Assessing the Relative Influence of Hospital and Surgeon Volume on Short-Term Mortality following Radical Cystectomy

To assess the relationship between surgeon and hospital volume on mortality following radical cystectomy (RC).

We queried the National Cancer Database (NCDB) for adult patients undergoing RC from 2010-2013. We calculated average volume for each surgeon (SV) and hospital (HV). Using propensity-scored weights for combined volume groups with a proportional hazards regression model, we compared association between HV and SV on 90-day survival following RC.

19,346 RC were performed at 927 hospitals by 2,927 surgeons from 2010 - 2013. Median HV and SV were 12.3 (IQR 5.0-35.5) and 4.3 (IQR 1.3-12.3) cases, respectively. For HV, 90 day unadjusted mortality was 8.5% in centers with <5 cases/year (95% CI 7.7-9.3) and 5.6% in those with >30 cases/year (95% CI 5.0-6.2). For SV, 90 day mortality was 8.1% for surgeons with <5 cases/year (95% CI 7.6-8.6) and 4.0% for those with >30 cases/year (95% CI 2.8-5.2; all p<0.05). 30-day mortality was lowest for the combined HV-SV groups with HV>30, ranging from 1.6% to 2.1%.

In hospitals reporting to the NCDB, volume is associated with improved mortality after RC. These associations appear to be driven by hospital rather than surgeon-level effects. Increased SV provides a beneficial effect on mortality at the highest volume hospitals. These findings inform efforts to regionalize complex surgical care and improve quality at community and safety net hospitals. This article is protected by copyright. All rights reserved.

BJU international. 2017 Feb 13 [Epub ahead of print]

Nikhil Waingankar, Katherine Mallin, Marc Smaldone, Brian L Egleston, Andrew Higgins, David P Winchester, Robert Uzzo, Alexander Kutikov

Icahn School of Medicine, The Mount Sinai Hospital, New York, NY., American College of Surgeons, National Cancer Database, Chicago, IL., Fox Chase Cancer Center, Philadelphia, PA.