kevin Chua
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Benjamin Lichtbroun
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Arnav Srivastava
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - David Golombos
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Thomas L Jang
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Henry A Pitt
- Rutgers Cancer Institute, New Brunswick, NJ, USA
| | - Vignesh T Packiam
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Saum Ghodoussipour
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Duwe G, Kamal MM, Wiesmann C, Banasiewicz KE, Wagner I, Fischer ND, Haack M, Frey LJ, Mager R, Höfner T, Sparwasser P, Tsaur I, Wiesner C, Thomas C, Thüroff JW, Hohenfellner R, Brandt MP, Haferkamp A. Temporal Trends in Urinary Diversion among Patients Undergoing Radical Cystectomy Between 1986 and 2022: Experience at the University Medical Center Mainz with 2224 Cases. Ann Surg Oncol 2024:10.1245/s10434-024-15730-x. [PMID: 38969859 DOI: 10.1245/s10434-024-15730-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/19/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Analysis of temporal trends of urinary diversion (UD) and identification of predictive factors for continent urinary diversion (CUD) in patients with bladder cancer (BC) is scarce and data on large cohorts are missing. We aimed to describe longitudinal temporal trends and predictive factors for UD among patients with BC receiving radical cystectomy (RC). PATIENTS AND METHODS We retrospectively analysed institutional data collected from patients undergoing RC from 1986 to 2022 to describe changes in patients' characteristics and UD. Primary end points were patients' characteristics associated with type of UD. Logistic regression analysis was used to determine predictive factors for CUD. RESULTS In total, 2224 patients (77.16% male, 22.84% female) with a mean age of 66 years [standard deviation (SD), 10.64 years] were included. We observed an increase in mean age from 59.86 (10.8) years (1986-1990) to 69.85 (9.99) years (2016-2022) (p < 0.001). The proportion of CUD gradually declined from 43.72% (94/215; 1986-1990) to 18.38% (86/468; 2016-2022). Patients who were male [odds ratio (OR): 1.92, 95% confidence interval (CI): 1.43-2.57, p < 0.001), younger (OR: 0.88, 95% CI: 0.87-0.89, p < 0.001) and had no hydronephrosis prior to RC (OR: 2.2, 95% CI: 1.66-2.92, p < 0.001) were more likely to receive CUD. CONCLUSIONS We report the largest European single-center cohort of UD after RC, demonstrating a significant shift from CUD to IUD, accompanied by an increasing age. Finally, our data mirrors the development and extensive experience with the Mainz Pouch-I in the 1980's and 1990's together with other colon pouches.
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Affiliation(s)
- Gregor Duwe
- Department of Urology and Paediatric Urology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
| | - Mohamed M Kamal
- Department of Urology and Paediatric Urology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Crispin Wiesmann
- Department of Urology and Paediatric Urology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Katarzyna E Banasiewicz
- Department of Urology and Paediatric Urology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Isabel Wagner
- Department of Urology and Paediatric Urology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Nikita Dhruva Fischer
- Department of Urology and Paediatric Urology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Maximilian Haack
- Department of Urology and Paediatric Urology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Lisa Johanna Frey
- Department of Urology and Paediatric Urology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Rene Mager
- Department of Urology and Paediatric Urology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Höfner
- Department of Urology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Peter Sparwasser
- Department of Urology, University Hospital and Faculty of Medicine Eberhard Karls University Tübingen, Tuebingen, Germany
| | - Igor Tsaur
- Department of Urology, University Hospital and Faculty of Medicine Eberhard Karls University Tübingen, Tuebingen, Germany
| | | | - Christian Thomas
- Department of Urology, University Hospital Carl Gustav-Carus, TU Dresden, Dresden, Germany
| | - Joachim Wolfgang Thüroff
- Department of Urology and Paediatric Urology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Rudolf Hohenfellner
- Department of Urology and Paediatric Urology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Maximilian Peter Brandt
- Department of Urology and Paediatric Urology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Axel Haferkamp
- Department of Urology and Paediatric Urology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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Treatment disparities in muscle-invasive bladder cancer: Evidence from a large statewide cancer registry. Urol Oncol 2022; 40:164.e17-164.e23. [DOI: 10.1016/j.urolonc.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/18/2021] [Accepted: 12/09/2021] [Indexed: 11/19/2022]
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Monaghan TF, Robins DJ, Suss NR, Miller CD, Flores VX, Smith MT, Weiss JP, McNeil BK, Winer AG. Determinants of neoadjuvant chemotherapy for urothelial muscle-invasive bladder cancer: Does location matter? Int J Clin Pract 2021; 75:e14262. [PMID: 33887115 DOI: 10.1111/ijcp.14262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 04/14/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Bladder cancer care has been increasingly concentrated in high-volume metropolitan medical centres (ie, "regionalisation" of care). We aimed to assess the potential role of geographic factors, including facility region and distance to treatment centre, as determinants of neoadjuvant chemotherapy (NAC) delivery in patients with non-metastatic urothelial muscle-invasive bladder cancer (MIBC) using nationally representative data from the United States. METHODS We queried the National Cancer Database to identify patients with cT2-cT4a, N0M0 urothelial MIBC who underwent radical cystectomy (RC) from 2006 to 2015. Patients who received radiation therapy, single-agent chemotherapy, adjuvant chemotherapy or systemic therapies other than multi-agent chemotherapy were excluded. Multivariate logistic regression analysis was performed to identify independent predictors of receiving NAC. RESULTS A total of 5986 patients met the criteria for inclusion, of whom 1788 (29.9%) received NAC and 4108 received RC alone. Younger age, increased Charlson-Deyo score, increased cT stage, increased annual income, increased distance from cancer treatment centre, treatment at an Academic Research Program or Integrated Network Cancer Program and a later year of diagnosis were independently predictive of NAC receipt. Older age, Medicare insurance and treatment in the East South Central or West South Central regions were independently associated with decreased odds of NAC receipt. CONCLUSIONS Distance to treatment centre and United States geographic region were found to affect the likelihood of NAC receipt independently of other established predictors of success in this quality-of-care metric. Access to transportation and related resources merits consideration as additional pertinent social determinants of health in bladder cancer care.
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Affiliation(s)
- Thomas F Monaghan
- Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
- Department of Urology, Kings County Hospital Center, Brooklyn, NY, USA
| | - Dennis J Robins
- Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
- Department of Urology, Kings County Hospital Center, Brooklyn, NY, USA
| | - Nicholas R Suss
- Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
- Department of Urology, Kings County Hospital Center, Brooklyn, NY, USA
| | - Connelly D Miller
- Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
- Department of Urology, Kings County Hospital Center, Brooklyn, NY, USA
| | - Viktor X Flores
- Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
- Department of Urology, Kings County Hospital Center, Brooklyn, NY, USA
| | - Matthew T Smith
- Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
- Department of Urology, Kings County Hospital Center, Brooklyn, NY, USA
| | - Jeffrey P Weiss
- Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
- Department of Urology, Brooklyn Campus of the Veterans Affairs New York Harbor Healthcare System, Brooklyn, NY, USA
| | - Brian K McNeil
- Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
- Department of Urology, Kings County Hospital Center, Brooklyn, NY, USA
| | - Andrew G Winer
- Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
- Department of Urology, Kings County Hospital Center, Brooklyn, NY, USA
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Golla V, Shan Y, Mehta HB, Klaassen Z, Tyler DS, Baillargeon J, Kamat AM, Freedland SJ, Gore JL, Chamie K, Kuo YF, Williams SB. Impact of Diagnosing Urologists and Hospitals on the Use of Radical Cystectomy. EUR UROL SUPPL 2020; 19:27-36. [PMID: 34337452 PMCID: PMC8317809 DOI: 10.1016/j.euros.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2020] [Indexed: 11/22/2022] Open
Abstract
Background One out of five patients with muscle-invasive bladder cancer undergo radical cystectomy—a guideline-recommended treatment. Previous studies have primarily evaluated patient characteristics associated with the use of radical cystectomy, ignoring potential nesting of data. Objective To determine the impact of patient, diagnosing urologist, and hospital characteristics on the variation in the use of radical cystectomy. Design, setting, and participants This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results Registry (SEER)-Medicare linked database. Outcome measurements and statistical analysis A total of 7097 muscle-invasive bladder cancer patients and 4601 diagnosing urologists affiliated to 822 hospitals from January 1, 2002 to December 31, 2012 were analyzed. Multilevel logistic regression analyses were used to determine variation and factors associated with the use of radical cystectomy. Results and limitations Of the 7097 patients, only 27% underwent radical cystectomy. The intraclass correlation coefficient for variation in the use of radical cystectomy attributed to the hospital level was 4.3%. Higher radical cystectomy volume by diagnosing urologists (more than five vs zero to one surgery: odds ratio [OR], 1.27; 95% confidence interval [CI], 1.00–1.62) and hospitals (more than five vs zero to four surgeries: OR,1.48; 95% CI, 1.14–1.93) was associated with increased use of radical cystectomy. Patients diagnosed by female rather than male urologists were more likely to undergo radical cystectomy (OR, 1.32; 95% CI, 1.07–1.62). Conclusions We found that 4.3% variation in the use of radical cystectomy was attributed to the hospital level, leaving 95.7% variation in use unexplained. We identified significantly increased use among higher-volume and female diagnosing urologists. These findings support further investigation into measures beyond hospital volume, which largely impact the utilization of radical cystectomy. Patient summary In this large population-based study, we found that 4.3% of variation in the use of radical cystectomy was attributed to the hospital level, leaving 95.7% variation in use unexplained. Higher radical cystectomy volume of diagnosing urologists and female urologists were independently associated with increased use of radical cystectomy. These findings support further investigation into measures beyond hospital volume, which largely impact the utilization of radical cystectomy.
