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Causes, Timing, Hospital Costs and Perioperative Outcomes of Index vs Nonindex Hospital Readmissions after Radical Cystectomy: Implications for Regionalization of Care.

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.

SUBMITTER: Chappidi MR

PROVIDER: S-EPMC5241219 | biostudies-literature | 2017 Feb

REPOSITORIES: biostudies-literature

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Causes, Timing, Hospital Costs and Perioperative Outcomes of Index vs Nonindex Hospital Readmissions after Radical Cystectomy: Implications for Regionalization of Care.

Chappidi Meera R MR Kates Max M Stimson C J CJ Johnson Michael H MH Pierorazio Phillip M PM Bivalacqua Trinity J TJ

The Journal of urology 20160818 2

<h4>Purpose</h4>We compared the timing, causes, hospital costs and perioperative outcomes of index vs nonindex hospital readmissions after radical cystectomy.<h4>Materials and methods</h4>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 ...[more]

PMID: 27545575

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Project description:ObjectivesTo evaluate primarily the relationship between postoperative complications and hospital costs, and secondarily the relationship between postoperative complications and mortality, following radical cystectomy.MethodsPostoperative complications were retrospectively examined for 147 patients undergoing radical cystectomy at a university hospital between January 2012 and July 2021. Complications were defined and graded using the Clavien-Dindo classification system. In-hospital cost was calculated using an activity-based costing methodology. Regression modelling was used to investigate the relationships among a priori selected perioperative variables, complications, and costs. The effect of complications on postoperative mortality was ascertained using time-dependent coefficients in a Cox proportional hazards regression model.Results135 (92%) patients experienced one or more postoperative complications. The medians of hospital cost for patients who experienced no complications and those who experienced complications were $42,796.3 (29,222.9-53,532.5) and $81,050.1 (49,614.8-122,533.6) respectively, p < 0.001. Hospital costs were strongly associated with complication severity: Clavien-Dindo grade II complications increased costs by 45.2% (p < 0.001, 95% CI 19.1%-76.6%), and Clavien-Dindo grade III to V complications increased costs by 107.5% (p < 0.001, 95% CI 52.4%-181.8%). Each additional count of complication and increase in Clavien-Dindo complication grade increased the risk of mortality 1.28-fold (RR = 1.28, p = 0.006, 95% CI 1.08-1.53) and 2.50-fold (RR = 2.50, p = 0.012 95% CI 1.23-5.07) respectively.ConclusionsThese findings demonstrate a high prevalence of complications following cystectomy and significant associated increases in hospital costs and mortality. Postoperative complications are a key target for cost-containment strategies.Trial registrationTrial Registration: Australian New Zealand Clinical Trials Registry (ACTRN:12622000057785.

Project description:ImportanceEarlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days.ObjectiveTo compare the 1-year costs associated with trimodal therapy vs radical cystectomy, accounting for survival and intensity effects on total costs.Design, setting, and participantsThis population-based cohort study used the US Surveillance, Epidemiology, and End Results-Medicare database and included 2963 patients aged 66 to 85 years who had received a diagnosis of clinical stage T2 to T4a muscle-invasive bladder cancer from January 1, 2002, through December 31, 2011. The data analysis was performed from March 5, 2018, through December 4, 2018.Main outcomes and measuresTotal Medicare costs within 1 year of diagnosis following radical cystectomy vs trimodal therapy were compared using inverse probability of treatment-weighted propensity score models that included a 2-part estimator to account for intrinsic selection bias.ResultsOf 2963 participants, 1030 (34.8%) were women, 2591 (87.4%) were white, 129 (4.4%) were African American, and 98 (3.3%) were Hispanic. Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83 754 vs $68 692; median difference, $11 805; 95% CI, $7745-$15 864), 180 days ($187 162 vs $109 078; median difference, $62 370; 95% CI, $55 581-$69 160), and 365 days ($289 142 vs $148 757; median difference, $109 027; 95% CI, $98 692-$119 363), respectively. Outpatient care, radiology, medication expenses, and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On inverse probability of treatment-weighted adjusted analyses, patients undergoing trimodal therapy had $136 935 (95% CI, $122 131-$152 115) higher mean costs compared with radical cystectomy 1 year after diagnosis.Conclusions and relevanceCompared with radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. The differences in costs were largely attributed to medication and radiology expenses associated with trimodal therapy. Extrapolating cost figures resulted in a nationwide excess spending of $468 million for trimodal therapy compared with radical cystectomy for patients who received a diagnosis of bladder cancer in 2017.

