The Association of Hospital Volume With Conditional 90-day Mortality After Cystectomy: An Analysis of the National Cancer Database
Nielsen ME, Mallin K, Weaver MA, Palis B, Stewart A, Winchester DP, Milowsky MI. BJU Int. 2013 Nov 13. doi: 10.1111/bju.12566. [Epub ahead of print]

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University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC; University of North Carolina School of Medicine, Department of Urology, Chapel Hill, NC; University of North Carolina Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, NC.


OBJECTIVE: To examine the association of hospital volume and 90-day mortality after cystectomy, conditional on survival to 30 days SUBJECTS AND METHODS: The National Cancer Database was used to evaluate 30- and 90-day mortality for 35,055 bladder cancer cases that received cystectomy at 1,118 hospitals. Patient data were aggregated into hospital volume categories based on average annual number of procedures [<10 low volume hospital (LVH), 10-19, ≥20 high volume (HVH)]. Associations between mortality and clinical, demographic and hospital characteristics were analyzed using hierarchical logistic regression models. To assess the association between hospital volume and 90-day mortality independent from shorter-term mortality, 90-day mortality conditional on 30-day survival was assessed in the multivariate modeling.

RESULTS: Unadjusted 30- and 90-day mortality rates were 2.7% and 7.2% overall, 1.9% and 5.7% among HVH, and 3.2% and 8.0% among LVH, respectively. Compared to HVH, the adjusted risks among LVH [OR (95% CI)] of 30- and 90-day mortality conditional on having survived through 30 days from the hierarchical models were 1.5 (1.3-1.9), and 1.2 (1.0-1.4), respectively.

CONCLUSION: Low hospital volume was associated with increased 30- and 90-day mortality. These data support the need for further research to better understand the relatively high mortality rates seen between 30-90 days, which are high and less variable across hospital volume strata. The stronger association between volume and 30-day mortality suggests that quality-reporting efforts should focus on shorter term outcomes.