title: Impact of surgeon volume on the morbidity and costs of radical cystectomy in the USA: a contemporary population-based analysis.
abstract: OBJECTIVE
  To evaluate the relationship between surgeon volume of radical cystectomy (RC) and postoperative morbidity, and to assess the economic burden of bladder cancer in the USA.
  
  
  METHODS
  We captured all patients who underwent RC (International Classification of Diseases, ninth revision, code 57.71) between 2003 and 2010, using a nationwide hospital discharge database. Patient, hospital and surgical characteristics were evaluated. The annual volume of RCs performed by the surgeons was divided into quintiles. Multivariable regression models were developed, adjusting for clustering and survey weighting, to evaluate the outcomes, including 90-day major complications (Clavien grade III-V) and direct patient costs. We adjusted for clustering and weighting to achieve a nationally representative analysis.
  
  
  RESULTS
  The weighted cohort included 49,792 patients who underwent RC, with an overall 90-day major complication rate of 16.2%. Compared with surgeons performing one RC annually, surgeons performing ≥7 RCs each year had 45% lower odds of major complications (odds ratio [OR] 0.55; P < 0.001) and lower costs by $1690 (P = 0.02). Results were consistent when we analysed surgeon volume as a continuous variable and when we examined the surgeons with the highest volumes (≥28 cases annually), which showed markedly lower odds of major complications compared with the surgeons with the lowest volumes (OR 0.45, 95% CI 0.31-0.67; P < 0.001). Compared with patients who did not have any complications, those who had a major complication were associated with significantly higher 90-day median direct hospital costs ($43,965 vs $24,341; P < 0.001).
  
  
  CONCLUSIONS
  We showed that there was an inverse relationship between surgeon volume and the development of postoperative 90-day major complication rates as well as direct hospital costs. Centralisation of RC to surgeons with higher volumes may reduce the development of postoperative major complications, thereby decreasing the burden of bladder cancer on the healthcare system.
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Division of Urology, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Leow
authors.forename: Stephen
authors.initials: S
authors.lastname: Reese
authors.forename: Quoc-Dien
authors.initials: QD
authors.lastname: Trinh
authors.forename: Joaquim
authors.initials: J
authors.lastname: Bellmunt
authors.forename: Benjamin I
authors.initials: BI
authors.lastname: Chung
authors.forename: Adam S
authors.initials: AS
authors.lastname: Kibel
authors.forename: Steven L
authors.initials: SL
authors.lastname: Chang
mesh_terms: D000368:Aged; D003365:Costs and Cost Analysis; D015653:Cystectomy / Q000191:economics* / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D014481:United States; D001749:Urinary Bladder Neoplasms / Q000191:economics* / Q000601:surgery*
keywords: complications; costs and cost analysis; cystectomy; morbidity; urinary bladder neoplasms