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Affiliation(s)
- Vishnukamal Golla
- Department of Urology, University of California, Los Angeles, CA, USA
| | - Yong Shan
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Hemalkumar B. Mehta
- Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, Augusta, GA, USA
| | - Zachary Klaassen
- Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, Augusta, GA, USA
| | - Douglas S. Tyler
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Jacques Baillargeon
- Department of Preventive Medicine and Community Health, Sealy Center of Aging, The University of Texas Medical Branch, Galveston, TX, USA
| | - Ashish M. Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - John L. Gore
- Department of Urology, The University of Washington, Seattle, WA, USA
| | - Karim Chamie
- Department of Urology, University of California, Los Angeles, CA, USA
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health, Sealy Center of Aging, The University of Texas Medical Branch, Galveston, TX, USA
| | - Stephen B. Williams
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
- Corresponding author. Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555, USA. Tel.: +1-409-747-7333; Fax: +1-409-772-0088.
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Coon C, Berger N, Eastwood D, Tsai S, Christians K, Mogal H, Clarke C, Gamblin TC. Primary Liver Cancer: An NCDB Analysis of Overall Survival and Margins After Hepatectomy. Ann Surg Oncol 2019; 27:1156-1163. [DOI: 10.1245/s10434-019-07843-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Indexed: 12/11/2022]
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7
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Delays in radical cystectomy for muscle‐invasive bladder cancer. Cancer 2019; 125:2011-2017. [DOI: 10.1002/cncr.32048] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/25/2018] [Accepted: 10/26/2018] [Indexed: 11/07/2022]
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8
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Assessing trends in urinary diversion after radical cystectomy for bladder cancer in the United States. Urol Oncol 2019; 37:180.e1-180.e9. [DOI: 10.1016/j.urolonc.2018.11.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/24/2018] [Accepted: 11/04/2018] [Indexed: 11/22/2022]
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Abstract
Introduction The aim of the study was to determine the most frequent early and late complications in different types of ileal urinary diversions. Patients and methods The study was conducted in a five-year period, on 106 patients who were diagnosed with invasive urinary bladder cancer and who had indication for radical cystectomy with one of the investigated types of urine derivation. They were divided into 2 groups, based on the type of ileal urinary diversions. Results The colonization of bacteria was more prominently present in the ileal conduit urinary diversion group (97%) compared to Ghoneim (25%) and Hautmann (10%) group, Ureteral stenosis was slightly less represented in the conduit group (9.1%). Wound infections were significantly more represented in the conduit (21.2%) than in the Ghoneim group (5%) Nighttime incontinence was present in 20% of patients in both groups or 4 patients in each group. Daytime incontinence in the Ghoneim group was present in 3 patients (15%) and in the Hautmann group 2 patients (10%). Late complications correlate significantly negative with the type of surgery and slightly negative with the grade, and significantly positively with the examined group and T stage, and slightly correlate positively to the N and R stages. Early complications correlate slightly negative with the type of surgery, slightly negative with the grade, and significantly positively with T stage, and slightly positively correlates with the N and R stage. Conclusion The most commonly reported complications in ileal conduit are: prolonged ileus, stoma infection, wound dehiscence and bacterial colonization, followed by peristomal skin complications and complications related only to the stoma, such as stenosis and stoma retraction, and prolaps of ileostoma and ileointestinal stenosis. The ileus rate in orthotopic derivation was significantly lower than that of the ileal conduit group, which led to the conclusion that the neomybladder position does not disturb the anatomic abdominal structure.
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Affiliation(s)
- Alden Prcic
- Bahrain Specialist Hospital, Manama, Bahrain
| | - Edin Begic
- Health Care Centre, Maglaj, Bosnia and Herzegovina
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10
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The relationship of travel distance with cystectomy access and outcomes. Urol Oncol 2018; 36:308.e1-308.e9. [DOI: 10.1016/j.urolonc.2018.03.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 03/02/2018] [Accepted: 03/05/2018] [Indexed: 11/18/2022]
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Haque W, Butler EB, Teh BS. Clinical benefit to regionalization of care for muscle invasive bladder cancer. Transl Androl Urol 2018; 7:S98-S100. [PMID: 29645016 PMCID: PMC5881207 DOI: 10.21037/tau.2018.01.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
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12
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The impact of readmission hospital on failure-to-rescue rates following major urologic cancer surgery. Urol Oncol 2018; 36:156.e1-156.e7. [DOI: 10.1016/j.urolonc.2017.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 08/30/2017] [Accepted: 10/24/2017] [Indexed: 11/23/2022]
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Ryan S, Serrell EC, Karabon P, Mills G, Hansen M, Hayn M, Menon M, Trinh QD, Abdollah F, Sammon JD. The Association between Mortality and Distance to Treatment Facility in Patients with Muscle Invasive Bladder Cancer. J Urol 2018; 199:424-429. [DOI: 10.1016/j.juro.2017.10.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Stephen Ryan
- Division of Urology, Maine Medical Center, Portland, Maine
| | | | - Patrick Karabon
- Vattikutti Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, Michigan
| | - Gregory Mills
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine
| | - Moritz Hansen
- Division of Urology, Maine Medical Center, Portland, Maine
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine
- Tufts University School of Medicine, Boston, Massachusetts
| | - Matthew Hayn
- Tufts University School of Medicine, Boston, Massachusetts
| | - Mani Menon
- Vattikutti Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, Michigan
| | - Quoc-Dien Trinh
- Division of Urology and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Firas Abdollah
- Vattikutti Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, Michigan
| | - Jesse D. Sammon
- Division of Urology, Maine Medical Center, Portland, Maine
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine
- Tufts University School of Medicine, Boston, Massachusetts
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Farber NJ, Faiena I, Dombrovskiy V, Tabakin AL, Shinder B, Patel R, Elsamra SE, Jang TL, Singer EA, Weiss RE. Disparities in the Use of Continent Urinary Diversions after Radical Cystectomy for Bladder Cancer. Bladder Cancer 2018; 4:113-120. [PMID: 29430511 PMCID: PMC5798533 DOI: 10.3233/blc-170162] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background: Radical cystectomy (RC) with ileal conduit (IC) or continent diversion (CD) is standard treatment for high-risk non-invasive and muscle-invasive bladder cancer. Objective: Our aim is to study contemporary trends in the utilization of ICs and CDs in patients undergoing RC. Methods: Using the National Inpatient Sample 2001–2012, we identified all patients diagnosed with a malignant bladder neoplasm who underwent RC followed by IC or CD. Patient demographics, comorbidities, length of stay (LOS), and in-hospital complications, mortality, and costs were compared. Multivariable logistic regression analysis, Chi square, and t-tests were used for analysis. Results: Between 2001–2012, approximately 69,049 ICs and 6,991 CDs were performed. CDs increased from 2001 to 2008, but declined after 2008 (p < 0.0001). Patients of all ages received ICs at a higher rate than CDs (40–59 years: 79.5% vs. 20.5%; 60–69 years: 88.0% vs. 12.0%; p < 0.0001). There was a difference in males vs. females (10.2% vs. 4.0%; OR 2.36) and Caucasians vs. African Americans (9.0% vs. 6.7%; OR 1.49) when comparing CD rates. CD rates were highest in the West, urban teaching centers, and large hospitals (p < 0.001). ICs were associated with higher rates of overall postoperative complications (p = 0.0185) including infection (p = 0.002) and mortality (p < 0.0001). In-hospital costs were greater for the CD group. Conclusions: The number of CDs has declined recently. Patients of all ages are more likely to receive ICs than CDs. Gender, racial, and geographic disparities exist among those receiving CDs. CDs are associated with lower rates of in-hospital complications and mortality, but higher in-hospital costs.
