Rodriguez-Homs M, Rodrigues Pessoa R, Konety B, et al. Association of surgical approach and urinary diversion in radical cystectomy for bladder cancer with costs and readmission: results from a large private health insurance cohort. Urol Pract. 2022; 9(6):551-558.

Study Need and Importance

Radical surgical management of bladder cancer is associated with excessive health care expenditures due to several factors including total hospital admission cost, high rate of postoperative complications, and frequent readmissions. Understanding outcomes following radical cystectomy (RC) is important to develop applicable interventions to reduce financial burden and improve patient care. We demonstrate the crucial contribution of type of surgical approach and urinary diversion on postoperative intensity of care and costs.

What We Found

Patients had higher odds of 90-day readmissions for open RC and neobladder (NB; OR: 1.36; P = .002) and robotic RC with NB (OR 1.60; P = .03) relative to open RC with ileal conduit (IC). After adjusting for patient covariates, we also found lower adjusted total 90-day health care costs for open RC with IC ($67,915) and open RC with NB ($67,371) compared to robotic RC with IC ($70,677) and NB ($70,818; P < .05; see Table).

Limitations

Our data were limited by the lack of information on surgeon volume and hospital characteristics. MarketScan also provides limited data on other key social determinants of health such as race and socioeconomic status.

Interpretation for Patient Care

A large proportion of the 90-day health care costs comes from the index hospitalization for RC, which highlights the importance of judicious instrument and operating room time use, and employment of strategies to reduce the length of stay from the initial hospitalization. Postoperative complications are another key driver of health care costs, underscoring the importance of referring patients to centers of expertise that can perform complex oncologic operations with better outcomes. Although still subject to controversy, our findings show that health care costs at 90 days for robotic surgery continued to have higher costs compared to open surgery and did not change or reduce over the study period. Finally, readmission within 90 days of the RC is a major driver of high costs, which seem to be highly influenced by type of diversion. Therefore, careful discussion and shared decision regarding type of diversion alongside with additional strategies to prevent patients from being readmitted are of paramount importance to decrease costs following RC.

Table. Unadjusted and Adjusted Health Care Costs by 90-day Hospitalization of the Index Surgery, Emergency Visits, and Readmission^a