Impact of hospital and surgeon volume on in-hospital mortality from radical cystectomy: Data from the Health Care Utilization Project

Purpose: We determined the influence of hospital and surgeon volume on various outcome parameters after radical cystectomy for bladder cancer. Materials and Methods: All inpatient discharges after radical cystectomy for bladder cancer (1988 to 1999) from the Health Care Utilization Project-Nationwide Inpatient Sample were included in the analysis. Hospital and individual surgeon volume of discharges per year were separated into terciles. Outcome measures were in-hospital mortality, length of stay (LOS), and inflation adjusted charge per admission. Mortality was compared among hospital volume levels using the Mantel-Haenszel chi-square test while the LOS and charges were compared using ANOVA. Multivariate linear and logistic regression analyses were used to adjust for confounding factors. All the analyses were also performed in 3 different age strata (younger than 50 years, 50 to 69 years and 70 years or more). Results: There were 13,964 patients who underwent radical cystectomy. Overall in-hospital mortality was 408 of 13,964 (2.9%), average LOS was 14 days (+/- SD 10.28) and average charges were $47,146 (+/- SD $45,263). In-hospital mortality was significantly associated with higher volume particularly for patients older than 50 years. Surgeon volume did not influence inhospital mortality except for patients in the 50 to 69-year-old age group. Results of multivariate regression analysis demonstrated hospital volume was a significant predictor of in-hospital mortality but this effect was lost when controlling for surgeon volume. LOS was significantly higher for low volume surgeons. High volume hospitals had lower average total charges compared with the low and moderate volume hospitals. Conclusions: Hospital and surgeon volume have a significant impact on in-hospital mortality and LOS after radical cystectomy. Radical cystectomy performed at a higher volume center may result in lower charges and shorter hospital stay while decreasing the likelihood of in-hospital mortality.