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Affiliation(s)
- Nicholas J Farber
- Division of Urology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Izak Faiena
- Division of Urology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Viktor Dombrovskiy
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Alexandra L Tabakin
- Division of Urology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Brian Shinder
- Division of Urology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Rutveej Patel
- Division of Urology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Sammy E Elsamra
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Thomas L Jang
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Eric A Singer
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Robert E Weiss
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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15
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Lieberman-Cribbin W, Galsky M, Casey M, Liu B, Oh W, Flores R, Taioli E. Hospital Centralization Impacts High-Risk Lung and Bladder Cancer Surgical Patients. Cancer Invest 2017; 35:652-661. [DOI: 10.1080/07357907.2017.1406495] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Wil Lieberman-Cribbin
- Department of Population Health Science and Policy and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Matthew Galsky
- Division of Hematology and Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Martin Casey
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bian Liu
- Department of Population Health Science and Policy and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William Oh
- Division of Hematology and Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raja Flores
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emanuela Taioli
- Department of Population Health Science and Policy and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Sadowski DJ, Warner H, Scaife S, McVary KT, Alanee SR. 30-day all-cause hospital readmission after cystectomy: no worse for rural Medicare residents. Urol Oncol 2017; 36:89.e7-89.e11. [PMID: 29249273 DOI: 10.1016/j.urolonc.2017.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 09/12/2017] [Accepted: 11/18/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate rural/urban disparities in 30-day all-cause hospital admission after cystectomy. MATERIALS AND METHODS We used the SEER-Medicare database to identify all Medicare beneficiaries who underwent radical cystectomy (ICD-9 codes 57.7, 57.71, 57.79, and 68.8) between the years 1991 and 2009, yielding a total sample size of 15,572. Our primary outcome was 30-day hospital readmission rate. Rural Urban Continuum Codes were used to designate county-level rural status based on patient residence. Location of surgery was not a variable considered in this analysis. A multivariable regression model was constructed with demographic and clinical variables as covariates. RESULTS A total of 2,003 rural and 2,904 urban patients (31.1% vs. 31.8%, P = 0.33) were readmitted within 30 days of discharge. In the multivariable model, older age, unmarried status, lower socioeconomic status, higher Charlson comorbidity score, shorter index admission hospital stay, and discharge to a skilled nursing facility were associated with higher odds of readmission. The variables for gender, race, cancer stage, tumor grade, and type of urinary diversion were not significant. The odds ratio for readmission was not significant for patients from rural counties in the final model. CONCLUSIONS Rural Medicare residents were not at higher risk for 30-day all-cause hospital readmission after cystectomy after accounting for various demographic and clinical variables.
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Affiliation(s)
- Daniel J Sadowski
- Division of Urology, Southern Illinois University School of Medicine, Springfield, IL.
| | - Hayden Warner
- Division of Urology, Southern Illinois University School of Medicine, Springfield, IL
| | - Steven Scaife
- Center for Clinical Research, Southern Illinois University School of Medicine, Springfield, IL
| | - Kevin T McVary
- Division of Urology, Southern Illinois University School of Medicine, Springfield, IL
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Abstract
OBJECTIVE To assess whether strict adherence to quality metrics by hospitals could explain the association between hospital volume and survival for ovarian cancer. METHODS We used the National Cancer Database to perform a retrospective cohort study of women with ovarian cancer from 2004 to 2013. Hospitals were stratified by annual case volume into quintiles (2 or less, 2.01-5, 5.01-9, 9.01-19.9, 20 cases or greater) and by adherence to ovarian cancer quality metrics into quartiles. Hospital-level adjusted 2- and 5-year survival rates were compared based on volume and adherence to the quality metrics. RESULTS A total of 100,725 patients at 1,268 hospitals were identified. Higher volume hospitals were more likely to adhere to the quality metrics. Both 2- and 5-year survival increased with hospital volume and with adherence to the measured quality metrics. For example, 2-year survival increased from 64.4% (95% CI 62.5-66.4%) at low-volume to 77.4% (95% CI 77.0-77.8%) at high-volume centers and from 66.5% (95% CI 65.5-67.5%) at low-quality to 77.3% (95% CI 76.8-77.7%) at high-quality hospitals (P<.001 for both). For each hospital volume category, survival increased with increasing adherence to the quality metrics. For example, in the lowest volume hospitals (two or less cases annually), adjusted 2-year survival was 61.4% (95% CI 58.4-64.5%) at hospitals with the lowest adherence to quality metrics and rose to 65.8% (95% CI 61.2-70.8%) at the hospitals with highest adherence to the quality metrics (P<.001). However, lower volume hospitals with higher quality scores still had survival that was lower than higher volume hospitals. CONCLUSION Although both hospital volume and adherence to quality metrics are associated with survival for ovarian cancer, low-volume hospitals that provide high-quality care still have survival rates that are lower than high-volume centers.
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Regionalization of radical cystectomy in the United States. Urol Oncol 2017; 35:528.e7-528.e13. [DOI: 10.1016/j.urolonc.2017.03.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/19/2017] [Accepted: 03/22/2017] [Indexed: 11/20/2022]
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Chappidi MR, Kates M, Stimson CJ, Johnson MH, Pierorazio PM, Bivalacqua TJ. Causes, Timing, Hospital Costs and Perioperative Outcomes of Index vs Nonindex Hospital Readmissions after Radical Cystectomy: Implications for Regionalization of Care. J Urol 2017; 197:296-301. [PMID: 27545575 PMCID: PMC5241219 DOI: 10.1016/j.juro.2016.08.082] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2016] [Indexed: 12/30/2022]
Abstract
PURPOSE We compared the timing, causes, hospital costs and perioperative outcomes of index vs nonindex hospital readmissions after radical cystectomy. MATERIALS AND METHODS The 2013 Nationwide Readmissions Database was queried for patients with bladder cancer undergoing cystectomy. Sociodemographic characteristics, hospital costs and causes of readmission were compared among index and nonindex readmitted patients. Univariable and multivariable logistic regression models were used to identify predictors of nonindex readmissions, mortality during the first readmission and subsequent readmission. RESULTS Among 4,991 patients identified 29% (1,447) and 11% (571) experienced an index and nonindex readmission, respectively. Compared to index readmissions, nonindex readmissions were more likely late readmissions (p <0.001) of older patients (p=0.047) who underwent cystectomy at higher volume hospitals (p=0.02) and were readmitted to hospitals located in less populated areas (p <0.001). Compared to index readmissions the percentage of nonindex readmissions for cardiovascular complications was higher (7.6% vs 2.9%, p=0.003), while the percentage of nonindex readmissions for gastrointestinal (6.0% vs 11.0%, p=0.04) and wound (5.3% vs 16.7%, p=0.0001) complications was lower. Predictors of nonindex readmission included longer length of stay (OR 1.02; 95% CI 1.001, 1.04), patient location in less populated areas, nonteaching hospital (OR 0.52; 95% CI 0.31, 0.86) and discharge to facility (OR 2.82; 95% CI 1.75, 4.55) or with home health (OR 1.49; 95% CI 1.05, 2.10). Nonindex readmissions had comparable mean readmission hospital costs ($14,147 vs $15,102, p=0.7), in-hospital mortality (OR 1.11; 95% CI 0.42, 2.87) and subsequent readmission (OR 1.32; 95% CI 0.87, 2.00) to index readmissions. CONCLUSIONS This nationally representative study of patients undergoing radical cystectomy demonstrated comparable perioperative outcomes and hospital costs between index and nonindex readmitted patients, which supports the continued regionalization of cystectomy care.
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Affiliation(s)
- Meera R Chappidi
- James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Max Kates
- James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - C J Stimson
- James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael H Johnson
- James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Phillip M Pierorazio
- James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Trinity J Bivalacqua
- James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Casey MF, Wisnivesky J, Le VH, Sarpel U, Stensland KD, Oh WK, Galsky MD. The Relationship between Centralization of Care and Geographic Barriers to Cystectomy for Bladder Cancer. Bladder Cancer 2016; 2:319-327. [PMID: 27500199 PMCID: PMC4969695 DOI: 10.3233/blc-160058] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background: Centralization of cystectomy treatment for bladder cancer, while associated with improved outcomes, may impose geographic barriers to care. However, whether this effect may be counterbalanced by an increased number of high volume centers has not previously been explored. Objective: To characterize changes in geographic disparities to high volume cystectomy centers over time. Methods: Data on all inpatient admissions for cystectomy in New York State (NYS) from 1997–2011 was obtained from the Department of Health. Using these data, we classified hospitals according to cystectomy volume and measured patient distance traveled to a cystectomy center. Population weights, from the US Census, were used to describe changes in minimum travel distance to high- or very high-volume (HV/VHV) facilities across the NYS population. Results: Bladder cancer patients underwent cystectomies at 195 hospitals during the study period. In 1997–2001, eleven HV/VHV facilities accounted for 37.5% of all cystectomies, while sixteen HV/VHV hospitals accounted for 71.5% of all procedures during 2007–2011. Median distance traveled by cystectomy patients to all hospitals increased from 9.6 to 14.4 miles in 1997–2001 to 2007–2011, respectively. In the same time span, the median travel distance for the NYS population to a HV/VHV center decreased by 1.9 and 9.4 miles at the median and 75th percentile, respectively. Conclusions: Our findings demonstrate a complicated relationship between centralization and geographic access. While centralization has led to a decrease in overall access to cystectomy facilities, the process simultaneously improved access to high volume centers.
