Hospitalisation and readmission costs after radical cystectomy in a nationally representative sample: does urinary reconstruction matter?

Comparing direct medical care costs of patients with bladder cancer who received an ileal conduit vs. neobladder in the year following cystectomy

PURPOSE

Bladder cancer is 1 of the most costly cancers, however there is limited research on medical care costs by type of urinary diversion. The objective of our study was to compare medical care costs of the 2 most common urinary diversions in the year following radical cystectomy.

METHODS

The Bladder Cancer Quality of Life Study included patients diagnosed with bladder cancer who underwent radical cystectomy and received an ileal conduit (IC, n = 821) or neobladder (NB, n = 181) in 3 integrated health systems. Medical care costs per patient per quarter were estimated for the year following cystectomy. Multivariable generalized linear models with a gamma distribution and log link were used to estimate mean monthly medical care costs (2022 USD$), adjusted for patient demographic and clinical characteristics.

RESULTS

In multivariable analysis, mean monthly costs per quarter were not significantly different between IC and NB patients in the 12 months following cystectomy. Overall, mean monthly costs in IC and NB patients were highest during the first quarter and decreased thereafter. Factors associated with higher mean costs across all quarters included presence of any complications and advanced tumor stage at cystectomy (all P < 0.001).

CONCLUSION

Our study addresses an important knowledge gap by quantifying the medical costs of bladder cancer patients by urinary diversion type and comparing costs of different treatment approaches. Studies that assess patient-reported outcomes and out-of-pocket costs, by urinary diversion type, are warranted to inform treatment decision-making and cost conversations.

Comparison of different urinary diversions after radical cystectomy in Iran: Assessment of health-related quality of life and financial burden in a Middle Eastern country

OBJECTIVES

To compare health-related quality of life (HRQOL), cost-effectiveness, and survival among different types of urinary diversion (UD) utilized after radical cystectomy (RC) for bladder cancer with consideration of the unique economic and cultural context in Iran.

PATIENTS AND METHODS

In this retrospective study, we examined all patients who underwent RC from May 2017 to December 2021 at two specialized centers by the same surgical team. Patients were grouped based on their UD. Post-surgical HRQOL (obtained from EORTC QLQ-C30 and QLQBLM-30), financial burden, surgical complications, and survival were compared. Kruskal-Wallis H test, One-way ANOVA, and Kaplan-Meier analyses were utilized; accordingly.

RESULTS AND LIMITATIONS

In total 187 patients were identified-orthotopic neobladder (ONB) (N = 75), ileal conduit (IC) (N = 57), and cutaneous ureterostomy (CU) (N = 55)-and were followed for a median 17.5 (Interquartile range: 7.0, 47.0) months. ONB was associated with better HRQOL, especially in the domains addressing physical, role and social functioning (p = 0.003, 0.011, 0.045) as well as better body image (p < 0.001), lower short- and long-term financial burden (p = 0.034 and <0.001, respectively), marginally lower complication rate (p = 0.049), and better 5-year overall survival (p < 0.001), in comparison with other UDs. Patients who underwent CU had the lowest HRQOL and worst survival. Limitations were retrospective design and possibility of selection bias.

CONCLUSIONS

In this first study that assesses a Middle Eastern collective; ONB seems to be the UD of choice with regard to HRQOL and economic burden when there is no contraindication.

Cost-Effectiveness and Economic Impact of Bladder Cancer Management: An Updated Review of the Literature

Bladder cancer remains one of the costliest malignancies to manage. We provide a narrative review of literature assessing the economic burden and cost-effectiveness of bladder cancer treatment and surveillance. This is an update to a previous review and focuses on data published within the past 10 years. We queried PubMed and MEDLINE for all bladder cancer cost-related literature between 2013 and 2023. After initial screening, 117 abstracts were identified, 50 of which were selected for inclusion in our review. Management of disease recurrence and treatment complications contributes significantly to the high cost of care. High-value interventions are therefore treatments that improve recurrence-free and overall survival at minimal additional toxicity. De-escalation of surveillance and diagnostic interventions may help to reduce costs in this space without compromising oncologic control. The persistently rising cost of novel cancer drugs undermines their value when only modest gains in efficacy are observed. Multiple cost-effectiveness analyses have been published and are useful for contextualizing the cost, efficacy, and impact on quality of life that interventions have in this population. Further cost-effectiveness work is needed to better characterize the impact that treatment costs have on patients' financial well-being and quality of life.

Cost of Care in Open Cystectomy Patients Across Time and Space: Does it matter?

BACKGROUND

Many variables may affect the cost of open radical cystectomy (RC) care, including surgical approach, diversion type, patient comorbidities, and postoperative complications.

