Economic impact of failed or delayed primary repair of bladder exstrophy: Differences in cost of hospitalization

Purpose: Patients with bladder exstrophy and failed primary newborn closure or who undergo delayed primary repair have suboptimal functional outcomes. We sought to determine whether these patients also have costlier, more resource intensive hospitalizations compared to patients who undergo neonatal primary closure. Materials and Methods: We reviewed hospital coding records to identify patients who underwent surgical repair of classic bladder exstrophy at The Johns Hopkins Hospital between 1997 and 2006, and obtained charge records for each hospitalization. Total hospital charges (excluding professional fees) were inflation adjusted to year 2005 dollars. Cases were identified as newborn primary repair, delayed primary repair or reclosure of failed prior repair. Results: Results of classic exstrophy repair were analyzed in 80 patients. A total of 34 procedures were newborn primary repairs, 15 were delayed primary repairs and 31 were reclosures of failed prior repair. All of the patients undergoing delayed primary repairs and reclosures underwent osteotomy, compared to only 21% of those undergoing newborn primary repair. Overall mean inflation adjusted hospitalization charge was $66,348 +/- $26,625 (range $29,689 to $179,403). Newborn closures were significantly less costly (mean charge $53,188 +/- $15,086) than either reclosure ($71,621 +/- $19,366) or delayed primary closure ($85,278 +/- $42,354, p < 0.0001). Controlling for multiple variables in a regression model showed that the primary factors associated with charges were operative time, days in intensive care unit and length of stay. Length of stay and operative times were significantly shorter in the newborn surgical group, likely accounting for the lower costs in this group (despite higher intensive care unit use). Mean hospital charges and mean length of stay increased during the study period. Conclusions: Primary newborn exstrophy repair is associated with lower surgical hospitalization costs compared to delayed primary repair and reclosure. Combined with previous data on clinical outcomes, these data reiterate the paramount importance of achieving a successful initial newborn closure whenever possible.