Variations in reconstruction after radical cystectomy

BACKGROUND. Most urologists specializing in the management of patients with bladder cancer consider continent urinary diversion the reconstructive technique that affords the best quality of life after radical cystectomy. The authors sought to evaluate factors that predict reconstructive technique after radical cystectomy. METHODS. Using linked data from Medicare and the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) program, 3611 subjects were identified who underwent radical cystectomy for bladder cancer between 1992 and 2000. Multivariate logistic regression was used to identify factors independently associated with utilization of continent reconstruction after radical cystectomy, incorporating patient and provider variables. RESULTS. In multivariate analysis, the likelihood of continent diversion was inversely associated with older age (odds ratio [OR] <= 0.68, P <=.002), African American race (OR 0.43, P =.003), and higher comorbidity index (OR 0.71, P =.03), and directly associated with male sex (OR 1.45, P =.002), higher education level (OR 1.54, P =.03), and year of surgery (OR >= 1.56, P <.001 for all year categories vs. 1992-1994). Treatment at academic (OR 1.43, P =.003) and NCI-designated cancer centers (OR 5.50, P <.001) and by high-volume providers (OR 1.49, P <.001) was independently associated with continent reconstruction. CONCLUSIONS. Disparities in the utilization of continent urinary diversion after radical cystectomy suggest that demographic, socioeconomic, provider-based, and clinical variables predict the likelihood that those undergoing radical cystectomy will receive continent reconstruction. Regionalization of bladder cancer care may ameliorate many of the disparities noted but must be balanced against the risk imposed by a delay in care.