# Presentation: 557559

## Trends in Regionalization of Inpatient Care for Urological Malignancies

**Trends in Regionalization of Inpatient**** ****Care for Urological Malignancies**

- Matthew R. Cooperberg
- Sanjukta Modak
- Badrinath R. Konety
- Department of Urology
- University of California,
- San Franicsco
*AHRQ Annual Conference*
*Bethesda, MD*
*September 10, 2008*

*A Heath Care Utilization Project Nationwide Inpatient Sample Study*

## Surgical Volume and Outcomes

**Introduction**

## Hospital surgical volume associated with better outcomes, first noted 1979 [Luft et al. NEJM 1979; 301:1364]
Major cancer surgery [Begg et al. JAMA 1998; 280:1747]
Urologic oncologic surgery [Joudi et al. J Urol 2005; 174:432]
HCUP NIS cystectomy studies: postop mortality 2.9% vs 6.4% in highest vs lowest quintile volume hospitals [Birkmeyer et al. NEJM 2002; 346:1128]
Higher volume assoc with shorter LOS, lower charges, lower complication rates [Konety et al. J Urol 2005; 175:1695. Konety et al. Urology 2006; 68:58]
HVH status for other urologic or non-urologic surgery not assoc with outcomes [Konety et al. J Clin Oncol 2006; 24:2006]

- Major cancer surgery [Begg et al. JAMA 1998; 280:1747]
- Urologic oncologic surgery [Joudi et al. J Urol 2005; 174:432]
- HCUP NIS cystectomy studies: postop mortality 2.9% vs 6.4% in highest vs lowest quintile volume hospitals [Birkmeyer et al. NEJM 2002; 346:1128]
- Higher volume assoc with shorter LOS, lower charges, lower complication rates [Konety et al. J Urol 2005; 175:1695. Konety et al. Urology 2006; 68:58]
- HVH status for other urologic or non-urologic surgery not assoc with outcomes [Konety et al. J Clin Oncol 2006; 24:2006]

**Associating volume and outcomes**

## Is hospital volume or surgeon volume more important?
Medicare analysis: surgeon volume accounts for 39% of the effect of hospital volume [Birkmeyer et al. NEJM 2004; 349:2117]
What else drives the association?
Hospital size (beds / capacity)
Urban location
Teaching mission
Staffing ratios
Patient age, LOS, other procedures

- Medicare analysis: surgeon volume accounts for 39% of the effect of hospital volume [Birkmeyer et al. NEJM 2004; 349:2117]
- What else drives the association?
- Hospital size (beds / capacity)
- Urban location
- Teaching mission
- Staffing ratios
- Patient age, LOS, other procedures

**“****Getting under the hood”**

- Hollenbeck et al. J Urol 2007; 177:2095 Konety et al. J Urol 2004; 172:1056
- Konety et al. J Urol 2005; 173:1695

## Volume-outcomes continued...

- IOM systemic review 2002: 135 studies across 27 diagnoses / procedures [Halm et al. Ann Intern Med 2002; 137:511]
- In general higher volumes associate with better outcomes, but magnitude of association varies widely, as does methodological quality of studies
- Provider variables may be outweighed by patient variables, perhaps insufficiently reflected in claims-based data (NSQIP investigators) [Khuri et al. World J Surg 2005; 29:1222, Best et al. J Am Coll Surg 2002; 194:257]
- Secular / temporal trends
- e.g., NIS analysis CABG: during period of declining volume, 50% decline in proportion of HVH, mortality declined consistently with greatest decline among LVHs [Ricciardi et al. Arch Surg 2008; 143:338]
- Regionalization already supported by policy (public and private, mostly reimbursement-driven) in some cases

## Methods

## 15-year Trends in Regionalization

- HCUP NIS data 1988-2002: accessible source of population-based data on health services trends
- Bladder cancer
- Renal cancer
- Prostate cancer
- Hospitals ranked to tertiles in each year by numbers of discharges (excluding those with no discharges)
- Separate analyses of surgical and non-surgical admissions
- Subset analyses by geographic region and primary payer

## Results

## Surgical volume thresholds

**Surgical volume thresholds**

**Notes:**
Bladder cancer: 26K surgical discharges at 1764 hospitals; HVH threshold >5
			  134K non-surgical discharges at 2645 hospitals; HVH threshold >21
Renal cancer: 64K surgical discharges at 2182 hospitals, HVH threshold >11
		       21K non-surgical discharges at 2288 hospitals, HVH threshold >4
Prostate cancer: 178K surgical discharges at 2065 hospitals, HVH threshold >25
			   146K non-surgical discharges at 2775 hospitals, HVH threshold >26