Project description:ImportanceThe value to payers of robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) when compared with open radical cystectomy (ORC) for patients with bladder cancer is unclear.ObjectivesTo compare the cost-effectiveness of iRARC with that of ORC.Design, setting, and participantsThis economic evaluation used individual patient data from a randomized clinical trial at 9 surgical centers in the United Kingdom. Patients with nonmetastatic bladder cancer were recruited from March 20, 2017, to January 29, 2020. The analysis used a health service perspective and a 90-day time horizon, with supplementary analyses exploring patient benefits up to 1 year. Deterministic and probabilistic sensitivity analyses were undertaken. Data were analyzed from January 13, 2022, to March 10, 2023.InterventionsPatients were randomized to receive either iRARC (n = 169) or ORC (n = 169).Main outcomes and measuresCosts of surgery were calculated using surgery timings and equipment costs, with other hospital data based on counts of activity. Quality-adjusted life-years were calculated from European Quality of Life 5-Dimension 5-Level instrument responses. Prespecified subgroup analyses were undertaken based on patient characteristics and type of diversion.ResultsA total of 305 patients with available outcome data were included in the analysis, with a mean (SD) age of 68.3 (8.1) years, and of whom 241 (79.0%) were men. Robot-assisted radical cystectomy was associated with statistically significant reductions in admissions to intensive therapy (6.35% [95% CI, 0.42%-12.28%]), and readmissions to hospital (14.56% [95% CI, 5.00%-24.11%]), but increases in theater time (31.35 [95% CI, 13.67-49.02] minutes). The additional cost of iRARC per patient was £1124 (95% CI, -£576 to £2824 [US $1622 (95% CI, -$831 to $4075)]) with an associated gain in quality-adjusted life-years of 0.01124 (95% CI, 0.00391-0.01857). The incremental cost-effectiveness ratio was £100 008 (US $144 312) per quality-adjusted life-year gained. Robot-assisted radical cystectomy had a much higher probability of being cost-effective for subgroups defined by age, tumor stage, and performance status.Conclusions and relevanceIn this economic evaluation of surgery for patients with bladder cancer, iRARC reduced short-term morbidity and some associated costs. While the resulting cost-effectiveness ratio was in excess of thresholds used by many publicly funded health systems, patient subgroups were identified for which iRARC had a high probability of being cost-effective.Trial registrationClinicalTrials.gov Identifier: NCT03049410.

Project description:ImportanceMortality rates resulting from bladder cancer have remained unchanged for more than 30 years. The surgical community has put hope in robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) in an effort to improve surgical outcomes and bladder cancer survival without strong supporting evidence.ObjectiveTo evaluate perioperative, safety, and survival outcome differences between RARC with ICUD and open radical cystectomy (ORC).Design, setting, and participantsThis nationwide population-based cohort study used data from the Swedish National Register of Urinary Bladder Cancer and population-based Cause of Death Register, which includes clinical information on tumor characteristics, treatment, and survival and covers approximately 97% of patients with urinary bladder cancer in Sweden. All patients who underwent radical cystectomy for bladder cancer in any hospital between January 2011 and December 2018 were included. Follow-up data were collected until December 2019. Data analysis was conducted from June to December 2020.ExposuresRARC or ORC.Main outcomes and measuresThe main outcomes were all-cause and cancer-specific mortality between RARC and ORC, compared using propensity score matching. Secondary outcomes were differences in perioperative outcomes after the different surgical approaches.ResultsThroughout the observation period, 889 patients underwent RARC and 2280 patients underwent ORC at 24 Swedish hospitals. The median (IQR) age was 71 (66-76) years and 2386 patients (75.3%) were men. After a median (IQR) follow-up of 47 (28-71) months, the 5-year cancer-specific mortality rates were 30.2% (variance, 1.59) for ORC and 27.6% (variance, 3.12) for RARC, and the overall survival rates were 57.7% (variance, 2.46) for ORC and 61.4% (variance, 5.11) for RARC. In the propensity score-matched analysis, RARC was associated with a lower all-cause mortality (hazard ratio, 0.71; 95% CI, 0.56-0.89; P = .004). Compared with ORC, RARC was associated with a lower estimated blood loss (median [IQR] 150 [100-300] mL vs 700 [400-1300] mL; P < .001), intraoperative transfusion rate (odds ratio [OR], 0.05; 95% CI, 0.03-0.08; P < .001), and shorter length of stay (median [IQR], 9 [6-13] days vs 13 [10-17] days; P < .001), and with a higher lymph node yield (median [IQR], 20 [15-27] lymph nodes vs 14 [8-24] lymph nodes; P < .001) and 90-day rehospitalization rate (OR, 1.28; 95% CI, 1.02-1.60; P = .03). The RARC group, compared with the ORC group had lower risk of Clavien-Dindo grade III or higher complications (OR, 0.62; 95% CI, 0.43-0.87; P = .009).Conclusions and relevanceThese findings suggest that compared with ORC, RARC with ICUD was associated with a lower overall mortality rate, fewer high-grade complications, and more favorable perioperative outcomes.

