Volume-based referral for cancer surgery: informing the debate.

PURPOSE: Mounting evidence suggests a relationship between hospital volume and outcomes after major cancer surgery; however, the absolute benefits of volume-based referral on a national basis are unclear. PATIENTS AND METHODS: Data from the Nationwide Inpatient Sample were used to measure the likelihood of operative mortality and a prolonged length of stay (LOS) after six cancer surgeries (prostatectomy, cystectomy, esophagectomy, pancreatectomy, pneumonectomy, and liver resection) between 1993 and 2003. Using sampling weights, the adjusted likelihood of the outcomes was used to calculate the number of lives saved (or prolonged LOS avoided) in the United States. RESULTS: The magnitude of the volume-operative mortality effect varied from an adjusted odds ratio (OR) of 1.3 (95% CI, 0.8 to 2.3) for cystectomy to 4.9 (95% CI, 2.4 to 10.1) for pancreatectomy. After accounting for varying rates of procedure utilization, the lives saved per 100 surgeries regionalized ranged from 0.2 (95% CI, 0.12 to 0.24 lives saved) for prostatectomy to 9.2 (95% CI, 6.7 to 10.4 lives saved) for pancreatectomy. The volume-prolonged LOS effect varied from an adjusted OR of 0.9 (95% CI, 0.5 to 1.6) for liver resection to 4.8 (95% CI, 3.5 to 6.7) for prostatectomy. After accounting for procedure use, the number of prolonged hospitalizations avoided ranged from -1.7 (95% CI, -11.3 to 3.6 hospitalizations) to 14.3 (95% CI, 12.9 to 15.4 hospitalizations) per 100 surgeries regionalized for liver resection and prostatectomy, respectively. CONCLUSION: For patients undergoing major cancer surgery, the benefits of volume-based referral depend on the interplay between procedure utilization, the magnitude of effect, and the outcome chosen.

Discharge practice patterns following cystectomy for bladder cancer: evidence for the shifting of the burden of care.

PURPOSE: Between 1985 and 2000 the incidence of bladder cancer in this country increased by 33%. Radical cystectomy is the primary treatment modality in patients with invasive disease. We characterized trends in cystectomy use and discharge practice patterns following cystectomy during a recent 13-year period. MATERIALS AND METHODS: The Nationwide Inpatient Sample comprises a 20% probability sample of hospital discharges in the United States each year. Patients who underwent cystectomy for bladder cancer from 1988 to 2000 were identified using International Classification of Disease, 9th Revision, Clinical Modification codes. Outcome variables included in-hospital mortality, length of stay and hospital discharge status. RESULTS: From 1988 to 2000 an estimated 119,491 patients underwent cystectomy for bladder cancer. Cystectomy rates decreased by 17% from 3.91/100,000 (1988 to 1990) to 3.25/100,000 (1997 to 2000), largely due to a decreasing number of partial cystectomies. In-hospital mortality decreased from 3.3% (1988 to 1990) to 2.5% (1997 to 2000) (p = 0.027). Similarly median length of stay decreased from 13 days (1988 to 1990) to 9 (1997 to 2000) (p <0.001). During the same period the percent of patients being discharged to subacute care facilities increased from 5.3% to 13.2% (p <0.001), as did the percent of patients requiring home health care services (24.1% to 38.7%, p <0.001). CONCLUSIONS: From 1988 to 2000 there was a decrease in the rate of cystectomies being performed for bladder cancer with a substantial decrease in partial cystectomy use. During this period short-term outcomes following cystectomy improved, while the use of subacute care facilities and home health services increased dramatically, underscoring a shift in the burden of care in this patient population.

The effects of adjusting for case mix on mortality and length of stay following radical cystectomy.

