Socioeconomic status is associated with urinary diversion utilization after radical cystectomy for bladder cancer.

Abstract

To assess socioeconomic disparities in urinary diversion utilization in a contemporary American cohort. In the National Cancer Database, we identified 4538 patients who underwent cystectomy with urinary diversion for clinical T1-2N0M0 bladder cancer from 2010 to 2013. Multivariable logistic regression was used to identify predictors of urinary diversion type: ileal conduit (IC), continent cutaneous reservoir (CCR), or orthotopic neobladder (ON). Covariates included age, gender, race, income, Charlson score, clinical T stage, hospital cystectomy volume, teaching status, and surgical approach. Subgroup analysis by hospital volume (low, intermediate, or high) and teaching status (academic or non-academic) was performed to ascertain the impact of regionalization on urinary diversion use. The final cohort included 4066 (89.6%) patients with IC, 292 (6.4%) with CCR, and 180 (4.0%) with ON. On multivariable analysis, younger age (p<.01), higher income (p<.01), and high cystectomy volume predicted increased use of CCR and ON. Female gender predicted increased use of CCR versus IC (p<.01), and academic hospital status predicted increased use of ON versus IC (p=.04). On subgroup analysis, after further adjustment for hospital volume and teaching status, higher income remained an independent predictor of ON use. Despite regionalization of care, higher income patients are more likely to receive complex urinary diversions after radical cystectomy. Other related socioeconomic factors, especially patient education, may influence this practice pattern.