The implications of hospital acquired adverse events on mortality, length of stay and costs for patients undergoing radical cystectomy for bladder cancer.
ABSTRACT The incidence of hospital acquired adverse events in radical cystectomy and their implications for hospital outcomes and costs remain poorly described. We describe the incidence of hospital acquired adverse events in radical cystectomy, and characterize its relationship with in-hospital mortality, length of stay and hospitalization costs.
We identified 10,856 patients who underwent radical cystectomy for bladder cancer at 1,175 hospitals in the Nationwide Inpatient Sample from 2001 to 2008. We used hospital claims to identify adverse events for accidental puncture, decubitus ulcer, deep vein thrombosis/pulmonary embolus, methicillin-resistant Staphylococcus aureus, Clostridium difficile, surgical site infection and sepsis. Logistic regression and generalized estimating equation models were used to test the associations of hospital acquired adverse events with mortality, predicted prolonged length of stay and total hospitalization costs.
Hospital acquired adverse events occurred in 11.3% of all patients undergoing radical cystectomy (1,228). Adverse events were associated with a higher odds of in-hospital death (OR 8.07, p<0.001), adjusted prolonged length of stay (41.3%) and total costs ($54,242 vs $26,306; p<0.001) compared to no adverse events on multivariate analysis. The incremental total costs attributable to hospital acquired adverse events were $43.8 million. Postoperative sepsis was associated with the highest risk of mortality (OR 17.56, p<0.001), predicted prolonged length of stay (62.22%) and adjusted total cost ($79,613).
With hospital acquired adverse events occurring in approximately 11% of radical cystectomy cases, they pose a significant risk of in-hospital mortality and higher hospitalization costs. Therefore, increased attention is needed to reduce adverse events by improving patient safety, while understanding the economic implications for tertiary referral centers with possible policy changes such as denial of payment for hospital acquired adverse events.
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ABSTRACT: Purpose: Enhanced recovery after surgery (ERAS) protocols aim to improve patient care, reduce complications, and shorten hospital stay. We evaluated our ERAS protocol focusing on length of stay (LOS), early complication and readmission rates following radical cystectomy (RC) for bladder cancer. Materials and Methods: From May 2012-July 2013, a perioperative protocol was applied to 126 consecutive patients who underwent open RC and urinary diversion. Non-consenting patients (n=2), those with previous diversion (n=2), prolonged postoperative intubation (n=3), and those who underwent additional surgery (n=9) were excluded. The protocol focuses on avoiding bowel preparation and nasogastric tube, early feeding, non-narcotic pain management, and use of cholinergic and µ-opioid antagonists. Outcomes were compared to matched controls from our bladder cancer database. Results: A total of 110 patients (median age, 69 years) were included. 68% of patients underwent continent urinary diversion. 82% of patients had bowel movement by postoperative day (POD) 2 and median LOS was 4 days. 30-day minor and major complication rates were 64% and 14%, respectively. The most common minor complication was anemia requiring transfusion (19%), UTI (13%) and dehydration (10%), with the latter two being the most common etiologies for readmission. 30-day readmission rate was 23 (21%). Patients ≥ 75 y/o had longer LOS (5 vs. 4 days, P=0.03) and higher minor complication rate (72% vs. 51%, P=0.04) compared to younger patients. Conclusion: Our ERAS protocol expedites bowel function recovery and shortens hospital stay following RC and urinary diversion without an increase in hospital readmission rates.The Journal of urology 01/2014; · 3.75 Impact Factor
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ABSTRACT: Venothrombolic events (VTEs) following radical cystectomy (RC) are a significant contributor to postoperative morbidity. A better understanding of the incidence and timing of VTE would clarify chemoprophylaxis strategies among RC patients. We sought to characterize the burden of VTE after RC by defining their timing and effect utilizing the MarketScan commercial databases.Urologic Oncology 05/2014; · 3.36 Impact Factor
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ABSTRACT: The purpose of this paper is to provide a current view of the economic burden of bladder cancer, with a focus on the cost effectiveness of available interventions. This review updates a previous systematic review and includes 72 new papers published between 2000 and 2013. Bladder cancer continues to be one of the most common and expensive malignancies. The annual cost of bladder cancer in the USA during 2010 was $US4 billion and is expected to rise to $US5 billion by 2020. Ten years ago, urinary markers held the potential to lower treatment costs of bladder cancer. However, subsequent real-world experiments have demonstrated that further work is necessary to identify situations in which these technologies can be applied in a cost-effective manner. Adjunct cytology remains a part of diagnostic standard of care, but recent research suggests that it is not cost effective due to its low diagnostic yield. Analysis of intravesical chemotherapy after transurethral resection of bladder tumor (TURBT), neo-adjuvant therapy for cystectomy, and robot-assisted laparoscopic cystectomy suggests that these technologies are cost effective and should be implemented more widely for appropriate patients. The existing literature on the cost effectiveness of bladder cancer treatments has improved substantially since 2000. The body of work now includes many new models, registry analyses, and real-world studies. However, there is still a need for new implementation guidelines, new risk modeling tools, and a better understanding of the empirical burden of bladder cancer.PharmacoEconomics 07/2014; 32(11). · 3.34 Impact Factor