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Affiliation(s)
- Martin F Casey
- Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | - Juan Wisnivesky
- Department of Medicine, Divisions of General Internal Medicine and Pulmonary and Critical Care, Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | - Valerie H Le
- Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | - Umut Sarpel
- Division of Surgical Oncology, Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | | | - William K Oh
- Division of Hematology and Medical Oncology, The Tisch Cancer Institute , Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthew D Galsky
- Division of Hematology and Medical Oncology, The Tisch Cancer Institute , Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Healy MA, Yin H, Wong SL. Multimodal cancer care in poor prognosis cancers: Resection drives long-term outcomes. J Surg Oncol 2016; 113:599-604. [PMID: 26953166 DOI: 10.1002/jso.24217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 02/20/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Hospitals with high complex oncologic surgical volume have improved short-term outcomes. However, for long-term outcomes, the influence of other therapies must be considered. We compared effects of resection with other therapies on long-term outcomes across U.S. hospitals. METHODS We examined claims in the Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset for patients with esophageal (EC) and pancreatic (PC) cancers between 2005-2009, with follow-up through 2011, performing multivariable Cox proportional hazards analyses. We stratified hospitals by volume and compared rates of treatments in the context of survival. RESULTS We studied 905 EC and 3,293 PC patients at 138 and 375 hospitals, respectively. For EC, resection rates were significantly higher (32.9% vs. 9.5%, P < 0.001) in the highest versus lowest volume hospitals. Adjusted survival was also statistically significantly better (48.5% vs. 43.1%, P < 0.001). For PC, resection rates were also statistically significantly higher (30.1% vs. 12.0%, P < 0.001) with higher adjusted survival (21.5% vs. 19.9%, P = 0.01). We did not find variation in rates of other cancer treatments across hospitals. CONCLUSIONS A significant association exists between long-term survival and rates of cancer-directed surgery across hospitals, without variation in rates of other therapies. Access to resection appears to be key to reducing variation in long-term survival. J. Surg. Oncol. 2016;113:599-604. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Mark A Healy
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.,Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan
| | - Huiying Yin
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan
| | - Sandra L Wong
- Department of Surgery, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire
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Olson DJ, Gore JL, Daratha KB, Roberts KP. Travel Burden and the Direct Medical Costs of Urologic Surgery. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2016; 4:47-54. [PMID: 34414247 PMCID: PMC8341619 DOI: 10.36469/9825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Background: Increased surgical volume is associated with better patient outcomes and shorter lengths of hospitalization. As a consequence, traveling to receive care from a high volume provider may be associated with better outcomes. However, travel may also be associated with a decision by the healthcare provider to increase the length of stay due to a decreased ability to return to the primary hospital should complications arise. Thus, research is needed to understand the relationship between the distance a patient must travel and their outcomes following urologic surgery. Objective: The purpose of this study was to determine whether the distance a patient travels to receive urologic surgery is associated with their length of hospital stay and direct medical hospitalization costs. Methods: This was a retrospective observational cohort study of 12 106 patients over 50 years of age undergoing transurethral resection of the prostate (TURP), radical prostatectomy (RP) or radical cystectomy (RC) in Washington State hospitals between 2009 and 2013. Distance traveled was determined by calculating the linear distance between zip code centroids of patient residence and the hospital performing their procedure. Patients were sorted into four groups classified by distance traveled (≤5 miles, 6-20 miles, 21-50 miles and ≥51 miles) and cost calculated using a charges-to-reimbursement ratio for each hospital. Statistical significance was determined using a Kruskal-Wallis test. Results: Patients traveling greater distances had significantly lower median medical costs compared with patients who lived closer to the hospitals where they underwent TURP and RP (TURP: ≤5 miles, $6243 and ≥51 miles, $5105, p≤0.001; RP: ≤5 miles, $12 407 and ≥51 miles, $11 882, p≤0.001), whereas there was no significant difference for patients undergoing RC (≤5 miles, $27 554 and ≥51 miles, $26 761, p=0.17). Likewise, patients traveling greater distances had significantly lower median lengths of hospitalization for TURP and RP (TURP: p≤0.001, RP: p≤0.001), while there was no difference for RC (p=0.50). Conclusions: Patient travel burden does appear to play a role in cost and length of hospital stay for select urologic procedures with variable levels of morbidity and recovery time. Although these findings are statistically significant, the magnitude of the effect is small.
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Krishnan N, Liu X, Lavieri MS, Hu M, Helfand A, Li B, Helm JE, He C, Hollenbeck BK, Skolarus TA, Jacobs BL. A Model to Optimize Followup Care and Reduce Hospital Readmissions after Radical Cystectomy. J Urol 2015; 195:1362-1367. [PMID: 26682758 DOI: 10.1016/j.juro.2015.11.063] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE Radical cystectomy has one of the highest readmission rates across all surgical procedures at approximately 25%. We developed a mathematical model to optimize outpatient followup regimens for radical cystectomy. MATERIALS AND METHODS We used delay-time analysis, a systems engineering approach, to maximize the probability of detecting patients susceptible to readmission through office visits and telephone calls. Our data source includes patients readmitted after radical cystectomy from the Healthcare Cost and Utilization Project State Inpatient Databases in 2009 and 2010 as well as from our institutional bladder cancer database from 2007 to 2011. We measured the interval from hospital discharge to the point when a patient first exhibits concerning symptoms. Our primary end point is 30-day hospital readmission. Our model optimized the timing and sequence of followup care after radical cystectomy. RESULTS The timing of office visits and telephone calls is more important in detecting a patient at risk for readmission than the sequence of these encounters. Patients are most likely to exhibit concerning symptoms between 4 and 5 days after discharge home. An optimally scheduled office visit can detect up to 16% of potential readmissions, which can be increased to 36% with 1 office visit followed by 4 telephone calls. CONCLUSIONS Our model improves the detection of concerning symptoms after radical cystectomy by optimizing the timing and number of outpatient encounters. By understanding how to design better outpatient followup care for patients treated with radical cystectomy we can help reduce the readmission burden for this population.
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Affiliation(s)
| | - Xiang Liu
- Departments of Industrial & Operations Engineering, University of Michigan College of Engineering, Ann Arbor, Michigan
| | - Mariel S Lavieri
- Departments of Industrial & Operations Engineering, University of Michigan College of Engineering, Ann Arbor, Michigan
| | - Michael Hu
- Departments of Industrial & Operations Engineering, University of Michigan College of Engineering, Ann Arbor, Michigan
| | | | | | - Jonathan E Helm
- Indiana University Kelley School of Business, Bloomington, Indiana
| | - Chang He
- Department of Urology, Ann Arbor, Michigan; Dow Division of Health Services Research, Ann Arbor, Michigan
| | - Brent K Hollenbeck
- Department of Urology, Ann Arbor, Michigan; Dow Division of Health Services Research, Ann Arbor, Michigan; Division of Oncology, University of Michigan, Ann Arbor, Michigan
| | - Ted A Skolarus
- Department of Urology, Ann Arbor, Michigan; Dow Division of Health Services Research, Ann Arbor, Michigan; Division of Oncology, University of Michigan, Ann Arbor, Michigan; VA HSR&D Center for Clinical Management Research and VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Laguna MP. Re: Benefit in Regionalization of Care for Patients Treated with Nephrectomy: A Nationwide Inpatient Sample. J Urol 2015; 194:664-5. [PMID: 26292853 DOI: 10.1016/j.juro.2015.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Indexed: 11/20/2022]
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Liu NW, Shatagopam K, Monn MF, Kaimakliotis HZ, Cary C, Boris RS, Mellon MJ, Masterson TA, Foster RS, Gardner TA, Bihrle R, House MG, Koch MO. Risk for Clostridium difficile infection after radical cystectomy for bladder cancer: Analysis of a contemporary series. Urol Oncol 2015; 33:503.e17-22. [PMID: 26278363 DOI: 10.1016/j.urolonc.2015.07.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 06/23/2015] [Accepted: 07/10/2015] [Indexed: 12/23/2022]
Abstract
INTRODUCTION This study seeks to evaluate the incidence and associated risk factors of Clostridium difficile infection (CDI) in patients undergoing radical cystectomy (RC) for bladder cancer. METHODS We retrospectively reviewed a single institution׳s bladder cancer database including all patients who underwent RC between 2010 and 2013. CDI was diagnosed by detection of Clostridium difficile toxin B gene using polymerase chain reaction-based stool assay in patients with clinically significant diarrhea within 90 days of the index operation. A multivariable logistic regression model was used to identify demographics and perioperative factors associated with developing CDI. RESULTS Of the 552 patients who underwent RC, postoperative CDI occurred in 49 patients (8.8%) with a median time to diagnosis after RC of 7 days (interquartile range: 5-19). Of the 122 readmissions for postoperative complications, 10% (n = 12) were related to CDI; 2 patients died of sepsis directly related to severe CDI. On multivariate logistic regression, the use of chronic antacid therapy (odds ratio = 1.9, 95% CI: 1.02-3.68, P = 0.04) and antibiotic exposure greater than 7 days (odds ratio = 2.2, 95% CI: 1.11-4.44, P = 0.02) were independently associated with developing CDI. The use of preoperative antibiotics for positive findings on urine culture within 30 days before surgery was not statistically significantly associated with development of CDI (P = 0.06). CONCLUSIONS The development of CDI occurs in 8.8% of patients undergoing RC. Our study demonstrates that use of chronic antacid therapy and long duration of antimicrobial exposure are associated with development of CDI. Efforts focusing on minimizing antibiotic exposure in patients undergoing RC are needed, and perioperative antimicrobial prophylaxis guidelines should be followed.
