Hospital volume and perioperative outcomes for radical cystectomy: a population study

Abstract

Objectives To evaluate the association between hospital volume and perioperative outcomes of radical cystectomy (RC) using state population data for a contemporary Australian cohort. Patients and Methods Patients undergoing RC for urothelial malignancy in the state of Victoria, Australia between July 2003 and June 2014 were identified using the Victorian Admitted Episodes Dataset (VAED). Hospitals were divided into tertiles according to their caseload per year. Hospitals performing <4 RCs/year were defined as low‐volume hospitals (LVH), 4–10 RCs/year as medium‐volume hospitals (MVH), and >10 RCs/year as high‐volume hospitals (HVH). Perioperative outcomes derived included: in‐hospital mortality (IHM), prolonged length of stay (LOS; >14 days), prolonged intensive care unit (ICU) admission (>24 h), and requirement for blood transfusion. The relationship between hospital volume and perioperative outcomes was assessed using logistic regression. Results During the 11‐year study period, 803 patients underwent RC for bladder cancer. The overall IHM rate was 2.2% (LVH 3.7%, MVH 2.5%, HVH 0.9%). Other outcomes observed were prolonged LOS (45%), prolonged ICU admission (31%) and requirement for blood transfusion (56%). On multivariate analysis, LVH was found to be associated with increased IHM (odds ratio [OR] 5.74, P = 0.04) and prolonged ICU admission (OR 11.58, P < 0.001) when compared to HVH. There was a lower rate of prolonged LOS for LVH (OR 0.60, P = 0.01). No significant relationship was identified for LVH and blood transfusion. Conclusion Perioperative outcomes in Victoria are comparable to international standards. Our results add further population study evidence to the volume–outcome relationship in RC. There was a significant association between LVH and both IHM and prolonged ICU admission. This subgroup of patients would appear to benefit from transfer of care to a HVH. The role of centralisation of RC in Australia should be further considered.

Outcomes following radical cystectomy: a population‐based study from Queensland, Australia

“…In keeping with our results, one previous Australian study of 804 RC patients reported no significant difference in risk of 30‐ and 90‐day mortalities among high‐volume (≥7 RCs/year) versus moderate‐volume (4–6/year) and low‐volume (≤3/year) hospitals following adjustment for casemix . A further state‐based Australian study ( n = 803 patients), did, however, report a significantly increased risk of in‐hospital mortality following RC at low‐volume hospitals (<4/year) . We conducted additional analyses using various hospital volume categories but found no association between hospital volume and any outcome.…”

“…Other population‐based studies have reported in‐hospital mortality rates of around 2.0–3.5% and 30‐day mortality between 3.0% and 5.5% . One previous Australian state‐based study reported an in‐hospital mortality rate of 2.2% . While overall the number of in‐hospital, 30‐ and 90‐day deaths over the 15 years of the study were relatively few, we did observe a reduction in deaths over time despite a significant increase in the number of RCs over the same period.…”

“…Few studies examining outcomes following RC have been conducted in Australia, and none to date have been conducted in Queensland, Australia's most decentralized state where around 40% of the population live outside the state capital . The development of our Cancer Quality Index through Cancer Alliance Queensland provides a structure for reporting on outcomes following major cancer surgery in public and private hospitals throughout Queensland.…”

High mortality rates after radical cystectomy: we must have acceptable protocols and consider the rationale of cutaneous ureterostomy for high-risk patients

“…If we go to other less selected settings, things start to change. An Australian epidemiologic study has observed a 2.2% rate after 803 surgeries (15). A British study evaluated 15,292 patients and have observed a mortality rate of 2.7% after 30 days and of 7% after 90 months (12).…”

Bladder cancer‐ time for a higher profile in our region

“…The use of haematuria clinics is still in its infancy in our region but other measures may also be utilised to avoid delays in definitive treatments. The concept of surgeon and hospital volume is also explored . The number of cystectomies per centre is certainly lower than what is considered ‘high volume’ in Europe – as always the focus must be on outcomes.…”