## Trends in Admissions

**Trends in Admissions**

**Notes:**
Increase in bladder HVH discharges from 67% in 1988-92 to 70% in 1998-02 (p<.0001)

## Trends in Admissions

**Trends in Admissions**

**Notes:**
Increase in renal cancer surgical discharges from 67% to 73% at HVH from 1988-92 to 1998-02

## Trends in Admissions

**Trends in Admissions**

**Notes:**
Minimal increase in prostate HVH surgical discharges from 76.1% to 76.5% (p=.029).
Decline in prosate HVH non-surgical discharges from 71% to 69% (p<.0001)

## Trends: Medicare / Medicaid

**Trends: Medicare / Medicaid**

## Trends: Medicare / Medicaid

**Trends: Medicare / Medicaid**

## Trends: Medicare / Medicaid

**Trends: Medicare / Medicaid**

## Bladder Cancer HVH Admissions

**Bladder Cancer HVH Admissions**

## Bladder Cancer HVH Admissions

**Bladder Cancer HVH Admissions**

## Bladder Cancer HVH Admissions

**Bladder Cancer HVH Admissions**

## Bladder Cancer HVH Admissions

**Bladder Cancer HVH Admissions**

## Renal Cancer HVH Admissions

**Renal Cancer HVH Admissions**

## Renal Cancer HVH Admissions

**Renal Cancer HVH Admissions**

## Renal Cancer HVH Admissions

**Renal Cancer HVH Admissions**

## Renal Cancer HVH Admissions

**Renal Cancer HVH Admissions**

## Prostate Cancer HVH Admissions

**Prostate Cancer HVH Admissions**

**Notes:**
Regional variation: increase in surgical but not non-surgical discharges from HVH in the northeast

## Prostate Cancer HVH Admissions

**Prostate Cancer HVH Admissions**

**Notes:**
Regional variation: slight increases in both surgical and non-surgical discharges from HVH in the Midwest

## Prostate Cancer HVH Admissions

**Prostate Cancer HVH Admissions**

**Notes:**
Regional variation: slight decreases in both surgical and non-surgical discharges from HVH in the South

## Prostate Cancer HVH Admissions

**Prostate Cancer HVH Admissions**

**Notes:**
Regional variation: slight decrease in surgical discharges, flat non-surgical discharges from HVH in the West

## Conclusions and Implications

## Summary of findings

- About 2/3 of urologic oncology admissions at HVHs
- Relative increase in regionalization
- 4.5% for bladder cancer
- 8.9% for renal cancer
- No increase for prostate cancer but higher baseline
- Substantial regional variation

## Is regionalization a good trend?

- HCUP study: hospitals meeting Leapfrog Group volume standards had similar in-hospital mortality to others. Volume standards would adversely impact low volume hospitals and increase patient travel time. [Ward et al. J Rural Health 2004; 20:344]
- Many rural areas lack the referral base to support even one HVH for some procedures. [Dimick et al. Health Aff 2004; web VAR45]
- For invasive bladder cancer a delay of >3 months from diagnosis to cystectomy is associated with increased mortality. [Chang et al. J Urol 2003; 170: 1085. Sanchez-Ortiz et al. J Urol 2003; 169:110]

## Is regionalization a good trend?

- Proportion of US hospitals performing cystectomy varied from 45 to 50% between 1988 and 1996, then fell to 39% by 2000. [Taub et al. J Urol 2006; 176:2612]
- Nonwhite patients, those with Medicaid / no insurance less likely to receive complex surgical care at HVH (in general and cystectomy) [Liu et al. JAMA 2006; 296:1973. Konety et al. Cancer 2007; 109:542]
- Bladder cancer patients tend to be older and low SES; radical cystectomy generally perceived to be under-compensated. Regionalization increases burden of uncompensated care on HVHs [Soloway. Cancer 2005; 104:1559]

## Urologist Distribution

**Urologist Distribution**

- Odisho et al. J Urol, in press

- Data from HRSA Area Resource File, 2006

## Urologist Distribution

**Urologist Distribution**

- Odisho et al. J Urol, in press

- Data from HRSA Area Resource File, 2006

## Conclusions

- Regionalization of bladder and renal cancer care has occurred over the past 15 years
- Trend is likely to continue given provider demographic trends
- Policy decisions must balance (possible) benefit due to regionalization with (likely) harm if access is reduced
- Alternative: identify and promulgate HVH processes of care
- HCUP/NIS invaluable for descriptive health services research; clinically rich data needed to better define volume-outcomes associations