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Affiliation(s)
- Nick W Liu
- Department of Urology, Indiana University Health, Indianapolis, IN.
| | | | - M Francesca Monn
- Department of Urology, Indiana University Health, Indianapolis, IN
| | | | - Clint Cary
- Department of Urology, Indiana University Health, Indianapolis, IN
| | - Ronald S Boris
- Department of Urology, Indiana University Health, Indianapolis, IN
| | - Matthew J Mellon
- Department of Urology, Indiana University Health, Indianapolis, IN
| | | | - Richard S Foster
- Department of Urology, Indiana University Health, Indianapolis, IN
| | - Thomas A Gardner
- Department of Urology, Indiana University Health, Indianapolis, IN
| | - Richard Bihrle
- Department of Urology, Indiana University Health, Indianapolis, IN
| | - Michael G House
- Department of Urology, Indiana University Health, Indianapolis, IN
| | - Michael O Koch
- Department of Urology, Indiana University Health, Indianapolis, IN
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Roghmann F, Ravi P, Hanske J, Meyer CP, Preston MA, Noldus J, Trinh QD. Perioperative outcomes after radical cystectomy at NCI-designated centres: Are they any better? Can Urol Assoc J 2015. [PMID: 26225174 DOI: 10.5489/cuaj.2621] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION In 1971, the National Cancer Institute (NCI) introduced a network of NCI-designated Cancer Centers (CC), which underwent a comprehensive approval process relying on research, education and prevention activities. In this study, we examine the effect of CC status on perioperative outcomes after radical cystectomy (RC). METHODS Within the Nationwide Inpatient Sample, we focused on RC performed from 2006 to 2010. As all recognized centres were residency teaching institutions, we stratified according to teaching and CC-teaching status. We examined the rates of in-hospital mortality, intra- and postoperative complications, prolonged length of hospital stay, as well as blood transfusion. Multivariable logistic regression analyses were further adjusted for confounding factors. RESULTS Overall, 22 840 RC patients (5451 at non-teaching, 10 857 at residency teaching, 6532 at CC-teaching institutions) were identified. Patients treated at residency teaching and CC-teaching institutions were younger, had less comorbidities, and more likely to have private insurance. In multivariable analyses, patients treated at residency and CC-teaching institutions were less likely to experience postoperative complications (odds ratio [OR] 0.73 and 0.66, respectively) and blood transfusions (OR 0.77 and 0.53, respectively) relative to patients treated at non-teaching institutions. In addition, CC patients were also less likely to experience in-hospital mortality (OR 0.61, all p < 0.001) as compared to non-teaching institutions. CONCLUSIONS On average, patients treated at residency and CC-teaching institutions are less likely to experience unfavourable outcomes after RC. Moreover, patients treated at CC fared better than patients treated at residency teaching institutions. Our findings acknowledge the quality of RC care at accredited centres.
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Affiliation(s)
- Florian Roghmann
- Department of Urology, Marien Hospital, Ruhr-University Bochum, Herne, Germany
| | - Praful Ravi
- The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Julian Hanske
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA ; Department of Urology, Marien Hospital, Ruhr-University Bochum, Herne, Germany
| | - Christian P Meyer
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mark A Preston
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Joachim Noldus
- Department of Urology, Marien Hospital, Ruhr-University Bochum, Herne, Germany
| | - Quoc-Dien Trinh
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Casey MF, Gross T, Wisnivesky J, Stensland KD, Oh WK, Galsky MD. The Impact of Regionalization of Cystectomy on Racial Disparities in Bladder Cancer Care. J Urol 2015; 194:36-41. [DOI: 10.1016/j.juro.2015.01.076] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2015] [Indexed: 10/24/2022]
Affiliation(s)
| | - Tal Gross
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York
| | - Juan Wisnivesky
- Divisions of General Internal Medicine and Pulmonary and Critical Care, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - William K. Oh
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Matthew D. Galsky
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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Understanding Hospital Readmission Intensity after Radical Cystectomy. J Urol 2015; 193:1500-6. [DOI: 10.1016/j.juro.2014.10.107] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2014] [Indexed: 11/18/2022]
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Comploj E, West J, Mian M, Kluth LA, Karl A, Dechet C, Shariat SF, Stief CG, Trenti E, Palermo S, Lodde M, Horninger W, Madersbacher S, Pycha A. Comparison of Complications from Radical Cystectomy between Old-Old versus Oldest-Old Patients. Urol Int 2014; 94:25-30. [DOI: 10.1159/000358731] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 01/15/2014] [Indexed: 11/19/2022]
Abstract
Introduction: The purpose of this study was to evaluate and compare complications after radical cystectomy in patients aged ≥75 years. Materials and Methods: 251 patients aged 75-95 years (median 79) underwent radical cystectomy between 2000 and 2012 at four institutions. The patients were divided into two groups: ≥75-84 years of age (group 1) versus ≥85 years of age (group 2). Comorbidities, body mass index, and complications were obtained retrospectively, except at the Central Hospital of Bolzano and Weill Cornell Medical Center, which collected data prospectively. Cancer-specific survival, overall mortality, hospital stay, clinical outcome and complications were assessed. Complications were categorized using the Clavien-Dindo classification reporting system. The mean follow-up was 21 months. Results: The median hospital stay was 17 (2-91) days. Perioperative Clavien-Dindo grade ≥III complications were seen in 24.1% (48/199) of group 1 patients and 19.2% (10/52) of group 2 patients (p = 0.045). 30- and 90-day mortality was 4.5 and 13.5% in group 1 and 6.5 and 32.3% in group 2, respectively. Only the 90-day mortality rate was statistically significant (p < 0.05) between the two groups. The 3-year overall survival was 40% in group 1 and 34% in group 2. The 3-year cancer-specific survival was 52% in group 1 and 50% in group 2. Conclusions: We evaluated a large series of elderly (≥75 years) patients undergoing radical cystectomy at four institutions. Comparing patients aged ≥75-84 and ≥85 years revealed no significant difference in complications, 30-day mortality, overall and cancer-specific survival rates. Only 90-day mortality rates were significantly higher in the ≥85-year-old patients.
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Nielsen ME, Mallin K, Weaver MA, Palis B, Stewart A, Winchester DP, Milowsky MI. Association of hospital volume with conditional 90-day mortality after cystectomy: an analysis of the National Cancer Data Base. BJU Int 2014; 114:46-55. [PMID: 24219110 DOI: 10.1111/bju.12566] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To examine the association of hospital volume and 90-day mortality after cystectomy, conditional on survival for 30 days. PATIENTS AND METHODS The National Cancer Data Base was used to evaluate 30- and 90-day mortality for 35,055 patients who underwent cystectomy for bladder cancer at one of 1118 hospitals. Patient data were aggregated into hospital volume categories based on the mean annual number of procedures (low-volume hospital: <10 procedures; intermediate-volume hospital: 10-19 procedures; high-volume hospital: ≥20 procedures). Associations between mortality and clinical, demographic and hospital characteristics were analysed using hierarchical logistic regression models. To assess the association between hospital volume and 90-day mortality independently of shorter-term mortality, 90-day mortality conditional on 30-day survival was assessed in the multivariate modelling. RESULTS Unadjusted 30- and 90-day mortality rates were 2.7 and 7.2% overall, 1.9 and 5.7% among high-volume hospitals, and 3.2 and 8.0% among low-volume hospitals, respectively. Compared with high-volume hospitals, the adjusted risks among low-volume hospitals (odds ratio [95% CI]) of 30- and 90-day mortality, conditional on having survived for 30 days, from the hierarchical models were 1.5 (1.3-1.9), and 1.2 (1.0-1.4), respectively. CONCLUSIONS A low hospital volume was associated with greater 30- and 90-day mortality. These data support the need for further research to better understand the relatively high mortality rates seen between 30 and 90 days, which are high and less variable across hospital volume strata. The stronger association between volume and 30-day mortality suggests that quality-reporting efforts should focus on shorter-term outcomes.
