Patient, Physician, Hospital Factors Associated With Readmission After Radical Cystectomy

Abstract

Patient and clinical factors are the most commonly identified variables associated with hospital readmission after radical cystectomy, but other factors may be important drivers of outcomes, such as hospital and physician characteristics. This study investigates the contribution of patient, physician, and hospital factors in hospital readmission after radical cystectomy. This was a retrospective review of the Surveillance, Epidemiology, and End Results-Medicare database focusing on bladder cancer patients who underwent radical cystectomy between 2007 and 2016. Medicare claims were identified using International Statistical Classification of Diseases-9/-10 or Healthcare Common Procedure Coding System codes from Medicare Provider Analysis and Review or National Claims History claims, from which the annual hospital/physician volumes were calculated and classified as low, medium, and high. A multivariable analysis was done for 90-day readmission as the outcome using a multilevel model to explore the association between readmission and characteristics of patient, hospital, and physician. Models with random intercepts were constructed to consider the variation from hospital and physician. Of 3,530 patients, 1,291 (36.6%) were readmitted within 90 days of the index surgery. On multilevel multivariable analysis, factors significantly associated with readmission included continent urinary diversion (OR 1.55, 95% CI 1.21, 2.00), greater National Cancer Institute comorbidity index (2<4 vs 0-<2, OR 1.35, 95% CI 1.05, 1.75; 4+ vs 0-<2, OR 1.76, 95% CI 1.20, 2.58), American Joint Committee on Cancer stage (P = .04), and hospital region (P = .05). Neither hospital volume, physician volume, teaching hospital status, nor National Cancer Institute center designation was associated with hospital readmission. The main source of variation was determined to be the patient factors (95.89%), followed by the physician (1.43%), and then hospital (2.68%) factors. Patient-specific factors are the most important in impacting the odds of readmission after radical cystectomy, while hospital and physician factors contribute minimally to this outcome.