PURPOSE: Prior studies evaluating quality of care following radical cystectomy have been constrained by the use of retrospective reviews of single institutional series and limited ability to examine risk factors in a comprehensive manner. Characterization of these factors could enhance preoperative patient counseling and facilitate perioperative management, thereby improving the quality of patient care. MATERIALS AND METHODS: The National Surgical Quality Improvement Project is a prospective quality management initiative at 123 Veterans Affairs Medical Centers nationwide. The project collects preoperative clinical and intraoperative data, and outcomes on a wide variety of surgical procedures from multiple surgical disciplines. Since 1991, 2,538 radical cystectomies have been captured by the National Surgical Quality Improvement Project. Modeling using logistic regression was performed to identify preoperative risk factors associated with mortality and prolonged length of stay (greater than 90th percentile) after radical cystectomy. RESULTS: The 30 and 90-day mortality rates following cystectomy were 2.9% and 6.8%, respectively, and median hospital stay was 11 days (90th percentile 30). Robust preoperative factors associated with mortality and prolonged length of stay that uniformly increased risk were older patient age (OR 1.2 to 1.4), American Society of Anesthesiologists class 3 or greater (OR 1.5 to 3.3), dependent functional status (OR 1.7 to 2.0) and low serum albumin (OR 2.1 to 12.0). CONCLUSIONS: A defined set of preoperative risk factors is independently associated with greater mortality and hospital stay following radical cystectomy. The breadth of these factors suggests that complex case mix adjustment is mandatory when comparing outcomes. Implementation of novel processes directed toward minimizing patient risk has the potential to improve outcomes following cystectomy.

Laparoscopy for renal cell carcinoma: diffusion versus regionalization?

PURPOSE: Recognizing the emergence of laparoscopy as a standard of care for surgical treatment in many patients with organ confined renal cell carcinoma, we explored the diffusion of this technology by examining temporal trends in the nationwide use of laparoscopic total and partial nephrectomy in patients with renal cell carcinoma. MATERIALS AND METHODS: Data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample were abstracted for 1991 through 2003. International Classification of Diseases-Ninth Revision, Clinical Modification 9 codes were used to identify patients undergoing open and laparoscopic total and partial nephrectomy for renal cell carcinoma. Using hospital sampling weights we calculated annual incidence rates for open and laparoscopic nephrectomy, thereby estimating the diffusion of laparoscopy. Bivariate and multivariate analyses were used to identify patient and hospital characteristics associated with the more frequent use of laparoscopic techniques. RESULTS: Data on 63,812 patients were abstracted from the Nationwide Inpatient Sample, yielding a weighted national estimate of 323,979 who underwent laparoscopic (4.9%) or open (95.1%) nephrectomy (total or partial) for renal cell carcinoma between 1991 and 2003. Although it is still infrequent, the use of laparoscopy has increased steadily since 1998 with a utilization peak in 2003 of 1.7 laparoscopic nephrectomies per 100,000 American population, representing 16% of all total and partial nephrectomies for renal cell carcinoma in 2003. Treatment year, overall hospital nephrectomy volume and teaching hospital status were the most robust determinants of increased laparoscopic use (each p <0.001). CONCLUSIONS: Although its use has increased progressively in the last decade, the dissemination of laparoscopy for renal cell carcinoma has been generally slow and limited in scope. The next step in this body of work is to identify specific technical, educational and policy interventions that will influence the diffusion of this alternative standard of care.

The economics of benign prostatic hyperplasia and lower urinary tract symptoms in the United States.

Throughout the past several decades, interest in health care economics has increased as health care spending has soared--currently in excess of 1.5 trillion dollars and comprising approximately 16% of the nation's Gross Domestic Product. Benign prostatic hyperplasia (BPH) and its associated clinical manifestation of lower urinary tract symptoms is one of the most common medical conditions of aging men. BPH has been, and continues to be, a major factor in health care expenditures in the United States, costing up to 4 billion dollars each year. During the past 15 years, considerable changes in the patterns of care for BPH patients have evolved, resulting in similarly profound economic alterations. In this article, we examine contemporary trends in practice patterns for BPH and their associated impact on the cost of care for this condition.

Regionalization of percutaneous nephrolithotomy: evidence for the increasing burden of care on tertiary centers.