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Affiliation(s)
- Matthew E Nielsen
- University of North Carolina Lineberger Comprehensive Cancer Center, USA; Department of Urology, University of North Carolina School of Medicine, USA; Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
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Mossanen M, Izard J, Wright JL, Harper JD, Porter MP, Daratha KB, Holt SK, Gore JL. Identification of underserved areas for urologic cancer care. Cancer 2014; 120:1565-71. [PMID: 24523042 DOI: 10.1002/cncr.28616] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 01/16/2014] [Accepted: 01/22/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND The delivery of urologic oncology care is susceptible to regional variation. In the current study, the authors sought to define patterns of care for patients undergoing genitourinary cancer surgery to identify underserved areas for urologic cancer care in Washington State. METHODS The authors accessed the Washington State Comprehensive Hospital Abstract Reporting System from 2003 through 2007. They identified patients undergoing radical prostatectomy, radical cystectomy (RC), partial nephrectomy (PN), radical nephrectomy, and transurethral resection of the prostate (TURP). TURP was included for comparison as a reference procedure indicative of access to urologic care. Hospital service areas (HSAs) are where the majority of local patients are hospitalized; hospital referral regions (HRR) are where most patients receive tertiary care. The authors created multivariate hierarchical logistic regression models to examine patient and HSA characteristics associated with the receipt of urologic oncology care out of the HRR for each procedure. RESULTS Greater than one-half of patients went out of their HRR in 7 HSAs (11%) for radical prostatectomy, 3 HSAs (5%) for radical nephrectomy, 10 HSAs (15%) for PN, and 14 HSAs (22%) for RC. No HSAs had high export rates for TURP. Few patient factors were found to be associated with surgical care out of the HRR. High-export HSAs for PN and RC exhibited lower socioeconomic characteristics than low-export HSAs, adjusting for HSA population, race, and HSA procedure rates for PN and RC. CONCLUSIONS Patients living in areas with lower socioeconomic status have a greater need to travel for complex urologic surgery. Consideration of geographic delineation in the delivery of urologic oncology care may aid in regional quality improvement initiatives.
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Affiliation(s)
- Matthew Mossanen
- Department of Urology, University of Washington, Seattle, Washington
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Benefit in regionalization of care for patients treated with nephrectomy: a Nationwide Inpatient Sample. World J Urol 2014; 32:1511-21. [DOI: 10.1007/s00345-014-1256-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 01/28/2014] [Indexed: 02/06/2023] Open
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Gore JL, Gilbert SM. Improving bladder cancer patient care: a pharmacoeconomic perspective. Expert Rev Anticancer Ther 2014; 13:661-8. [PMID: 23773101 DOI: 10.1586/era.13.58] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Bladder cancer is the most expensive cancer per capita to treat in the US healthcare system. Substantial costs associated with the diagnosis, management and surveillance of bladder cancer account for the bulk of the expense; yet, for that cost, patients may not receive high-quality care. Herein the authors review the sources of expenditure associated with bladder cancer care, review population-level analyses of the quality of bladder cancer care in the USA, and discuss opportunities for quality improvement that may yield greater value for men and women newly diagnosed with bladder cancer.
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Affiliation(s)
- John L Gore
- Department of Urology, University of Washington, Seattle, WA, USA.
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Factors affecting choice between ureterostomy, ileal conduit and continent reservoir after radical cystectomy: Japanese series. Int J Clin Oncol 2014; 19:1098-104. [PMID: 24395445 DOI: 10.1007/s10147-013-0655-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 12/02/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Little is known about the disparity of choices between three urinary diversions after radical cystectomy, focusing on patient and institutional factors. METHODS We identified urothelial carcinoma patients who received radical cystectomy with cutaneous ureterostomy, ileal conduit or continent reservoir using the Japanese Diagnosis Procedure Combination database from 2007 to 2012. Data comprised age, sex, comorbidities (converted into the Charlson index), TNM classification (converted into oncological stage), hospitals' academic status, hospital volume, bed volume and geographical region. Multivariate ordinal logistic regression analyses fitted with the proportional odds model were performed to analyze factors affecting urinary diversion choices. For dependent variables, the three diversions were converted into an ordinal variable in order of complexity: cutaneous ureterostomy (reference), ileal conduit and continent reservoir. Geographical variations were also examined by multivariate logistic regression models. RESULTS A total of 4790 patients (1131 cutaneous ureterostomies [23.6 %], 2970 ileal conduits [62.0 %] and 689 continent reservoirs [14.4 %]) were included. Ordinal logistic regression analyses showed that male sex, lower age, lower Charlson index, early tumor stage, higher hospital volume (≥3.4 cases/year) and larger bed volume (≥450 beds) were significantly associated with the preference of more complex urinary diversion. Significant geographical disparity was also found. CONCLUSION Good patient condition and early oncological status, as well as institutional factors, including high hospital volume, large bed volume and specific geographical regions, are independently related to the likelihood of choosing complex diversions. Recognizing this disparity would help reinforce the need for clinical practice uniformity.
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Smaldone MC, Simhan J, Kutikov A, Canter DJ, Starkey R, Zhu F, Nielsen ME, Stitzenberg KB, Greenberg RE, Uzzo RG. Trends in regionalization of radical cystectomy in three large northeastern states from 1996 to 2009. Urol Oncol 2013; 31:1663-9. [DOI: 10.1016/j.urolonc.2012.04.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 03/24/2012] [Accepted: 04/20/2012] [Indexed: 02/06/2023]
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Trends in hospital volume and patterns of referral for women with gynecologic cancers. Obstet Gynecol 2013; 121:1217-1225. [PMID: 23812455 DOI: 10.1097/aog.0b013e31828ec686] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To estimate trends in hospital volume and referral patterns for women with uterine and ovarian cancer. METHODS The Surveillance, Epidemiology, and End Results-Medicare database was used to identify women aged 65 years or older with ovarian and uterine cancer who underwent surgery from 2000 to 2007. "Volume creep," when a greater number of patients undergo surgery at the same hospitals, and "market concentration," when a similar overall number of patients undergo a procedure but at a smaller number of hospitals, were analyzed. RESULTS Among 4,522 patients with ovarian cancer, mean hospital volume increased from 3.1 cases during 2000-2001 to 3.4 cases during 2006-2007 (P=.62) suggesting minimal volume creep. Similarly, there was little evidence of market concentration. In 2000-2001, 37.8% of women were treated at the top decile by volume hospitals compared with 41.4% in 2006-2007 (P=.14). In 2006-2007, 201 (63.2%) of the hospitals had an ovarian cancer surgery volume of two or fewer cases. Among 9,908 women with uterine cancer, the mean hospital volume increased slightly from 4.5 in 2000-2001 to 5.4 in 2006-2007 (P=.10). The percentage of patients treated at the top decile by volume of hospitals increased from 40.4% in 2000-2001 to 44.7% in 2006-2007 (P<.001). In 2006-2007, 243 (49.3%) of the hospitals had a uterine cancer surgery volume of two or fewer cases. CONCLUSION There have been only modest changes in the referral patterns of women with ovarian and uterine cancer. A large number of hospitals have a very low procedural volume.
