The effect of hospital caseload on perioperative morbidity and treatment-related costs in patients undergoing radical cystectomy

Pyrgidis, Nikolaos (2023): The effect of hospital caseload on perioperative morbidity and treatment-related costs in patients undergoing radical cystectomy = Der Effekt des Krankenhaus-Caseloads auf die perioperative Morbidität und behandlungsassoziierte Kosten bei der radikalen Zystektomie. Dissertation, LMU München: Medizinische Fakultät

Abstract

The European guideline recommendations on bladder cancer suggest that hospitals should perform at least ten, and preferably more than twenty RC per year, to achieve acceptable perioperative outcomes. Still, the optimal annual caseload volume for RC remains unknown. Thus, the present dissertation aimed to determine an evidence-based optimal annual RC hospital volume threshold and to evaluate its clinical significance based on major perioperative outcomes (mortality, morbidity, length of hospital stay, and hospital revenues). Based on the DRG dataset provided by the Research Data Center of the Fed-eral Bureau of Statistics from 2005 to 2020 (agreement: LMU - 4710-2022), an optimal annual hospital volume threshold was defined through ROC analyses. The DRG dataset contains all reimbursed inpatient cases in Germany apart from psychiatric, forensic, and military cases. All data are available and stored anonymized at the Research Data Center of Federal Bureau of Statistics. All hospitals are required to code and transfer to the Institute for the Hospital Re-muneration System patient data on inpatient diagnoses, coexisting conditions, as well as on perioperative outcomes, and surgical procedures. These data are mandatory for all German hospitals to receive their corresponding remu-neration. These diagnoses and perioperative outcomes are coded according to the ICD-10-GM, whereas surgical procedures are coded according to the German OPS. Based on these ROC analyses, the optimal annual hospital vol-ume threshold for RC that reduces mortality, ileus, sepsis, transfusion, hospital stay, and costs was determined by 54, 50, 44, 44, 71, and 76 RCs/year, re-spectively. Thus, both the annual threshold of 50 and 70 cases/year and the annual threshold of 20 cases/year as proposed by the European recommen-dations on bladder cancer were used to perform multiple analyses on a patient level. Overall, 95,841 patients were included. Of them, 28,291 (30%) under-went RC in low- (<20 cases/year), 49,616 (52%) in intermediate- (20-49 cas-es/year), and 17,934 (19%) in high-volume (≥50 cases/year) hospitals in Ger-many. After adjusting for major determinants, patients undergoing surgery in high-volume hospitals were associated with statistically significant lower risk for mortality (OR: 0.72, 95% CI: 0.64 to 0.8, p < 0.001) compared to patients undergoing surgery in low-volume hospitals. Moreover, the costs were re-duced by 457 euros (95% CI: 207 to 707, p < 0.001) and the length of hospital stay by 2.7 days (95% CI: 2.4 to 2.9, p < 0.001) after RC in high-volume hospi-tals. It should be highlighted that patients that underwent surgery in low-volume hospitals developed more perioperative complications (transfusion, ileus, and sepsis). Furthermore, the threshold of 70 cases/year was also asso-ciated with improved perioperative outcomes (mortality, morbidity, hospital stay, and costs). The centralization of aggressive bladder cancer care seems to not only improve morbidity and mortality but also to reduce both the length of hospital stay and hospital revenues. Based on the present analyses, hospi-tals that perform at least 50 RCs/year should be considered referral centers, hospitals that perform at least 70 RCs/year should be considered excellence centers and hospitals that perform less than 10 RCs/year should refer patients to other centers.

• Dokumententyp: Dissertationen (Dissertation, LMU München)
• Keywords: Radical cystectomy, Bladder Cancer, Urothelial Carcinoma, Perioperative outcomes, Hospital caseload
• Themengebiete: 600 Technik, Medizin, angewandte Wissenschaften ; 600 Technik, Medizin, angewandte Wissenschaften > 610 Medizin und Gesundheit
• Fakultäten: Medizinische Fakultät
• Sprache der Hochschulschrift: Englisch
• Datum der mündlichen Prüfung: 20. Dezember 2023
• 1. Bericht­erstatter:in: Schulz, Gerald