Defining a “High Volume” Radical Cystectomy Hospital: Where Do We Draw the Line?

Background: Centralization of radical cystectomy (RC) to “high volume” centers can lead to decreased morbidity but also limits access to care. In the context of centralization, there is a need to systematically define the hospital volume cutoffs for this procedure. Objective: To systematically examine the effect of hospital volume on inpatient complications of RC) for bladder cancer, and to define a threshold that will minimize morbidity of RC. Design, Setting, and Participants: Retrospective analysis of 6790 adults undergoing RC for nonmetastatic bladder cancer during 2008-2011, from the National Inpatient Sample (weighted population estimate of 33,249 RCs in the United States during this period). Intervention: RC. Outcome Measurements and Statistical Analysis: Overall and major complications were defined per ICD-9, diagnosis and procedure codes. To define the relationship of hospital volume and morbidity, logistic regression analyses within generalized estimating equation framework, with restricted cubic splines (RCS), were used. Results and Limitation: Inpatient complication rate was 4769/6790 (70.2%); 1572/6790 (23.2%) were major complications. On RCS analysis there was a significant inverse nonlinear association between hospital volume and complications. The odds of complications decreased with increasing volume, with plateauing seen at 50-55 cases annually for any complications (p = 0.024) and 45-50 cases for major complications (p = 0.007). Conclusions: The relationship of hospital volume and morbidity of RC is nonlinear. Plateauing of the complication rate is seen at 50-55 cases annually. Restricting RC to centers with such high thresholds will restrict access to care. There is a need to identify and publish best practices from high volume centers in quality improvement initiatives to improve morbidity at low volume centers.https://scholarlycommons.henryford.com/merf2019hvc/1005/thumbnail.jp