Radical cystectomy (RC) for invasive bladder cancer is a highly morbid surgery. At 21% to 31%, the national 30-day readmission rate is significantly higher than for other urological procedures and other procedures of similar scope and complexity. Using a quality improvement (QI) approach under the Stanford Clinical Effectiveness and Leadership Training Program, a multidisciplinary team of urology faculty (MD), fellows, residents, advanced practice providers (APPs), and nurses (RNs) succeeded in reducing the rate of readmission due to infection at Stanford to 10.8% from 18% to 21%, findings reported during the AUA 2022 Annual Meeting in New Orleans (awarded Best Poster of the MP-23 Muscle Invasive Bladder Cancer Session).

Figure 1. Pareto chart of readmission causes following RC at Stanford 2018-2020.

The team employed QI tools to achieve the reduction. They measured the baseline readmission rate at Stanford using American College of Surgeons National Surgical Quality Improvement Program^® data, billing data, and manual review of all RC procedures at Stanford from 2018 to 2020. The team identified 217 cases with a readmission rate of 28% to 32%. These were categorized to produce a Pareto chart (Fig. 1). The principal cause of readmission was intra-abdominal and urinary tract infection (18% to 21%). They identified an “intervention bundle” based on this chart review and the literature to reduce cystectomy readmissions. The intervention bundle is detailed in the Table and includes preoperative nutrition referral, enrolling patients in the SeamlessMD perioperative education platform, standardized teaching for patients during hospitalization, removal of ureteral stents by postoperative day 4, methenamine urinary tract infection prophylaxis on hospital discharge, and outpatient care coordination with telehealth followup visits at 3, 10, and 17 days post discharge.

Figure 2. Run chart depicting overall readmission rate (blue) and readmission rate due to infection (green) with intervention on April 1, 2022.

The intervention bundle was initiated on April 1, 2021 and data were collected through October 1, 2021 (Fig. 2). During this period 37 RCs were performed. Nine patients were readmitted within 30 days of surgery. Four of these readmissions were due to intra-abdominal and urinary tract infections. This represented a 24.3% overall readmission rate, and 10.8% readmission rate due to infection. Process measures also improved: days to stent removal improved from 21.3 days to 7.7 days, and days to clinic followup on discharge improved from 6.3 days to 3.6 days. Notably, the overall and infection readmission rates began dropping after the initiation of the QI project but before the intervention date (Fig. 2).

QI provides a potent set of tools to implement changes in the clinical environment rapidly for the betterment of patient health. It has distinct advantages and limitations compared with clinical research. QI can be applied more rapidly, and allows for implementation of interventions informed by peer-reviewed research, as well as clinical judgment. By lacking control groups, it allows all patients to benefit from the designed intervention, though this feature does limit the conclusions drawn.

Early rehospitalization after surgery has come into focus due to the impact on patient experience, high cost, and associated poor downstream health outcomes. The Stanford team reduced readmissions due to infection following RC from 18% to 21% to 10.8%, an estimated 6 to 10 prevented readmissions annually, with a corresponding impact of $1 M–$1.5 M. Insights from this initiative provide a template for improving important clinical metrics using data from chart and literature review. This QI initiative included a spectrum of practitioners and may yield strategies and insights to reduce readmission following other complex and morbid surgeries. These answers can improve the experience for urology patients in the United States and abroad.