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Ravi P, Bianchi M, Hansen J, Trinh QD, Tian Z, Meskawi M, Abdollah F, Briganti A, Shariat SF, Perrotte P, Montorsi F, Karakiewicz PI, Sun M. Benefit in regionalisation of care for patients treated with radical cystectomy: a nationwide inpatient sample analysis. BJU Int 2013; 113:733-40. [DOI: 10.1111/bju.12288] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Praful Ravi
- West Middlesex University Hospital; London UK
| | - Marco Bianchi
- Cancer Prognostics and Health Outcomes Unit; University of Montreal Health Center; Montreal QC Canada
- Department of Urology; Urologic Research Institute; Vita-Salute San Raffaele University; Milan Italy
| | - Jens Hansen
- Cancer Prognostics and Health Outcomes Unit; University of Montreal Health Center; Montreal QC Canada
- Martini-Klinic; Prostate Cancer Center Hamburg-Eppendorf; Hamburg Germany
| | - Quoc-Dien Trinh
- Division of Urology; Brigham and Women's Hospital/Dana Farber Cancer Institute; Harvard Medical School; Boston MA USA
- Center for Surgery and Public Health; Brigham and Women's Hospital and Harvard School of Public Health; Boston MA USA
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit; University of Montreal Health Center; Montreal QC Canada
| | - Malek Meskawi
- Cancer Prognostics and Health Outcomes Unit; University of Montreal Health Center; Montreal QC Canada
| | - Firas Abdollah
- Department of Urology; Urologic Research Institute; Vita-Salute San Raffaele University; Milan Italy
| | - Alberto Briganti
- Department of Urology; Urologic Research Institute; Vita-Salute San Raffaele University; Milan Italy
| | - Shahrokh F. Shariat
- Department of Urology; Weill Medical College of Cornell University; New York NY USA
| | - Paul Perrotte
- Department of Urology; University of Montreal Health Center; Montreal QC Canada
| | - Francesco Montorsi
- Department of Urology; Urologic Research Institute; Vita-Salute San Raffaele University; Milan Italy
| | - Pierre I. Karakiewicz
- Cancer Prognostics and Health Outcomes Unit; University of Montreal Health Center; Montreal QC Canada
- Department of Urology; University of Montreal Health Center; Montreal QC Canada
| | - Maxine Sun
- Cancer Prognostics and Health Outcomes Unit; University of Montreal Health Center; Montreal QC Canada
- Department of Public Health; Faculty of Medicine; University of Montreal; Montreal QC Canada
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Chamie K, Litwin MS, Bassett JC, Daskivich TJ, Lai J, Hanley JM, Konety BR, Saigal CS. Recurrence of high-risk bladder cancer: a population-based analysis. Cancer 2013; 119:3219-27. [PMID: 23737352 DOI: 10.1002/cncr.28147] [Citation(s) in RCA: 234] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 03/12/2013] [Accepted: 04/08/2013] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patients with bladder cancer are apt to develop multiple recurrences that require intervention. The recurrence, progression, and bladder cancer-related mortality rates were examined in a cohort of individuals with high-grade non-muscle-invasive bladder cancer. METHODS Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data, subjects were identified who had a diagnosis of high-grade, non-muscle-invasive disease in 1992 to 2002 and who were followed until 2007. Multivariate competing-risks regression analyses were then used to examine recurrence, progression, and bladder cancer-related mortality rates. RESULTS Of 7410 subjects, 2897 (39.1%) experienced a recurrence without progression, 2449 (33.0%) experienced disease progression, of whom 981 succumbed to bladder cancer. Using competing-risks regression analysis, the 10-year recurrence, progression, and bladder cancer-related mortality rates were found to be 74.3%, 33.3%, and 12.3%, respectively. Stage T1 was the only variable associated with a higher rate of recurrence. Women, black race, undifferentiated grade, and stage Tis and T1 were associated with a higher risk of progression and mortality. Advanced age (≥ 70) was associated with a higher risk of bladder cancer-related mortality. CONCLUSIONS Nearly three-fourths of patients diagnosed with high-risk bladder cancer will recur, progress, or die within 10 years of their diagnosis. Even though most patients do not die of bladder cancer, the vast majority endures the morbidity of recurrence and progression of their cancer. Increasing efforts should be made to offer patients intravesical therapy with the goal of minimizing the incidence of recurrences. Furthermore, the high recurrence rate seen during the first 2 years of diagnosis warrants an intense surveillance schedule.
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Affiliation(s)
- Karim Chamie
- Department of Urology, Health Services Research Group, David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, California; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, California
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Kim SP, Shah ND, Weight CJ, Thompson RH, Wang JK, Karnes RJ, Han LC, Ziegenfuss JY, Frank I, Tollefson MK, Boorjian SA. Population-based trends in urinary diversion among patients undergoing radical cystectomy for bladder cancer. BJU Int 2013; 112:478-84. [PMID: 23452020 DOI: 10.1111/j.1464-410x.2012.11508.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
UNLABELLED What's known on the subject? and what does the study add?: Variations in the type of urinary diversion exist for patients undergoing radical cystectomy. Although its use has been increasing from 2001 to 2008, patients who are older, female, and primary insured by Medicaid are less likely to receive continent diversions. Furthermore, patients treated surgically at high-volume and teaching hospitals are more likely to receive continent diversions. OBJECTIVE To describe the contemporary trends in urinary diversion among patients undergoing radical cystectomy (RC) for bladder cancer; and elucidate whether socioeconomic disparities persist in the type of diversion performed in the USA from a population-based cohort. PATIENTS AND METHODS Using the Nationwide Inpatient Sample, we identified patients who underwent RC for bladder cancer between 2001 and 2008. Multivariable regression models were used to identify patient and hospital covariates associated with continent urinary diversion and enumerate predicted probabilities for statistically significant variables over time. RESULTS Overall, 55635 (92%) patients undergoing RC for bladder cancer received incontinent urinary diversion, while 4552 (8%) patients received continent diversion from 2001 to 2008. Receipt of continent urinary diversion increased from 6.6% in 2001-2002 to 9.4% in 2007-2008 (P < 0.001 for trend). Patients who were older (odds ratio [OR] 0.93; P < 0.001), female (OR 0.52; P < 0.001) and insured by Medicaid (OR 0.54; P = 0.002) were less likely to receive continent urinary diversion. However, patients treated at teaching (OR 2.14; P < 0.001) and high-volume hospitals (OR 2.39; P = 0.04) had higher odds of continent urinary diversion. Predicted probabilities of continent diversion remained lower for female patients, Medicaid insurance status, and non-teaching and medium/low-volume hospitals over time. CONCLUSIONS In this nationally representative sample of hospitals from 2001 to 2008, the use of continent diversion in RC gradually increased. Although variations in urinary diversion exist by hospital teaching status, case volume, patient gender and primary health insurance, increased attention in expanding the use of continent diversions may help reduce these disparities for patients undergoing RC for bladder cancer.
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Affiliation(s)
- Simon P Kim
- Department of Urology, Mayo Clinic, Rochester, MN 55905, USA.
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Allareddy V, Ackerman MB, Venugopalan SR, Yadav S, Nanda VS, Nanda R. Longitudinal trends in discharge patterns of orthognathic surgeries: is there a regionalization of procedures in teaching hospitals? Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 115:583-8. [PMID: 23254372 DOI: 10.1016/j.oooo.2012.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 09/02/2012] [Accepted: 09/12/2012] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The aim of this study was to determine if there is regionalization of orthognathic surgeries to teaching hospitals during the study period. STUDY DESIGN The Nationwide Inpatient Sample for years 2000-2008 was used. Every hospitalization that had an orthognathic surgery was selected. Patient and hospital level variables were examined. The odds of an orthognathic surgery procedure being performed in a teaching hospital over the study period was computed with the use of a multivariable logistic regression model. RESULTS During the study period, a total of 108,264 hospitalizations underwent orthognathic surgeries in the United States. The average age ranged from 27 years during the years 2006-2008 to 28.2 years during the years 2000-2002. After adjusting for multiple patient and hospital level factors, the year of procedure was not a significant predictor of increasing odds of an orthognathic surgery being performed in a teaching hospital. CONCLUSIONS There is no evidence of concentration of orthognathic surgical procedures in teaching hospitals.
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Affiliation(s)
- Veerasathpurush Allareddy
- Director, Predoctoral Orthodontics, Harvard School of Dental Medicine, Boston, Massachusetts 02115, USA.
