title: Impact of provider volume on operative mortality after radical cystectomy in a publicly funded healthcare system.
abstract: BACKGROUND
  We assess the effect of cystectomy provider volume on postoperative mortality in a publicly funded healthcare system. Hospital and surgeon (provider) volume have been shown to be associated with clinically important outcomes for many types of surgery. Volume-outcome studies in patients undergoing radical cystectomy for bladder cancer have primarily originated from privately funded healthcare systems.
  
  
  METHODS
  We identified patients undergoing cystectomy in Ontario, Canada, between 1992 and 2004 using administrative databases. The effect of provider volume on postoperative mortality was assessed with multilevel (hierarchical or random effects) logistic regression models, adjusted for patient characteristics. Separate models were fit to examine the effect of surgeon volume and the effect of hospital volume.
  
  
  RESULTS
  Of the 3296 cystectomy patients identified, 126 (3.8%) experienced a postoperative death. Neither hospital volume (odds ratio [per 1 unit increase in volume] 0.98, 95% confidence interval [CI] 0.95-1.00; p = 0.074) nor surgeon volume (odds ratio 0.96, 95% CI 0.90-1.02; p = 0.143) were statistically significantly associated with postoperative cystectomy mortality.
  
  
  CONCLUSIONS
  In Ontario's publicly funded healthcare system, provider volume was not significantly associated with postoperative mortality.
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON; ; Division of Urology, Department of Surgery, University Health Network, University of Toronto, Toronto, ON; ; Institute for Clinical Evaluative Sciences, Toronto, ON.
authors.forename: Girish S
authors.initials: GS
authors.lastname: Kulkarni
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON; ; Division of General Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto, ON; ; Institute for Clinical Evaluative Sciences, Toronto, ON.
authors.forename: David R
authors.initials: DR
authors.lastname: Urbach
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON; ; Institute for Clinical Evaluative Sciences, Toronto, ON.
authors.forename: Peter C
authors.initials: PC
authors.lastname: Austin
authors.affiliation: Division of Urology, Department of Surgery, University Health Network, University of Toronto, Toronto, ON;
authors.forename: Neil E
authors.initials: NE
authors.lastname: Fleshner
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON; ; Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, ON; ; Institute for Clinical Evaluative Sciences, Toronto, ON.
authors.forename: Andreas
authors.initials: A
authors.lastname: Laupacis