The incidence of hospital acquired adverse events in radical cystectomy and their implications for hospital outcomes and costs remain poorly described. We describe the incidence of hospital acquired adverse events in radical cystectomy, and characterize its relationship with in-hospital mortality, length of stay and hospitalization costs. We identified 10,856 patients who underwent radical cystectomy for bladder cancer at 1,175 hospitals in the Nationwide Inpatient Sample from 2001 to 2008. We used hospital claims to identify adverse events for accidental puncture, decubitus ulcer, deep vein thrombosis/pulmonary embolus, methicillin-resistant Staphylococcus aureus, Clostridium difficile, surgical site infection and sepsis. Logistic regression and generalized estimating equation models were used to test the associations of hospital acquired adverse events with mortality, predicted prolonged length of stay and total hospitalization costs. Hospital acquired adverse events occurred in 11.3% of all patients undergoing radical cystectomy (1,228). Adverse events were associated with a higher odds of in-hospital death (OR 8.07, p<0.001), adjusted prolonged length of stay (41.3%) and total costs ($54,242 vs $26,306; p<0.001) compared to no adverse events on multivariate analysis. The incremental total costs attributable to hospital acquired adverse events were $43.8 million. Postoperative sepsis was associated with the highest risk of mortality (OR 17.56, p<0.001), predicted prolonged length of stay (62.22%) and adjusted total cost ($79,613). With hospital acquired adverse events occurring in approximately 11% of radical cystectomy cases, they pose a significant risk of in-hospital mortality and higher hospitalization costs. Therefore, increased attention is needed to reduce adverse events by improving patient safety, while understanding the economic implications for tertiary referral centers with possible policy changes such as denial of payment for hospital acquired adverse events.

We described population level trends in radical prostatectomy for patients with prostate cancer by hospitals with robotic surgery, and assessed whether socioeconomic disparities exist in access to such hospitals. After merging the NIS (Nationwide Inpatient Sample) and the AHA (American Hospital Association) survey from 2006 to 2008, we identified 29,837 patients with prostate cancer who underwent radical prostatectomy. The primary outcome was treatment with radical prostatectomy at hospitals that have adopted robotic surgery. Multivariate logistic regression was used to identify patient and hospital characteristics associated with radical prostatectomy performed at hospitals with robotic surgery. Overall 20,424 (68.5%) patients were surgically treated with radical prostatectomy at hospitals with robotic surgery, while 9,413 (31.5%) underwent radical prostatectomy at hospitals without robotic surgery. There was a marked increase in radical prostatectomy at hospital adopters from 55.8% in 2006 and 70.7% in 2007 to 76.1% in 2008 (p <0.001 for trend). After adjusting for patient and hospital features, lower odds of undergoing radical prostatectomy at hospitals with robotic surgery were seen in black patients (OR 0.81, p <0.001) and Hispanic patients (OR 0.77, p <0.001) vs white patients. Compared to having private health insurance, being primarily insured with Medicaid (OR 0.70, p <0.001) was also associated with lower odds of being treated at hospitals with robotic surgery. Although there was a rapid shift of patients who underwent radical prostatectomy to hospitals with robotic surgery from 2006 to 2008, black and Hispanic patients or those primarily insured by Medicaid were less likely to undergo radical prostatectomy at such hospitals.

What's known on the subject? and What does the study add?: Variations in the type of urinary diversion exist for patients undergoing radical cystectomy. Although its use has been increasing from 2001 to 2008, patients who are older, female, and primary insured by Medicaid are less likely to receive continent diversions. Furthermore, patients treated surgically at high‐volume and teaching hospitals are more likely to receive continent diversions. Objective: To describe the contemporary trends in urinary diversion among patients undergoing radical cystectomy ( RC ) for bladder cancer; and elucidate whether socioeconomic disparities persist in the type of diversion performed in the USA from a population‐based cohort. Patients and Methods: Using the Nationwide Inpatient Sample, we identified patients who underwent RC for bladder cancer between 2001 and 2008. Multivariable regression models were used to identify patient and hospital covariates associated with continent urinary diversion and enumerate predicted probabilities for statistically significant variables over time. Results: Overall, 55 635 (92%) patients undergoing RC for bladder cancer received incontinent urinary diversion, while 4552 (8%) patients received continent diversion from 2001 to 2008. Receipt of continent urinary diversion increased from 6.6% in 2001–2002 to 9.4% in 2007–2008 ( P < 0.001 for trend). Patients who were older (odds ratio [ OR ] 0.93; P < 0.001), female ( OR 0.52; P < 0.001) and insured by Medicaid ( OR 0.54; P = 0.002) were less likely to receive continent urinary diversion. However, patients treated at teaching ( OR 2.14; P < 0.001) and high‐volume hospitals ( OR 2.39; P = 0.04) had higher odds of continent urinary diversion. Predicted probabilities of continent diversion remained lower for female patients, Medicaid insurance status, and non‐teaching and medium/low‐volume hospitals over time. Conclusions: In this nationally representative sample of hospitals from 2001 to 2008, the use of continent diversion in RC gradually increased. Although variations in urinary diversion exist by hospital teaching status, case volume, patient gender and primary health insurance, increased attention in expanding the use of continent diversions may help reduce these disparities for patients undergoing RC for bladder cancer.