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Burks FN, Salmon SA, Smith AC, Santucci RA. Urethroplasty: A Geographic Disparity in Care. J Urol 2012; 187:2124-7. [DOI: 10.1016/j.juro.2012.01.078] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2011] [Indexed: 11/24/2022]
Affiliation(s)
| | - Scott A. Salmon
- Department of Urology, Detroit Medical Center, Detroit, Michigan
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Kim SP, Shah ND, Karnes RJ, Weight CJ, Frank I, Moriarty JP, Han LC, Borah B, Tollefson MK, Boorjian SA. The implications of hospital acquired adverse events on mortality, length of stay and costs for patients undergoing radical cystectomy for bladder cancer. J Urol 2012; 187:2011-7. [PMID: 22498229 DOI: 10.1016/j.juro.2012.01.077] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Simon P Kim
- Department of Urology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Kim SP, Boorjian SA, Shah ND, Karnes RJ, Weight CJ, Moriarty JP, Tollefson MK, Shippee ND, Frank I. Contemporary trends of in-hospital complications and mortality for radical cystectomy. BJU Int 2012; 110:1163-8. [PMID: 22443271 DOI: 10.1111/j.1464-410x.2012.10990.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
UNLABELLED What's known on the subject? and What does the study add? Radical cystectomy (RC) carries significant risks of morbidity and mortality. Little is known whether in-hospital outcomes are improving for RC. Using a contemporary population-based cohort, the present study suggests minimal improvement in postoperative complications and mortality overall or by hospital-volume category from 2001 to 2008. About 29% and 2% of patients undergoing RC will experience a postoperative complication or die during hospitalisation, respectively. OBJECTIVE To characterise the contemporary trends of in-hospital complications and mortality for radical cystectomy (RC) from a contemporary population-based cohort, as patients undergoing RC for bladder cancer are at significant risk for complications and mortality and the degree to which in-hospital outcomes have changed over time is unknown. PATIENTS AND METHODS We identified 50 625 individuals who underwent RC for bladder cancer between 2001 and 2008 from the Nationwide Inpatient Sample. Multivariable regression models were used to identify hospital and patient covariates associated with in-hospital complications and mortality and to estimate predicted probabilities of each outcome. Temporal trends of in-hospital mortality and complications were assessed by Wilcoxon rank-sum test. RESULTS The proportion of patients with in-hospital complications remained stable at 28.3% in 2001-2002 compared with 28.0% in 2007-2008 (P = 0.81 for trend). In-hospital mortality was also unchanged from 2.4% in 2001-2002 compared with 2.3% in 2007-2008 (P = 0.87 for trend). While high-volume hospitals were associated with lower odds of in-hospital complications (odds ratio [OR] 0.77, P = 0.01) and mortality (OR 0.60, P = 0.02) compared with low-volume hospitals, the predicted probabilities of in-hospital complications or mortality were unchanged within each volume category between 2001 and 2008. CONCLUSIONS In-hospital complications and mortality for RC remain unchanged from 2001 to 2008. While high-volume hospitals continue to have better outcomes, there is little evidence that postoperative mortality and morbidity are improving among low-, medium- and high-volume hospitals. Increased attention is needed to identify the modifiable aspects of postoperative care to improve in-hospital outcomes and safety for patients undergoing RC.
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Affiliation(s)
- Simon P Kim
- Department of Urology, Mayo Clinic, Rochester, MN 55905, USA
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Trinh QD, Sun M, Sammon J, Bianchi M, Sukumar S, Ghani KR, Jeong W, Dabaja A, Shariat SF, Perrotte P, Agarwal PK, Rogers CG, Peabody JO, Menon M, Karakiewicz PI. Disparities in access to care at high-volume institutions for uro-oncologic procedures. Cancer 2012; 118:4421-6. [DOI: 10.1002/cncr.27440] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 11/02/2011] [Accepted: 12/13/2011] [Indexed: 11/09/2022]
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Lee CT, Mei M, Ashley J, Breslow G, O'Donnell M, Gilbert S, Lemmy S, Saxton C, Sagalowsky A, Sansgiry S, Latini DM. Patient Resources Available to Bladder Cancer Patients: A Pilot Study of Healthcare Providers. Urology 2012; 79:172-7. [DOI: 10.1016/j.urology.2011.07.1405] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Revised: 07/18/2011] [Accepted: 07/22/2011] [Indexed: 11/25/2022]
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Allareddy V, Ward MM, Wehby GL, Konety BR. The connection between selective referrals for radical cystectomy and radical prostatectomy and volume-outcome effects: an instrumental variables analysis. Am J Med Qual 2011; 27:434-40. [PMID: 22205768 DOI: 10.1177/1062860611423728] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study delineates the roles of "selective referrals" and "practice makes perfect" in the hospital procedure volume and in-hospital mortality association for radical cystectomy and radical prostatectomy. This is a retrospective analysis of the Nationwide Inpatient Sample (years 2000-2004). All hospitalizations with primary procedure codes for radical cystectomy and radical prostatectomy were selected. The association between hospital procedure volume and in-hospital mortality was examined using generalized estimating equations and by instrumental variables approaches. There was an inverse association between hospital procedure volume and in-hospital mortality for radical cystectomy (odds ratio = 0.57; 95% confidence interval = 0.38-0.87; P < .05). Results from the 2-stages least squares regression approach suggested that receiving treatment in high-volume hospitals decreased the probability of in-hospital mortality by 0.02 points, compared with 0.01 points using the ordinary least squares regression approach. Outcomes following radical cystectomy appear to be driven by "practice makes perfect."
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Jacobs BL, Montgomery JS, Zhang Y, Skolarus TA, Weizer AZ, Hollenbeck BK. Disparities in bladder cancer. Urol Oncol 2011; 30:81-8. [PMID: 22127016 DOI: 10.1016/j.urolonc.2011.08.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 08/19/2011] [Accepted: 08/22/2011] [Indexed: 12/24/2022]
Abstract
Among men, bladder cancer is the fourth most common malignancy and ninth leading cause of death from cancer in the United States. In contrast, it is the 11th most common malignancy and 12th leading cause of death from cancer among women. The successful management of bladder cancer largely depends on its timely diagnosis and treatment. Unfortunately, barriers disproportionately delay detection and treatment for individuals with social, economic, and community disadvantages. This imbalance creates health disparities (i.e., differences in health outcomes that are closely linked to these disadvantages), which negatively affect vulnerable populations, such as racial and ethnic minority groups, those from lower socioeconomic classes, and the uninsured. To obtain a better understanding of this issue, we review the current state of bladder cancer disparities research.
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Affiliation(s)
- Bruce L Jacobs
- Department of Urology, Divisions of Oncology, University of Michigan, Ann Arbor, MI 48109, USA.
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Abstract
A systematic review of the literature on perioperative morbidity (POM) was done using Medline software with a combination of keywords like mortality, morbidity, and complications. In addition, we review the analysis of our hospital data of 261 Radical cystectomies (RCs) performed in an 11-year period and our latest clinical pathway for RC. Age range in our series was 50 to 81 years with 240 males and 21 females. RCs were performed by intraperitoneal method in 172 patients and by our extraperitoneal (EP) method in 89 patients. Urinary diversion was ileal conduit in 159 patients and neobladder in 102 patients. Blood loss ranged between 500 and 1500 ccs. Postoperative mortality occurred in eight patients (3%). Among the other early post-op complications, major urinary leak was seen in nine and minor in 11, requiring PCN in five patients and reoperation in four patients. Bowel leak or obstruction was seen in six and four patients, respectively, requiring reoperation in six patients. EP RC in our series showed some benefit in reduction of POM. The mortality of RC has declined but the POM still ranges from 11 to 68%, as reported in 23 series (1999-2008) comprising of 14 076 patients. Various risk factors leading to POM and some corrective measures are discussed in detail. However, most of these series are retrospective and lack standard complication reporting, which limits the comparison of outcomes. Various modifications in open surgical technique and laparoscopic and Robotic approaches are aimed at reduction in mortality and POM of RC.
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Affiliation(s)
- Jagdeesh N Kulkarni
- Department of Urology, Bombay Hospital Institute of Medical Sciences, Mumbai, India
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Abstract
BACKGROUND There were numerous efforts in the United States during the previous decade to concentrate selected surgical procedures in high-volume hospitals. It remains unknown whether referral patterns for high-risk surgery have changed as a result and how operative mortality has been affected. METHODS We used national Medicare data to study patients undergoing one of eight different cancer and cardiovascular operations from 1999 through 2008. For each procedure, we examined trends in hospital volume and market concentration, defined as the proportion of Medicare patients undergoing surgery in the top decile of hospitals by volume per year. We used regression-based techniques to assess the effects of volume and market concentration on mortality over time, adjusting for case mix. RESULTS Median hospital volumes of four cancer resections (lung, esophagus, pancreas, and bladder) and of repair of abdominal aortic aneurysm (AAA) rose substantially. Depending on the procedure, higher hospital volumes were attributable to an increasing number of cases nationwide, an increasing market concentration, or both. Hospital volumes rose slightly for aortic-valve replacement but fell for coronary-artery bypass grafting and carotid endarterectomy. Operative mortality declined for all eight procedures, ranging from a relative decline of 8% for carotid endarterectomy (1.3% mortality in 1999 and 1.2% in 2008) to 36% for AAA repair (4.4% in 1999 and 2.8% in 2008). Higher hospital volumes explained a large portion of the decline in mortality for pancreatectomy (67% of the decline), cystectomy (37%), and esophagectomy (32%), but not for the other procedures. CONCLUSIONS Operative mortality with high-risk surgery fell substantially during the previous decade. Although increased market concentration and hospital volume have contributed to declining mortality with some high-risk cancer operations, declines in mortality with other procedures are largely attributable to other factors. (Funded by the National Institute on Aging.).
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Affiliation(s)
- Jonathan F Finks
- Center for Healthcare Outcomes and Policy and the Section of General Surgery, Department of Surgery, University of Michigan, Ann Arbor, USA.
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