PURPOSE: The regionalization of procedures to specialized medical centers has been suggested as a means to improve the quality of care for select high risk procedures. Prior work has demonstrated the spontaneous regionalization of high risk procedures to tertiary centers. Similar concentration of complex, low risk procedures (e.g. percutaneous nephrolithotomy) to these centers would underscore the increasing burden of care placed on these hospitals. MATERIALS AND METHODS: We used the Nationwide Inpatient Sample to identify 12,948 patients who underwent percutaneous nephrolithotomy for stones between 1988 and 2002. Regionalization was measured based on the 6 structural hospital qualities of teaching status, urban location, bed capacity, hospital throughput (all diagnoses), annual percutaneous nephrolithotomy volume and for-profit status. Logistic regression was used to determine the propensity of percutaneous nephrolithotomy to concentrate to these medical centers. RESULTS: Compared to procedures performed between 1988 and 1990, patients were more likely to undergo percutaneous nephrolithotomy at teaching (OR 1.6, 95% CI 1.3-1.9), high percutaneous nephrolithotomy volume (OR 1.7, 95% CI 1.6-1.9), large bed capacity (OR 1.2, 95% CI 1.1-1.3) and high throughput hospitals (OR 1.4, 95% CI 1.3-1.4) in the years 2000 to 2002. CONCLUSIONS: Percutaneous nephrolithotomy, a technically complex but low risk procedure, has spontaneously regionalized to tertiary centers, suggesting the migration of complex surgical care to these centers. The impact of this increasing burden of care on tertiary centers is unclear but may be problematic in the current reimbursement environment.

Temporal trends in the use of percutaneous nephrolithotomy.

PURPOSE: Treatment for nephrolithiasis has evolved because of the dissemination of less invasive techniques, such as ureteroscopy and shock wave lithotripsy. We examined temporal trends in PCNL use and characterized the determinants of a prolonged LOS and in-hospital mortality to provide insight into the evolution of practice patterns for nephrolithiasis treatment. MATERIALS AND METHODS: We abstracted data on 12,948 patients undergoing percutaneous procedures for urinary calculi between 1988 and 2002 from the Nationwide Inpatient Sample using International Classification of Disease, 9th revision, Clinical Modification procedure and diagnostic codes. A weighted sample was used to estimate national PCNL use rates. Adjusted models were constructed to measure the association of hospital structure and patient demographics with mortality and a prolonged LOS (greater than 90th percentile). RESULTS: Annual PCNL use increased temporally during the study from 1.2/100,000 to 2.5/100,000 United States residents (p <0.0001). The in-hospital mortality rate was low at 0.2%, although a volume-outcome relationship was still evident (high and low volume 0.1% and 0.2%, respectively, p = 0.002). Treatment at hospitals with lower hospital PCNL volume and lower discharge volume (all diagnoses) was associated with an increasing likelihood of in-hospital mortality (each p <0.01). CONCLUSIONS: Despite the advent of less invasive techniques PCNL remains a popular means of managing stone disease. Although mortality was rare, it was significantly lower at high than at low volume hospitals. Low short-term mortality rates coupled with shorter LOS and high success rates may make PCNL increasingly palatable from a patient perspective and provide a potential basis for its increasing use.

Ureteroscopic laser papillotomy to treat papillary calcifications associated with chronic flank pain.

OBJECTIVES: To evaluate retrospectively the efficacy and durability of a novel approach using ureteroscopic laser papillotomy for the treatment of painful papillary calcifications. Chronic pain due to renal papillary calcifications has not been addressed by current techniques. METHODS: Ureteroscopic holmium laser lithotripsy and papillotomy were performed on patients with chronic pain and radiographically visible papillary calcifications without free collecting system calculi. The papillary urothelium overlying all cystic dilations and intraductal calcifications was vaporized. Treated patients answered a telephone survey to assess pain scores, duration of response, use of narcotics, and patient satisfaction. We reviewed the medical records to evaluate for procedure-related complications and serum creatinine measurements. RESULTS: Of 20 patients who underwent laser papillotomy and responded to the telephone survey, 7 had bilateral procedures, yielding 27 renal units available for analysis. "Much less pain" was reported after 85% of the procedures, with a durable improvement reported after 59% of the procedures, at a median follow-up of 14.5 months. Significant improvements in the median pain scores were seen at 1 month (1.0, P <0.001), 6 months (2.0, P <0.001), and 1 year (1.5, P <0.001) compared with a median preoperative pain score of 9.0. The mean serum creatinine was unchanged after the procedure. CONCLUSIONS: Ureteroscopic laser papillotomy appears to be an effective treatment option for the chronic pain associated with papillary calcifications. Laser papillotomy offers hope to patients who would otherwise have been denied an attempt at treatment because of a lack of free calculi within the collecting system.