OBJECTIVE

To determine factors associated with changes in cost of care following open radical cystectomy (ORC) for bladder cancer using the National Inpatient Sample (NIS).

METHODS

Patients in the NIS with a diagnosis of bladder cancer who underwent ORC with ileal conduit from 2012-2017 using ICD-9-CM and ICD-10-CM codes were identified. Baseline demographics including age, race, region, postoperative complications, and length of stay were obtained. Univariable and multivariable logistic regression were used to identify factors associated with cost variation including demographics, clinical characteristics, surgical factors, and discharge quarter (Q1-Q4).

RESULTS

5,189 patients were included in the analysis, with 4,379 at urban teaching hospitals. On multivariable regression analysis, female sex [$1,734 ($1,024-2,444) p < 0.001)], a greater Elixhauser comorbidity score [$93 ($62-124), p < 0.001], presence of any inpatient complication [$1,531 ($894-2,168), p < 0.001], and greater length of stay [$1,665 ($1,536-1,793), p < 0.001] were associated with a greater cost of hospitalization. Discharge in Q3 (July to September) relative to Q2 (April to June) was associated with a higher cost [$1,113 ($292-1,933), p = 0.008. Trends were similar at urban non-teaching and rural hospitals, except discharge quarter was not associated with a significant change in cost.

CONCLUSIONS

Significant differences in cost of ORC with ileal conduit exist with respect to patient sex, medical comorbidities, and discharge timing. These differences may relate to greater disease burden in female patients, patient complexity, and variation in postoperative care in academic programs.

Intracorporeal Versus Extracorporeal Neobladder After Robot-assisted Radical Cystectomy: Results From the International Robotic Cystectomy Consortium

OBJECTIVE

To compare perioperative and oncologic outcomes of intracorporeal (ICNB) and extracorporeal neobladder (ECNB) following robot assisted radical cystectomy (RARC) from a multi-institutional, prospectively maintained database, the International Robotic Cystectomy Consortium (IRCC).

METHODS

A retrospective review of IRCC database between 2003 and 2020 (3742 patients from 33 institutions across 14 countries) was performed (I-79606). The Cochran-Armitage trend test was used to assess utilization of ICNB over time. Multivariate logistic regression models were fit to evaluate variables associated with receiving ICNB, overall complications, high-grade complications, and readmissions after RARC. Kaplan Meier curves were used to depict recurrence-free, disease-specific, and overall survival.

RESULTS

Four hundred eleven patients received neobladder, 64% underwent ICNB. ICNB utilization increased significantly over time (P <.01). Patients who received ICNB were readmitted and received neoadjuvant chemotherapy more frequently (36% vs 24%, P = .03, 35% vs 8%, P <.01, respectively). ICNB was associated with older age (OR 1.04, 95% CI 1.01-1.07, P = .001), receipt of neoadjuvant chemotherapy (OR 4.63, 95% CI 2.34-9.18, P <.01), and more recent RARC era (2016-2020) (OR 12.6, 95% CI 5.6-28.4, P <.01). On multivariate analysis, ICNB (OR 5.43, 95% CI 2.34-12.58, P <.01), positive surgical margin (OR 4.88, 95% CI 1.29-18.42, P = .019), longer operative times (OR 1.26, 95% CI 1.00-1.58, P = .048), and institutional annual RARC volume (OR 1.09, 95% CI 1.05-1.12, P <.01) were associated with readmissions.

CONCLUSION

Utilization of ICNB increased significantly over time. Patients who underwent RARC and ICNB had shorter hospital stays and fewer 30-d reoperations but were readmitted more frequently compared to those who underwent ECNB.

Clinical indications for necessary and discretionary hospital readmissions after radical cystectomy

BACKGROUND

To assess predictors, indicators and medical necessity of readmissions after neoadjuvant chemotherapy and radical cystectomy in order to identify opportunities for reducing readmission rates.

METHODS

Records for patients treated with cisplatin-based neoadjuvant chemotherapy followed by radical cystectomy between 2007 and 2017 were reviewed for 90-day complications and readmission. Readmissions were classified as necessary vs. discretionary based on independent clinician review. The association between postoperative complications and necessary or discretionary readmission were examined with adjusted regression models.

