Variations in the Costs of Radical Cystectomy for Bladder Cancer in the USA

Background: Radical cystectomy (RC) for muscle-invasive bladder cancer (BCa) has potential for serious complications, prolonged length of stay and readmissions-all of which may increase costs. Although variations in outcomes are well described, less is known about determinants driving variation in costs.

Objective: To assess surgeon- and hospital-level variations in costs and predictors of high- and low-cost RC.

Design, Setting, And Participants: Cohort study of 23 173 patients who underwent RC for BCa in 208 hospitals in the USA from 2003 to 2015 in the Premier Healthcare Database.

Outcome Measurements And Statistical Analysis: Ninety-day direct hospital costs; multilevel hierarchal linear models were constructed to evaluate contributions of each variable to costs.

Results And Limitations: Mean 90-d direct hospital costs per RC was $39 651 (standard deviation $34 427), of which index hospitalization accounted for 87.8% ($34 803) and postdischarge readmission(s) accounted for 12.2% ($4847). Postoperative complications contributed most to cost variations (84.5%), followed by patient (49.8%; eg, Charlson Comorbidity Index [CCI], 40.5%), surgical (33.2%; eg, year of surgery [25.0%]), and hospital characteristics (8.0%). Patients who suffered minor complications (odds ratio [OR] 2.63, 95% confidence interval [CI]: 2.03-3.40), nonfatal major complications (OR 12.7, 95% CI: 9.63-16.8), and mortality (OR 13.5, 95% CI: 9.35-19.4, all p<0.001) were significantly associated with high costs. As for low-cost surgery, sicker patients (CCI=2: OR 0.41, 95% CI: 0.29-0.59; CCI=1: OR 0.58, 95% CI: 0.46-0.75, both p<0.001), those who underwent continent diversion (vs incontinent diversion: OR 0.29, 95% CI: 0.16-0.53, p<0.001), and earlier period of surgery were inversely associated with low costs.

Conclusions: This study provides insight into the determinants of costs for RC. Postoperative morbidity, patient comorbidities, and year of surgery contributed most to observed variations in costs, while other hospital- and surgical-related characteristics such as volume, use of robot assistance, and type of urinary diversion contribute less to outlier costs.

Patient Summary: Efforts to address high surgical cost must be tailored to specific determinants of high and low costs for each operation. In contrast to robot-assisted radical prostatectomy where surgeon factors predominate, high costs in radical cystectomy were primarily determined by postoperative complication and patient comorbidities.