Objectives: To assess regionalization trends and short-term clinical outcomes in patients undergoing radical cystectomy for urothelial carcinoma.
Materials and methods: Using 1996-2009 discharge data from New York (NY), New Jersey (NJ) and Pennsylvania (PA), all patients ≥ 18 years with urothelial carcinoma undergoing cystectomy were identified using ICD-9 coding. We assigned hospital volume status by quintiles based on relative proportions of cystectomies performed on a per hospital basis in 1996; very low volume hospitals: 0-2 (VLVH), low: 3-4 (LVH), moderate: 5-8 (MVH), high: 9-31 (HVH), and very high: ≥ 32 (VHVH). Changes in the proportion of procedures performed by volume categories were assessed over time, and patient characteristics were compared between groups.
Results: A total of 14,404 patients met inclusion criteria. For each year increase from 1996 to 2009, the odds of having surgery performed at a VHVH increased by 22% (odds ratio [OR] 1.22, confidence interval [CI] 1.04-1.44). Patients undergoing surgery at a VHVH were less likely to be African American (OR 0.59 [CI 0.39-0.91]), or insured through Medicaid (OR 0.65 [CI 0.50-0.84]) or Medicare (OR 0.84 [CI 0.75-0.94]). Controlling for year treated, total procedures performed, and patient characteristics, median hospital length of stay (HLOS) was shorter (median difference -0.89 days [CI -1.12 to -0.66]), and patients were significantly less likely to die during their hospital stay if treated at a VHVH compared with a VLVH (OR 0.33 [CI 0.22-0.49]).
Conclusions: There has been extensive regionalization of cystectomy to VHVHs in NY, NJ, and PA since 1996. Despite apparent improvements in mortality and HLOS in patients treated at higher volume centers in our sample, future investigations more rigorously adjusting for hospital structural characteristics and patient severity are necessary to confirm these findings. Disparities in access to VHVH care are still evident and must be addressed.
Keywords: Centralization; Cystectomy; Mortality; Regionalization; Urothelial carcinoma; Volume-outcomes.
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