Associations of specific postoperative complications with costs after radical cystectomy

Abstract

ObjectiveTo quantify the financial impact of complications after radical cystectomy (RC) and their associations with respective 90-day costs, as RC is a morbid surgery plagued by complications and the expenditure attributed to specific complications after RC is not well characterised. Patients and MethodsWe used the Premier Hospital Database (Premier Inc., Charlotte, NC, USA) to identify 9 137 RC patients (weighted population of 57 553) from 360 hospitals between 2003 and 2013. Complications were categorised according to Agency for Healthcare Research and Quality Clinical Classifications. Patients with and without complications were compared, and multivariable analysis was performed. ResultsAn index complication increased costs by $9 262 (95% confidence interval [CI] 8 300-10 223) and a readmission complication increased costs by $20 697 (95% CI 18 735-22 660). The four most costly index complications (descending order) were venous thromboembolism (VTE), infection, wound and soft tissue complications, and pulmonary complications (P < 0.001, vs no complication). A complication increased length of stay by 4 days (95% CI 3.6-4.3). One in five patients were readmitted in 90 days and the four costliest readmission complications (descending order) were pulmonary, bleeding, VTE, and gastrointestinal complications (P < 0.001, vs no complication). Readmitted patients had multiple complications upon readmission (median of 3, interquartile range 2-4). On multivariable analysis, more comorbidities, longer surgery (>6 h), transfusions of >3 units, and teaching hospitals were associated with higher costs (P < 0.05), whilst high-volume surgeons and shorter surgeries (<4 h) were associated with lower costs (P < 0.05). ConclusionsComplications after RC increase index and readmission costs for hospitals, and can be categorised based on magnitude. Future initiatives in RC may also consider costs of complications when establishing quality improvement priorities for patients, providers, or policymakers.

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

“…Ultimately, the decision on type of diversion is based on patient and surgeon preference, cancer‐specific factors, and medical comorbidities. The overwhelming majority of patients with bladder cancer will choose an ileal conduit with estimates between 70% and 95% .…”

Examining the relationship between complications and perioperative mortality following radical cystectomy: a population‐based analysis

“…It is not surprising that compromise of these major organ systems are associated with a significantly increased probability for postoperative mortality after RC because hypertension, chronic pulmonary disease, and heart disease impact at least 15% of patients, and almost 40% of patients were current or former smokers . Our present results stress the importance of a multidisciplinary effort to maintain and optimise cardiac, pulmonary, and renal function in the perioperative period, especially because patients undergoing RC are often elderly, subject to additional comorbidities, have limited functional status, and suboptimal nutrition . Moreover, many patients with bladder cancer are in their 70s or even 80s, and for example amongst octogenarians undergoing general surgery, nearly 20% will have at least one complication that entails a significant increase in 30‐day mortality (26% vs 4%, P < 0.001) .…”

“…Hospital characteristics included teaching status (teaching, non‐teaching), hospital size (<400, 400–600, >600 beds), location (urban, rural), and region (Northeast, Midwest, West, South). Surgical characteristics included year of surgery, performance of lymphadenectomy, approach (open, minimally invasive), type of urinary diversion (incontinent, continent), operative time, blood transfusion (0, 1–2, 3–4, >4 units), hospital volume (cases/year), surgeon volume (cases/year), and 90‐day readmission rate . Index stay was defined as inpatient hospitalisation following RC.…”

“…Complications were stratified by events that occurred during the admission for the initial surgery and those that occurred after discharge resulting in an emergency room visit or readmission. Complications were categorised as follows: infectious, pulmonary, cardiac, surgical, venous thromboembolism, neurological, bleeding, wound and soft tissue, genitourinary, gastrointestinal, and renal .…”

“…In RC, comorbidities and complications are major determinants of variations in cost . In fact, a complication during the hospital stay after RC may increase the length of stay by 4 days and raise overall healthcare costs by >$9000 (American dollars) .…”