Use of nephrectomy at select medical centers--a case of follow the crowd?

PURPOSE: Regionalization of high risk surgical procedures to larger, teaching hospitals has been suggested as a means to improve the quality of care. We determined the extent to which the regionalization of nephrectomy has occurred and describe the potential causes and implications of any observed regionalization. MATERIALS AND METHODS: The Nationwide Inpatient Sample comprises a 20% sampling of hospital discharges in the United States yearly. Patients undergoing nephrectomy for kidney cancer between 1988 and 2002 were identified using International Classification of Disease, Ninth Revision, Clinical Modification codes. Regionalization was assessed using 6 structural hospital measures, including teaching status, urban location, discharge volume, nephrectomy volume, bed capacity and for-profit status. Adjusted models were developed to identify the significance of temporal trends in each regionalization measure. RESULTS: We identified 66,621 patients undergoing nephrectomy during the study period. Compared to procedures performed between 1988 and 1990 the likelihood of undergoing nephrectomy at teaching, high nephrectomy volume and high throughput (all diagnoses) hospitals increased by 2.0 (CI 1.9 to 2.2), 7.4 (CI 7.1 to 7.7) and 2.2 times (CI 2.1 to 2.2), respectively, in 2000 to 2002. Conversely nephrectomy was less likely to be performed at for-profit hospitals (OR 0.5, CI 0.5 to 0.6). Patients were more likely to undergo partial nephrectomy at teaching, high volume, high throughput, urban hospitals. CONCLUSIONS: Regionalization of nephrectomy to teaching and high volume (nephrectomy and all diagnoses) hospitals is currently under way. Although the implications are not entirely clear, this study provides further evidence for the crowding of complex surgical procedures into these institutions.

Racial disparities in resource utilization for cystectomy.

OBJECTIVES: To examine the association of race with mortality and resource use among patients requiring cystectomy for bladder cancer, given the known racial differences with regard to bladder cancer incidence and survival. METHODS: Using the Nationwide Inpatient Sample (a nationally representative data set), 22,088 patients who underwent cystectomy for bladder cancer from 1988 to 2000 were identified using the International Classification of Disease, Ninth Revision, codes. The outcomes included in-hospital mortality, length of stay (LOS), and discharge status. Multivariable models were developed to perform risk-adjusted analyses and identify factors associated with these outcomes. RESULTS: The overall mortality rate after cystectomy was 2.9%. Unadjusted analyses revealed significant racial differences with respect to in-hospital mortality, LOS, and discharge disposition. Whites had a mortality rate of 2.8% compared with 4.2% for blacks and 3.9% for Hispanics (P = 0.006). Whites had a prolonged LOS 24.9% of the time compared with 38.2% for blacks and 24.6% for Hispanics (P < 0.001). The rate at which whites were discharged to subacute care facilities was 9.9% compared with 11.2% for black patients and 7.7% for Hispanics (P < 0.001). After adjusting for confounding factors, blacks were more likely to experience in-hospital mortality and prolonged LOS (odds ratios 1.66 and 2.10, respectively) compared with whites, although no significant differences were observed for Hispanics. No significant racial differences were noted for discharge status after risk adjustment. CONCLUSIONS: Black patients undergoing cystectomy for bladder cancer had greater mortality and greater LOS than did white patients. Additional study using detailed clinical data is necessary to identify the underlying causes of these differences.

National utilization trends of partial nephrectomy for renal cell carcinoma: a case of underutilization?

