Introduction:

Previous studies have primarily evaluated patient characteristics associated with radical cystectomy (RC) use. The objective of this study is to determine the impact of patient, urologists, and hospital characteristics on variation in the use of RC.

Methods:

Using the Surveillance, Epidemiology, and End Results Registry (SEER) Medicare linked database, we identified 7,097 patients, aged 66–85 years, diagnosed with clinical stage T2–4a muscle-invasive bladder cancer from January 1, 2002 through December 31, 2011. We identified 4,601 diagnosing urologists, 4,582 treating urologists and 822 hospitals and performed hierarchical modeling to determine variation in use of RC.

Results:

Out of 7,097 patients, only 26% underwent RC. There was wide variation in RC use among hospitals (10–37%), even after adjusting for case-mix differences. The percentage of variance in RC use attributable to the hospital was 5%. Higher RC volume (10+ vs. 0 surgeries) by diagnosing urologists (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.83–2.60) and hospitals (40+ vs. 0 surgeries) (OR,1.62; 95% CI, 1.13–2.32) increased RC use. Patients diagnosed by female rather than male urologists were more likely to undergo RC (OR, 1.62; 95% CI, 1.31–2.01). Treating urologist volume (10+ vs. 0 surgeries) was associated with up to a 6-fold likelihood of undergoing RC (OR, 6.38; 95% CI, 5.31–7.67).

Conclusion:

Use of RC was largely attributed to urologist surgical volume after controlling for patient and hospital characteristics. These findings further support centralization of RC to higher volume urologists to improve use.

Funding: This study was conducted with the support of a Department of Defense Peer Reviewed Cancer Research Program (PRCRP) Career Development Award (W81XWH1710576) and the Herzog Foundation (SBW). This study was supported by a Center for Translational Science Award by the NIH (TL1TR001440 and UL1TR001439) (MF).Yes