We assessed the relationship of surgical margins across different surgical approaches to partial nephrectomy in patients with clinical T1a renal cell carcinoma in a population based cohort. We used NCDB (National Cancer Database) to identify all patients who underwent partial nephrectomy for clinical T1a renal cell carcinoma (tumor size less than 4 cm) from 2010 to 2011. The primary outcome was surgical margin status in patients treated with partial nephrectomy by the open, laparoscopic or robotic approach. Multivariable logistic regression analysis was done to identify patient, hospital and surgical factors associated with positive surgical margins. Partial nephrectomy was done in 11,587 patients, including open, laparoscopic and robotic nephrectomy in 5,094 (44%), 1,681 (14%) and 4,812 (42%), respectively. Mean±SD age was 56±12 years. Overall 806 patients (7%) had positive surgical margins. The positive surgical margin prevalence was 4.9%, 8.1% and 8.7% for the open, laparoscopic and robotic approaches, respectively (p<0.001). Laparoscopic and robotic partial nephrectomy had a higher adjusted OR for positive surgical margins (OR 1.81 and 1.79, respectively, each p<0.001) than open nephrectomy. When stratified by hospital type, differences in positive surgical margin rates remained, such that patients treated at academic medical centers who underwent laparoscopic and robotic partial nephrectomy had a higher adjusted OR (1.38, p=0.074 and 1.73, p<0.001, respectively) than patients treated with open partial nephrectomy. Laparoscopic and robotic partial nephrectomy is associated with higher positive surgical margin rates compared to open partial nephrectomy for clinical T1a renal cell carcinoma. The effect of margin status on long-term oncologic outcomes in this context remains to be determined.

Prostate cancer is the most common cancer among males and the second most common reason for cancer-related deaths in US men.¹ Among the 238 000 patients diagnosed with prostate cancer each year, most men are diagnosed as having localized disease because of the widespread use of prostate-specific antigen screening.^2,3 Men diagnosed as having clinically localized prostate cancer have multiple disease management options, including active surveillance, surgery, or radiotherapy.⁴ Patients, physicians, and key stakeholders are currently confronted with a paucity of high-quality evidence to effectively guide treatment decisions.⁵ As a result, clinical practice guidelines recommend radical prostatectomy, radiotherapy, or active surveillance based on the patient’s prostate cancer risk stratification, life expectancy, and patient preferences.^6-8 Because each treatment carries significant adverse effects on health-related quality of life (QOL),^9,10 it is well recognized that high-quality treatment decisions incorporate patient preferences and values into the treatment decision and require adequate patient knowledge about prostate cancer and all relevant treatments.

Background and Objectives: The paradoxical rise in overall and cancer-specific mortality despite increased detection and treatment of renal cell carcinoma (RCC) is termed “treatment disconnect.” We reassess this phenomenon by evaluating impact of missing data and rising incidence on mortality trends. Research Design, Subjects, and Measures: Using Surveillance, Epidemiology, and End Results data, we identified patients with RCC diagnosis from 1973 to 2011. We estimated mortality rates by tumor size after accounting for lags from diagnosis to death using multiple imputations for missing data from 1983. Mortality rates were estimated irrespective of tumor size after adjustment for prior cumulative incidence using ridge regression. Results: A total of 78,891 patients met inclusion criteria. Of 70,212 patients diagnosed since 1983, 10.4% had missing data. Significant attenuation in cancer-specific mortality was noted from 1983 to 2011 when comparing observed with imputed rates: Δ_obs0.05 versus Δ_imp0.10 (P=0.001, <2 cm tumors); Δ_obs0.29 versus Δ_imp0.18 (P=0.005, 2–4 cm tumors); Δ_obs0.46 versus Δ_imp–0.20 (P<0.001, 4–7 cm tumors); Δ_obs0.93 versus Δ_imp–0.15 (P7 cm tumors). Holding incidence of RCC constant to 2011 rates, temporal increase in overall mortality for all patients was attenuated (P<0.001) when comparing observed estimates (3.9–6.8) with 2011 adjusted estimates (5.9–7.1), suggesting that rapidly rising incidence may influence reported overall mortality trends. These findings were supported by assessment of mortality to incidence ratio trends. Conclusions: Missing data and rising incidence may contribute substantially to the “treatment disconnect” phenomenon when examining mortality rates in RCC using tumor registry data. Caution is advised when basing clinical and policy decisions on these data.