Project description:ImportanceUse of robotic surgery has increased in urological practice over the last decade. However, the use, outcomes, and costs of robotic nephrectomy are unknown.ObjectivesTo examine the trend in use of robotic-assisted operations for radical nephrectomy in the United States and to compare the perioperative outcomes and costs with laparoscopic radical nephrectomy.Design, setting, and participantsThis retrospective cohort study used the Premier Healthcare database to evaluate outcomes of patients who had undergone robotic-assisted or laparoscopic radical nephrectomy for renal mass at 416 US hospitals between January 2003 and September 2015. Multivariable regression modeling was used to assess outcomes.ExposuresRobotic-assisted vs laparoscopic radical nephrectomy.Main outcomes and measuresThe primary outcome of the study was the trend in use of robotic-assisted radical nephrectomy. The secondary outcomes were perioperative complications, based on the Clavien classification system, and defined as any complication (Clavien grades 1-5) or major complications (Clavien grades 3-5, for which grade 5 results in death); resource use (operating time, blood transfusion, length of hospital stay); and direct hospital cost.ResultsAmong 23 753 patients included in the study (mean age, 61.4 years; men, 13 792 [58.1%]), 18 573 underwent laparoscopic radical nephrectomy and 5180 underwent robotic-assisted radical nephrectomy. Use of robotic-assisted surgery increased from 1.5% (39 of 2676 radical nephrectomy procedures in 2003) to 27.0% (862 of 3194 radical nephrectomy procedures) in 2015 (P for trend <.001). In the weighted-adjusted analysis, there were no significant differences between robotic-assisted and laparoscopic radical nephrectomy in the incidence of any (Clavien grades 1-5) postoperative complications (adjusted rates, 22.2% vs 23.4%, difference, -1.2%; 95% CI, -5.4 to 3.0%) or major (Clavien grades 3-5) complications (adjusted rates, 3.5% vs 3.8%, difference, -0.3%; 95% CI, -1.0% to 0.5%). The rate of prolonged operating time (>4 hours) for patients undergoing the robotic-assisted procedure was higher than for patients receiving the laparoscopic procedure in the adjusted analysis (46.3% vs 25.8%; risk difference, 20.5%; 95% CI, 14.2% to 26.8%). Robotic-assisted radical nephrectomy was associated with higher mean 90-day direct hospital costs ($19 530 vs $16 851; difference, $2678; 95% CI, $838 to $4519), mainly accounted for operating room ($7217 vs $5378; difference, $1839; 95% CI, $1050 to $2628) and supply costs ($4876 vs $3891; difference, $985; 95% CI, $473 to $1498).Conclusions and relevanceAmong patients undergoing radical nephrectomy for renal mass between 2003 and 2015, the use of robotic-assisted surgery increased substantially. The use of robotic-assistance was not associated with increased risk of any or major complications but was associated with prolonged operating time and higher hospital costs compared with laparoscopic surgery.

Project description:BACKGROUND AND OBJECTIVES:The use of patient-controlled epidural analgesia after various operations has been associated with an early return of bowel function, thus decreasing patients' length of stay (LOS). The primary aim of this study was to compare LOS after radical cystectomy between patients who received epidural analgesia versus those who received intravenous patient-controlled analgesia. Our secondary analysis included the assessment of other metrics such as total opioid requirements, pain scores, return of bowel function, and complication rates between the 2 groups. METHODS:We conducted a retrospective review using the electronic medical records of 308 patients who underwent radical cystectomies at Memorial Sloan Kettering between 2006 and 2011. We aimed to understand if epidural analgesia was associated with a reduced LOS compared with patient-controlled intravenous opioid analgesia. We also aimed to identify performance improvements as a function of epidural analgesia status using various metrics such as pain management, bowel function return, and complication rates. We used both univariate and multivariate analyses to identify if epidural analgesia was associated with meaningful differences in the aforementioned metrics. RESULTS:Median age at radical cystectomy, body mass index, sex, American Society of Anesthesiologists score, and T stage were similar for both groups. For our primary objective of LOS, we found no significant difference between the 2 cohorts (8 vs 7 days, P = 0.2). Analysis of our secondary outcome measures revealed that epidural analgesia use was associated with less total opioid requirement for the first 3 postoperative days (PODs) (P = 0.0001). In addition, epidural analgesia was found to be associated with improved postoperative pain scores compared with intravenous patient-controlled analgesia on PODs 1 (P = 0.0001) and 2 (P = 0.004), and there was a slight improvement on POD 3, but this was not significant (P = 0.77). In contrast, we found no difference between pain management types with regard to proportion of patients who experienced a delay in gastrointestinal recovery, fluid bolus requirements within the first 3 perioperative days, rates of infection, pulmonary complications, and grade 3 or greater complications. CONCLUSIONS:We have demonstrated that, despite significant improvements in initial pain control and less opioid requirement with patient-controlled epidural analgesia, there was no association between analgesic approach and LOS, return of bowel function, or complications.

Dataset Information

Causes, Timing, Hospital Costs and Perioperative Outcomes of Index vs Nonindex Hospital Readmissions after Radical Cystectomy: Implications for Regionalization of Care.

Publications

Causes, Timing, Hospital Costs and Perioperative Outcomes of Index vs Nonindex Hospital Readmissions after Radical Cystectomy: Implications for Regionalization of Care.

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