Racial variation in the quality of surgical care for bladder cancer

Abstract

Background: Differences in quality of care may contribute to racial variation in outcomes of bladder cancer (BCa). Quality indicators in patients undergoing surgery for BCa include the use of high-volume surgeons and high-volume hospitals, and, when clinically indicated, receipt of pelvic lymphadenectomy, receipt of continent urinary diversion, and undergoing radical cystectomy instead of partial cystectomy. The authors compared these quality indicators as well as adverse perioperative outcomes in black patients and white patients with BCa.

Methods: The Healthcare Cost and Utilization Project State Inpatient Databases for New York, Florida, and Maryland (1996-2009) were used, because they consistently included race, surgeon, and hospital identifiers. Quality indicators were compared across racial groups using regression models adjusting for age, sex, Elixhauser comorbidity sum, insurance, state, and year of surgery, accounting for clustering within hospital.

Results: Black patients were treated more often by lower volume surgeons and hospitals, they had significantly lower receipt of pelvic lymphadenectomy and continent diversion, and they experienced higher rates of adverse outcomes compared with white patients. These associations remained significant for black patients who received treatment from surgeons and at hospitals in the top volume decile.

Conclusions: Black patients with BCa had lower use of experienced providers and institutions for BCa surgery. In addition, the quality of care for black patients was lower than that for whites even if they received treatment in a high-volume setting. This gap in quality of care requires further investigation.

Keywords: bladder cancer; health disparities; quality of care; surgery.

Figure 1. Model predictions based on race and interaction terms

A. Odds of undergoing Pelvic Lymph Node Dissection by Race over Surgeon Volume B. Odds of undergoing Continent Diversion by Race over Age C. Odds of In-Hospital Mortality by Race over Hospital Volume Independent variables are adjusted to median values for all patients (age = 70; sex = male; comorbidity = 1; state = NY; Year = 2003; Payer = Medicare), except where they are present in the x-axis. Surgeon and hospital volume, are set to the 90th percentile (>5 cases per year for surgeon and>12 cases per year for hospital) when not present in the x-axis. Vertical bar represents specific scenario in Table 5. Shading indicates 95% confidence interval.