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Surgeon and Hospital Variation in the Costs of Radical Cystectomy for Bladder Cancer in the United States
Alexander P. Cole, MD1, Jeffrey J. Leow, MBBS, MPH2, Steven L. Chang, MD, MS1, Quoc-Dien Trinh, MD1.
1Harvard Medical School, Brigham and Womens Hospital, Boston, MA, USA, 2Tan Tock Seng Hospital, Singapore, Singapore.

Introduction: On a per-patient basis, bladder cancer (BCa) is the most expensive cancer, requiring ongoing, sophisticated treatment and surveillance modalities. Of these, radical cystectomy (RC) is the most involved, with potential for serious complications, lengthy hospitalizations and costly readmissions. Though there is known variation in outcomes and practices with RC, there is no national-level data on individual surgeon and hospital impact on costs. Given this, we designed a study to assess surgeon- and hospital-level variation and predictors of 90-day hospital costs after RC.
Materials and Methods: We analyzed data from Premier Hospital Database (Premier, Inc., Charlotte, NC), a nationally representative all-payer dataset capturing over 45 million hospital inpatient discharges, representing approximately 20% of all hospitalizations at over 600 hospitals in the US. We defined a weighted cohort of 11,255 men and women who had a radical cystectomy performed by 292 unique surgeons at 144 different hospitals from 2003-2013. Using direct line-item costs, we extracted total 90-day hospital costs (2014 USD). In addition, we examined patient, hospital, and surgeon characteristics and predictors of high and low costs.
Results: The mean 90-day direct hospital cost per RC was $32,261 (95% CI $31220 - $33,302). The least costly decile of surgeons (<$16,278/RC) performed RC for an average cost of $13,654 (95% CI: $13,191 to $14,116). The most costly decile of surgeons (>$51,285/RC) performed RC for an average cost of $82,642 (95% CI: $76,541 to $88,744). Patient, hospital and surgical characteristics explained only a small amount of total variance in costs (4.9%, 2.1%, 0.6% respectively). In contrast, the presence of a 90-day major complication and a prolonged LOS explained 18.1% and 18.2% of variability in costs (Table 1). Comorbid patients were likelier to incur costs above the 90th percentile (Charlson score 1: OR: 1.57, p=0.03; Charlson score ≥2: OR: 3.45, p<0.001), as were patients in the Northeast (OR 2.53, 95% CI 1.2-5.3, p0.01). Compared to the open RC, the laparoscopic approach was more than twice as likely to incur high costs (OR 2.83, 95% CI: 1.52 to 5.27, p=0.0004). The robot-assisted approach was less likely to incur high costs, however this association did not reach statistical significance (OR: 0.69, p=0.14).
Conclusions: This study provides insight into the determinants of RC costs. In contrast to other surgeries were surgeon and hospital level factors have been shown to strongly influence cost, in RC patient and disease related factors predominate. While the scale of surgeon and hospital-level cost variation is significant, the majority of variability is explained by complications, comorbidity and prolonged length of stay—not surgeon identity or characteristics. These findings highlight the importance of patient selection and preoperative risk assessment for this complex and morbid procedure.


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