Patient Function and the Value of Surgical Care for Kidney Cancer

Abstract

Purpose: Frailty and functional status have emerged as significant predictors of morbidity and mortality for patients undergoing cancer surgery. To articulate the impact on value (ie quality per cost), we compared perioperative outcomes and expenditures according to patient function for older adults undergoing kidney cancer surgery.

Materials and methods: Using linked SEER (Surveillance, Epidemiology and End Results)-Medicare data, we identified 19,129 elderly patients with kidney cancer treated with nonablative surgery from 2000 to 2009. We quantified patient function using function related indicators (claims indicative of dysfunction and disability) and measured 30-day morbidity, mortality, resource use and cost. Using multivariable, mixed effects models to adjust for patient and hospital characteristics, we estimated the relationship of patient functionality with both treatment outcomes and expenditures.

Results: Of 19,129 patients we identified 5,509 (28.8%) and 3,127 (16.4%) with a function related indicator count of 1 and 2 or greater, respectively. While surgical complications did not vary (OR 0.95, 95% CI 0.86-1.05), patients with 2 or more indicators more often experienced a medical event (OR 1.22, 95% CI 1.10-1.36) or a geriatric event (OR 1.55, 95% CI 1.33-1.81), or died within 30 days of surgery (OR 1.43, 95% CI 1.10-1.86) compared with patients with no baseline dysfunction. These patients utilized significantly more medical resources and amassed higher acute care expenditures (p <0.001).

Conclusions: During kidney cancer surgery, patients in poor functional health can face a more eventful medical recovery at elevated cost, indicating lower value care. Greater consideration of frailty and functional status during treatment planning and transitions may represent areas for value enhancement in kidney cancer and urology care.

Keywords: SEER Program; health care costs; kidney neoplasms; nephrectomy; perioperative period.

Figure 1:

Predicted probability of morbidity and mortality after kidney cancer surgery according to patient function as measured using function-related indicators. Estimates are derived from multivariable, mixed-effects models, adjusted for patient and hospital characteristics. 95% confidence intervals obtained using bootstrapping with replacement for 1000 replications. Abbreviation: FRI, function-related indicator.

Figure 2:

Predicted probability of resource use after kidney cancer surgery according to patient function as measured using function-related indicators. Estimates are derived from multivariable, mixed-effects models, adjusted for patient and hospital characteristics. 95% confidence intervals obtained using bootstrapping with replacement for 1000 replications. Abbreviation: FRI, function-related indicator.