OBJECTIVES: Partial nephrectomy is perceived to be more technically demanding than radical nephrectomy; concurrently, the increasing incidence of small renal tumors has suggested a greater role for nephron-sparing techniques. From a quality-of-care perspective, the underuse of partial nephrectomy may represent suboptimal delivery of healthcare. METHODS: A total of 66,621 subjects undergoing radical and partial nephrectomy for kidney cancer between 1988 and 2002 were identified from the Nationwide Inpatient Sample, a nationally representative data set of hospital discharges. Adjusted models were developed to identify clinical factors and structural measures independently associated with the use of partial nephrectomy. RESULTS: Overall, 7.5% of patients treated underwent partial nephrectomy. The utilization rates for partial nephrectomy ranged from 0.21 cases per 100,000 U.S. residents in 1988 to 1.6 cases per 100,000 U.S. residents in 2002. The percentage of patients with renal cell carcinoma treated with partial nephrectomy has increased more than threefold during the study interval (3.7% in 1988 to 1990 compared with 12.3% in 2000 to 2002, P <0.0001 for trend). Patients treated at urban (odds ratio 1.1), teaching (odds ratio 1.3), and high nephrectomy volume (odds ratio 2.5) hospitals were more likely to undergo partial nephrectomy (each, P <0.01). CONCLUSIONS: The national use of partial nephrectomy has increased but remains lower than expected in certain settings, suggesting underuse or selective referral. Subjects with kidney cancer are more likely to be treated with partial nephrectomy at teaching institutions with high surgical volumes. The practice patterns of physicians at institutions more commonly using partial nephrectomy may reflect a better quality of care, although additional work in delineating the disparate utilization rates is warranted.

Complications following surgical intervention for stress urinary incontinence: a national perspective.

AIMS: Stress urinary incontinence (SUI) impacts many women. Treatment is primarily surgical. Post-operative morbidity considerably affects individuals and the health care system. Our objective is to describe complications following surgery for SUI and how they affect resource utilization. METHODS: Utilizing the Nationwide Inpatient Sample (a nationally representative dataset), 147,473 patients who underwent surgery for SUI from 1988 to 2000 were identified by ICD-9 codes. Comorbid conditions/complications were extracted using ICD-9 codes, including complication rates, length of stay (LOS), hospital charges, and discharge status. RESULTS: Overall complication rate was 13.0% (not equal to sum of complication sub-types, as each woman may have had = 1 complication), with 2.8% bleeding, 1.4% surgical injury, 4.3% urinary/renal, 4.4% infectious, 0.1% wound, 1.1% pulmonary insufficiency, 0.5% myocardial infarction, 0.2% thromboembolic. The "gold standard" surgical technique for SUI, the pubovaginal sling, had the lowest morbidity at 12.5%. Mean LOS increased with morbidity: from 2.9 to 4.1 to 6.1 days for those with 0, 1, and =2 complications respectively (P < 0.001). Similarly, inflation-adjusted hospital charges increased with morbidity: from 7,918 dollars to 9,828 dollars to 15,181 dollars for those with 0, 1, and =2 complications respectively (P < 0.001). The percentage of patients requiring post-discharge subacute or home care increased with morbidity: from 4.4% to 8.4% to 14.3% for those with 0, 1, and =2 complications (P < 0.001). CONCLUSIONS: A substantial percentage of women experience complications following surgery for SUI. Post-operative morbidity leads to dramatically increased resource utilization. Prospective studies are needed to identify pre-operative risk factors and intraoperative process measures to optimize the quality of care.

The regionalization of radical cystectomy to specific medical centers.

PURPOSE: Regionalization of high risk surgical procedures to larger teaching hospitals has been suggested as a means to improve the quality of care. We established a novel framework for characterizing regionalization, implemented it to determine the extent to which regionalization of radical cystectomy has occurred and delineated whether specific patient characteristics are associated with this phenomenon. MATERIALS AND METHODS: We used the Nationwide Inpatient Sample to identify 22,088 patients who underwent radical cystectomy for bladder cancer from 1988 to 2000. Regionalization was assessed using 5 structural hospital measures, including teaching status, urban location, discharge volume, cystectomy volume and bed capacity. Adjusted models were developed to identify the significance of temporal trends and assess the association of demographic factors with structural qualities. RESULTS: Compared with 1988 to 1990 subjects were more likely to undergo cystectomy at teaching hospitals (OR 1.8), high cystectomy volume hospitals (OR 1.2), high discharge volume hospitals (OR 1.7) and large bed capacity medical centers (OR 1.4) in 1998 to 2000. The concentration of cystectomy to urban medical centers during the study years was 90% to 92%. The proportion of subjects undergoing partial cystectomy decreased from 23.9% to 16.6% as regionalization occurred. Older subjects were less likely to be treated at these regionalized centers. CONCLUSIONS: Without broad legislation from health care payers radical cystectomy has increasingly regionalized to specific medical centers. Despite this regionalization disparities in its use exist among specific, vulnerable patients. Addressing this may facilitate further concentration of this procedure.

