title: Sources of variation in follow-up expenditure after radical cystectomy.
abstract: BACKGROUND
  Follow-up care after radical cystectomy is poorly defined, with extensive variation in practice patterns. We sought to determine sources of these variations in care as well as examine the economic effect of standardization of care to guideline-recommended care.
  
  
  METHODS
  Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 1992 to 2007, we determined follow-up care expenditures (time and geography standardized) for 24 months after surgery. Accounted expenditures included office visits, imaging studies, urine tests, and blood work. A multilevel model was implemented to determine the effect of region, surgeon, and patient factors on care delivery. We then compared the actual expenditures on care in the Medicare system (interquartile range) with the expenditures if patients received care recommended by current clinical guidelines.
  
  
  RESULTS
  Expenditures over 24 months of follow-up were calculated per month and per patient. The mean and median total expenditures per patient were $1108 and $805 respectively (minimum $0, maximum $9,805; 25th-75th percentile $344-$1503). Variations in expenditures were most explained at the patient level. After accounting for surgeon and patient levels, we found no regional-level variations in care. Adherence to guidelines would lead to an increase in expenditures by 0.80 to 10.6 times the expenditures exist in current practice.
  
  
  CONCLUSIONS
  Although some regional-level and surgeon-level variations in care were found, the most variation in expenditure on follow-up care was at the patient level, largely based on node positivity, chemotherapy status, and final cancer stage. Standardization of care to current established guidelines would create higher expenditures on follow-up care than current practice patterns.
authors.affiliation: Division of Urology, Department of Surgery, Washington University, St. Louis, MO.
authors.forename: Goutham
authors.initials: G
authors.lastname: Vemana
authors.affiliation: Division of Urology, Department of Surgery, Washington University, St. Louis, MO.
authors.forename: Joel
authors.initials: J
authors.lastname: Vetter
authors.affiliation: Division of Biostatistics, Washington University, St. Louis, MO.
authors.forename: Ling
authors.initials: L
authors.lastname: Chen
authors.affiliation: Division of Urology, Department of Surgery, Washington University, St. Louis, MO.
authors.forename: Gurdarshan
authors.initials: G
authors.lastname: Sandhu
authors.affiliation: Division of Urology, Department of Surgery, Washington University, St. Louis, MO. Electronic address: stropes@wudosis.wustl.edu.
authors.forename: Seth A
authors.initials: SA
authors.lastname: Strope
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D015653:Cystectomy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005102:Health Expenditures / Q000592:standards*; D006801:Humans; D008297:Male; D001749:Urinary Bladder Neoplasms / Q000191:economics* / Q000601:surgery*
keywords: Bladder cancer; Cost analysis; Cystectomy; Expenditure; Follow-up