Variability in Health Care Utilization and Perioperative Outcomes Among Urinary Diversion Patients: Analysis of the National Surgical Quality Improvement Program Database

Abstract

Introduction: Bladder cancer (BC) urinary diversion (UD) outcomes remain the benchmark to which all other UDs are compared. However, a sizable proportion are performed for other invasive cancers or benign etiologies of the bladder. We aim to compare health care utilization (HU) and 30-day morbidity among benign and malignant UD etiologies.

Methods: The American College of Surgeons National Surgical Quality Improvement Program was used to collect data on 20,885 patients who underwent UD for various indications: BC, gastrointestinal/gynecologic cancer (GC), radiation (R), interstitial cystitis/benign bladder, and neurogenic bladder/bowel (NGB; assigned using International Classification of Diseases codes). Risk-adjusted regression models were developed to identify predictors of HU, prolonged length of stay (PLOS), 30-day readmissions, discharge to continued care (DCC), and morbidity (30-day complications and mortality). Frailty was also compared among different etiologies using the 5-Item Frailty Index.

Results: Most patients had primary BC (91%, N = 19,060). GC had the highest complication rate (71%) and PLOS (50%), R had the highest readmission rate (23%), while NGB had the highest DCC (30%). GC was the least frail (≈14% with 5-Item Frailty Index ≥2) while NGB and R were the frailest (28% and 27%, respectively, P < .05). Moreover, frail radiated patients had the highest HU rate (81%, P < .001) while frail patients with GC had the highest complication rate (77%, P < .001). Compared with patients with BC, adjusted odds of PLOS, DCC, and 30-day complication rates significantly differed among UD etiologies (P < .05), except for interstitial cystitis/benign bladder.

Conclusions: Postoperative HU and morbidity are greatly influenced by UD etiology. Care management in these vulnerable patient populations requires an individualized etiology-centered approach and cannot be benchmarked against those undergoing BC UD.

Keywords: etiology; outcome; urinary diversion.