RESULTS

Among a total of 250 patients, 76 patients (30.4%) were readmitted within 90 days of surgery (19 discretionary and 57 necessary). Age, insurance coverage, and comorbidity were similar between readmitted and non-readmitted patients. Readmission was more likely after neobladder than ileal conduit (39% vs. 23%, P = 0.02). Major (grade ≥ 3) complications within 90-day of surgery including index admission and post-discharge period were significantly more common among re-admitted patients compared to patients who were not readmitted (40% in necessary, 21% in discretionary, 3% in none, P < 0.001). Median length of stay on readmission was twice as long in necessary cases compared to discretionary cases (5 vs. 2.5 days, P < 0.001). Gastrointestinal and infectious complications were associated with discretionary readmission in adjusted analyses, while infectious, renal/genitourinary and thromboembolic complications were associated with necessary readmission.

CONCLUSIONS

Twenty-five percent of readmissions were categorized as discretionary and were driven primarily by low-grade gastrointestinal complications, marginal oral intake and failure to thrive, suggesting that better coordinated post-discharge supportive care could help avoid a substantial proportion of readmissions.

Impact of hospital and surgeon volumes on short-term and long-term outcomes of radical cystectomy

PURPOSE OF REVIEW

There is heightened awareness and trends towards centralizing high-risk, complex surgeries such as radical cystectomy to minimize complications and improve survival. However, after nearly a decade of mandated and/or passive centralization of care, debate regarding its benefits and harms continues.

RECENT FINDINGS

During the past decade, mandated and passive centralization has led to an increase in radical cystectomies performed in high-volume hospitals (HVHs) and, perhaps by high-volume surgeons (HVS), in addition to efforts to increase the uptake of multidisciplinary strategies in the management of radical cystectomy patients. Consequently, 30 and 90-day mortality rates and overall survival have improved, and major complications and transfusion rates have decreased. Factors impacting surgical quality, such as negative surgical margin(s), pelvic lymphadenectomy and/or lymph node yield rates have increased. However, current studies have not demonstrated a coadditive impact of centralization on oncological outcomes (i.e. cancer-specific and recurrence-free survival). The benefits of centralization on oncologic survival of radical cystectomy remain unclear given the varied definitions of HVHs and HVSs across studies. In fact, centralization of radical cystectomy could lead to an increase in patient load in HVHs and for HVSs, thereby leading to longer surgery waiting times, a factor that is important in the management of muscle-invasive bladder cancer.

SUMMARY

The benefits of centralization of radical cystectomy with multidisciplinary management are shown increasingly and convincingly. More studies are necessary to prospectively test the benefits, risks and harms of centralization.

Review of the evidence for robotic-assisted robotic cystectomy and intra-corporeal urinary diversion in bladder cancer

Radical cystectomy, pelvic lymph node dissection and urinary diversion is the gold-standard treatment for muscle-invasive bladder cancer. The surgery is both complex and highly morbid. Robotic cystectomy is now in its 16th year with established techniques and sufficient research maturity to enable comparison with its open counterpart. The present review focuses on the current evidence for robotic cystectomy and assesses various metrics including oncological, perioperative, functional, surgeon-specific and cost outcomes. The review also encapsulates the current evidence for intra-corporeal urinary diversion and its current status in the cystectomy arena.

Association of super-extended lymphadenectomy at radical cystectomy with perioperative complications and re-hospitalization

Purpose

We performed a retrospective analysis of patients treated with radical cystectomy and lymphadenectomy (LAD) for bladder cancer to assess the differential association of the extent of LAD with perioperative complications and re-hospitalization.

Materials and methods

LAD templates were defined as limited (lLAD = external, internal iliac and obturator), extended (eLAD = up to crossing of ureter and presacral lymph nodes), and super-extended (sLAD = up to the inferior mesenteric artery). Logistic regression models investigated the association of LAD templates with intraoperative, 30- and 30–90-day postoperative complications, as well as re-hospitalizations within 30 and 30–90 days.

Results

A total of 284 patients were available for analysis. sLAD led to a higher lymph-node yield (median 39 vs 13 for lLAD and 31 for eLAD, p < 0.05) and N2/N3 status compared to lLAD and eLAD (p = 0.04). sLAD was associated with a blood loss of > 500 ml (OR 1.3, 95% CI 1.08–1.49, p = 0.003) but not with intraoperative transfusion, operation time, or length of hospital stay (p > 0.05). Overall, 11 (4%) patients were readmitted within 30 days and 50 (17.6%) within 30–90 days. The 30- and 30–90-day mortality rates were 2.8% and 1.4%, respectively. On logistic regression, LAD template was not associated with postoperative complications or re-hospitalization rates.

Conclusions

sLAD leads to higher lymph-node yield and N2/N3 rate but not to higher complication rate compared to lLAD and eLAD. With the advent of novel adjuvant systemic therapies, precise nodal staging will have a crucial role in patients counseling and clinical decision making.

Electronic supplementary material

The online version of this article (10.1007/s00345-019-02769-9) contains supplementary material, which is available to authorized users.