Quality of care: partial cystectomy for bladder cancer--a case of inappropriate use?

PURPOSE: Partial cystectomy is perceived to be a less morbid, less technically demanding procedure than radical cystectomy, although only select patients (approximately 6% to 10%) are appropriate candidates (solitary tumor in space/time, absence of carcinoma in situ). From a quality of care perspective, overuse of partial cystectomy may signify inappropriate delivery of health care. MATERIALS AND METHODS: Subjects who underwent extirpative treatment for bladder cancer between 1988 and 2000 were identified within the Surveillance, Epidemiology and End Results (SEER, 3,381) registry and the Nationwide Inpatient Sample (NIS, 22,088). Adjusted models were developed to identify clinical factors independently associated with the use of partial cystectomy for bladder cancer treatment within each sample. RESULTS: Among patients who underwent extirpative surgery for bladder cancer, 18% and 20% of those in SEER and NIS, respectively, underwent partial cystectomy. Significant decreases in use between early and later years were noted in both samples (SEER-22% to 13%, NIS-24% to 17%, both p <0.0001). Partial cystectomy was preferentially used in the elderly, those with stage I disease, females and black patients. Furthermore, partial cystectomy was more commonly provided in rural, nonteaching, low volume hospitals. CONCLUSIONS: Trends in national use of partial cystectomy are consistent between the NIS and SEER with 13% to 17% of patients currently being treated with partial in lieu of radical cystectomy. Partial cystectomy is disproportionately used in certain medical centers (nonteaching, rural, low volume) and patient populations (elderly, black, females, stage I disease) reflecting selective referral or overuse.

Impact of surgical volume on mortality and length of stay after nephrectomy.

OBJECTIVES: To evaluate the volume-outcome relationship in patients undergoing nephrectomy for neoplastic disease by examining the impact of the number of cases performed on in-hospital mortality and length of stay. Surgical volume is associated with postoperative mortality for many complex procedures; however, this relationship has not been characterized for patients undergoing nephrectomy for neoplastic disease. METHODS: Using the Nationwide Inpatient Sample database, 20,765 patients who underwent nephrectomy for neoplasm from 1993 through 1997 were identified by International Classification of Disease, Ninth Revision codes. Cases were stratified into volume groups on the basis of annual nephrectomy rates: low-volume hospitals performed 1 to 14 nephrectomies per year, medium-volume hospitals performed 15 to 33 per year, and high-volume hospitals performed more than 33 per year. Unadjusted and risk-adjusted analyses were performed. RESULTS: Overall mortality was 1.39%. Mortality declined as surgical volume increased. The mortality rate for low-volume hospitals was 1.60% versus 1.49% for medium-volume hospitals and 1.04% for high-volume hospitals (P = 0.017). After adjusting for case mix, high-volume hospitals had a 32% lower risk of in-hospital mortality than medium-volume hospitals (P = 0.029) and a 25% lower risk than low-volume hospitals (P = 0.094). Length of stay was not affected by hospital volume. Other independent risk factors for in-hospital mortality included age older than 65 years, chronic pulmonary disease, metastatic disease, and the urgent nature of the admission. CONCLUSIONS: A greater surgical volume, age younger than 65 years, elective conditions, and less comorbidity are associated with a significantly decreased risk of in-hospital mortality after nephrectomy. These findings provide compelling evidence that hospital volume and patient characteristics have important effects on surgical outcome specific to renal neoplasms.