RESUMEN
Importance: Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. Objective: To compare the 1-year costs associated with trimodal therapy vs radical cystectomy, accounting for survival and intensity effects on total costs. Design, Setting, and Participants: This population-based cohort study used the US Surveillance, Epidemiology, and End Results-Medicare database and included 2963 patients aged 66 to 85 years who had received a diagnosis of clinical stage T2 to T4a muscle-invasive bladder cancer from January 1, 2002, through December 31, 2011. The data analysis was performed from March 5, 2018, through December 4, 2018. Main Outcomes and Measures: Total Medicare costs within 1 year of diagnosis following radical cystectomy vs trimodal therapy were compared using inverse probability of treatment-weighted propensity score models that included a 2-part estimator to account for intrinsic selection bias. Results: Of 2963 participants, 1030 (34.8%) were women, 2591 (87.4%) were white, 129 (4.4%) were African American, and 98 (3.3%) were Hispanic. Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83â¯754 vs $68â¯692; median difference, $11â¯805; 95% CI, $7745-$15â¯864), 180 days ($187â¯162 vs $109â¯078; median difference, $62â¯370; 95% CI, $55â¯581-$69â¯160), and 365 days ($289â¯142 vs $148â¯757; median difference, $109â¯027; 95% CI, $98â¯692-$119â¯363), respectively. Outpatient care, radiology, medication expenses, and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On inverse probability of treatment-weighted adjusted analyses, patients undergoing trimodal therapy had $136â¯935 (95% CI, $122â¯131-$152â¯115) higher mean costs compared with radical cystectomy 1 year after diagnosis. Conclusions and Relevance: Compared with radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. The differences in costs were largely attributed to medication and radiology expenses associated with trimodal therapy. Extrapolating cost figures resulted in a nationwide excess spending of $468 million for trimodal therapy compared with radical cystectomy for patients who received a diagnosis of bladder cancer in 2017.
Asunto(s)
Cistectomía/métodos , Costos de la Atención en Salud , Estadificación de Neoplasias , Puntaje de Propensión , Sistema de Registros , Programa de VERF , Neoplasias de la Vejiga Urinaria/terapia , Anciano , Anciano de 80 o más Años , Terapia Combinada/economía , Cistectomía/economía , Femenino , Humanos , Masculino , Invasividad Neoplásica , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Resultado del Tratamiento , Estados Unidos/epidemiología , Neoplasias de la Vejiga Urinaria/diagnóstico , Neoplasias de la Vejiga Urinaria/epidemiologíaRESUMEN
CONTEXT: The centralization of cancer care is associated with better clinical outcomes and may be a method for optimizing value-based health care systems. OBJECTIVE: To systematically review the literature regarding the impact of centralization of care on clinical outcomes for genitourinary malignancies. EVIDENCE ACQUISITION: A systematic review was conducted using Ovid and MEDLINE to identify studies between 1970 and 2018 reporting on the centralization of care for genitourinary malignancies. Prospective and retrospective studies were screened. EVIDENCE SYNTHESIS: There were no published randomized control trials (RCTs) on the centralization of care for genitourinary malignancies. Twenty-two retrospective studies met inclusion criteria. Centralization of radical cystectomy was the most studied. Care for bladder cancer, prostate cancer, penile cancer, testicular cancer, and renal cancer was reportedly associated with better morbidity and survival outcomes for patients treated at high-volume centers. However, evidence of better outcomes for centralization of care remains limited for penile, renal, and testicular cancers owing to the paucity of data and/or the lower incidence of these genitourinary malignancies. CONCLUSIONS: Care for genitourinary malignancies by high-volume providers was associated with greater utilization of cancer surgery, lower morbidity, and better survival outcomes. Centralization of care was most appropriate for complex procedures such as radical cystectomy when interpreted in the context of survival outcomes. Further research is needed to address the impact of centralizing care for all urologic malignancies with consideration of the associated costs and patient-reported measures, including quality of life and patient experience. PATIENT SUMMARY: We explored the evidence for moving major operations into larger centers. We focused on surgery for cancers of the bladder, prostate, testicle, penis, and kidney, and found that larger-volume hospitals had better survival outcomes and fewer complications when compared to smaller hospitals. The difference may be greatest for complex major surgeries such as radical cystectomy.
Asunto(s)
Atención a la Salud/organización & administración , Hospitales de Alto Volumen/estadística & datos numéricos , Neoplasias Urogenitales/terapia , Instituciones Oncológicas , Cistectomía/estadística & datos numéricos , Cistectomía/tendencias , Atención a la Salud/tendencias , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Resultado del Tratamiento , Neoplasias Urogenitales/mortalidadRESUMEN
CONTEXT: Despite established guidelines for the treatment of muscle-invasive bladder cancer, it has been reported that radical cystectomy (RC) is markedly underused, especially among patients of advanced age and those with higher comorbidity burden and lower access to care. Understanding the interactions between patient, provider, and hospital factors may inform targeted interventions to optimize RC utilization. OBJECTIVE: To systematically review the literature regarding factors associated with RC utilization. EVIDENCE ACQUISITION: A systematic search was conducted using Ovid and Medline according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify studies between 1970 and 2017 reporting on RC utilization. Prospective and retrospective studies were included. EVIDENCE SYNTHESIS: There are no published randomized control trials on RC utilization. Variations in study quality and design precluded a formal statistical meta-analysis. RC receipt significantly depended on patient, provider, and hospital factors. Patient factors associated with lower RC use included advanced age, African American and Hispanic race/ethnicity, higher comorbidity burden, unmarried marital status, higher tumor stage and grade, and lower socioeconomic status. Provider factors associated with underutilization included lower surgeon volume and a metropolitan location. Finally, hospital factors associated with lower RC use included low hospital volume, nonacademic affiliation, and hospital location in the Midwest. CONCLUSIONS: RC is reportedly underutilized. We found that age, race, marital status, socioeconomic factors, cancer severity, comorbidity burden, surgeon volume, and facility type and location significantly determined RC receipt. Improved understanding of the varying contributions of the risk factors according to patient, provider, and hospital determinants may assist in developing targeted interventions to improve RC utilization. PATIENT SUMMARY: In this review we explored the clinical evidence for factors predicting the utilization of radical cystectomy for muscle-invasive bladder cancer. Many factors related to the patient, provider, and hospital determine whether patients receive this guideline-recommended treatment. However, there remains a lack of understanding on characterization and targeted interventions according to these levels, which may improve use.