BACKGROUND Radical cystectomy (RC) for muscle-invasive bladder cancer (BCa) has potential for serious complications, prolonged length of stay and readmissions-all of which may increase costs. Although variations in outcomes are well described, less is known about determinants driving variation in costs. OBJECTIVE To assess surgeon- and hospital-level variations in costs and predictors of high- and low-cost RC. DESIGN, SETTING, AND PARTICIPANTS Cohort study of 23 173 patients who underwent RC for BCa in 208 hospitals in the USA from 2003 to 2015 in the Premier Healthcare Database. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Ninety-day direct hospital costs; multilevel hierarchal linear models were constructed to evaluate contributions of each variable to costs. RESULTS AND LIMITATIONS Mean 90-d direct hospital costs per RC was $39 651 (standard deviation $34 427), of which index hospitalization accounted for 87.8% ($34 803) and postdischarge readmission(s) accounted for 12.2% ($4847). Postoperative complications contributed most to cost variations (84.5%), followed by patient (49.8%; eg, Charlson Comorbidity Index [CCI], 40.5%), surgical (33.2%; eg, year of surgery [25.0%]), and hospital characteristics (8.0%). Patients who suffered minor complications (odds ratio [OR] 2.63, 95% confidence interval [CI]: 2.03-3.40), nonfatal major complications (OR 12.7, 95% CI: 9.63-16.8), and mortality (OR 13.5, 95% CI: 9.35-19.4, all p<0.001) were significantly associated with high costs. As for low-cost surgery, sicker patients (CCI=2: OR 0.41, 95% CI: 0.29-0.59; CCI=1: OR 0.58, 95% CI: 0.46-0.75, both p<0.001), those who underwent continent diversion (vs incontinent diversion: OR 0.29, 95% CI: 0.16-0.53, p<0.001), and earlier period of surgery were inversely associated with low costs. CONCLUSIONS This study provides insight into the determinants of costs for RC. Postoperative morbidity, patient comorbidities, and year of surgery contributed most to observed variations in costs, while other hospital- and surgical-related characteristics such as volume, use of robot assistance, and type of urinary diversion contribute less to outlier costs. PATIENT SUMMARY Efforts to address high surgical cost must be tailored to specific determinants of high and low costs for each operation. In contrast to robot-assisted radical prostatectomy where surgeon factors predominate, high costs in radical cystectomy were primarily determined by postoperative complication and patient comorbidities.

中文翻译：

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美国膀胱癌根治性膀胱切除术费用的变化。

背景 肌肉浸润性膀胱癌 (BCa) 的根治性膀胱切除术 (RC) 可能会导致严重并发症、延长住院时间和再入院——所有这些都可能增加成本。尽管结果的变化得到了很好的描述，但对导致成本变化的决定因素知之甚少。目的 评估外科医生和医院级别的成本差异以及高成本和低成本 RC 的预测因素。设计、设置和参与者 2003 年至 2015 年 Premier Healthcare Database 中美国 208 家医院接受 RC 治疗 BCa 的 23173 名患者的队列研究。结果测量和统计分析 90 天的直接住院费用；构建了多级层次线性模型来评估每个变量对成本的贡献。结果和限制 每个 RC 的平均 90 天直接住院费用为 39651 美元（标准差 34427 美元），其中指数住院占 87.8%（34803 美元），出院后再入院占 12.2%（4847 美元）。术后并发症对成本变化的影响最大（84.5%），其次是患者（49.8%；例如，查尔森合并症指数 [CCI]，40.5%）、手术（33.2%；例如，手术年份 [25.0%]）和住院特征（8.0％）。患有轻微并发症（比值比 [OR] 2.63，95% 置信区间 [CI]：2.03-3.40）、非致命性主要并发症（OR 12.7，95% CI：9.63-16.8）和死亡率（OR 13.5，95%）的患者CI：9.35-19.4，所有 p<0.001）与高成本显着相关。至于低成本手术，病情较重的患者（CCI=2：OR 0.41，95% CI：0.29-0.59；CCI=1：OR 0.58，95% CI：0.46-0.75，均p<0。001），接受大陆转移（与失禁转移：OR 0.29，95% CI：0.16-0.53，p<0.001）和早期手术的患者与低成本成反比。结论 本研究提供了对 RC 成本决定因素的深入了解。术后发病率、患者合并症和手术年份对观察到的成本变化贡献最大，而其他与医院和手术相关的特征，如体积、机器人辅助的使用和尿流改道类型对异常成本的贡献较小。患者总结 解决高手术成本的努力必须针对每次手术成本高低的具体决定因素进行调整。与外科医生因素占主导地位的机器人辅助根治性前列腺切除术相比，