The volume-mortality relation for radical cystectomy in England: retrospective analysis of hospital episode statistics

We read with interest the paper by Mayer and colleagues [1]
evaluating the relation between volume and mortality for radical
cystectomy in England. Their finding - that patients undergoing surgery in
medium volume hospitals have a poorer outcome than those in low volume
hospitals, contrasts with the majority of published data on this subject
[2-3].

One weakness of Mayer and colleagues study is that they only report
short-term outcomes following radical cystectomy – namely in-hospital and
30-day mortality. Mortality after cystectomy has been reported to rise
significantly beyond the 30-day period [4].

To evaluate if hospital volume influences longer term outcomes after
cystectomy, we identified patients undergoing radical cystectomy, again
within the HES database, but in a slightly more recent period (2002/03 -
2007/08).

Our data was consistent with Mayer and colleagues demonstrating that
30-day mortality was not statistically different between the different
hospital-volume bands (low volume: 3.0%; medium volume: 2.7%; high volume:
2.4%, p=0.22).

However, when 90-day mortality was evaluated, high volume hospitals
significantly outperformed both medium and low volume hospitals (low
volume: 7.6%, medium volume: 6.2%, high volume 5.7%, p=0.007).

The National Institute for Clinical Excellence recommends that
radical cystectomy only be performed in hospitals doing more than 50
pelvic cancer procedures a year [5]. Although we did not adjust for
structural and processes of care as Mayer and colleagues did, our results
support this guidance. When outcomes of pelvic cancer surgery are being
evaluated, analysis of 30-day mortality may result in erroneous
conclusions.

References

1. Mayer EK, Bottle A, Darzi AW, Athanasiou T, Vale JA.The volume-
mortality relation for radical cystectomy in England: retrospective
analysis of hospital episode statistics.BMJ. 2010 Mar 19;340:c1128. doi:
10.1136/bmj.c1128.

2.Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I,
Welch HG, Wennberg DE. Hospital volume and surgical mortality in the
United States.N Engl J Med. 2002 Apr 11;346(15):1128-37.

3. Joudi FN, Konety BR.The impact of provider volume on outcomes from
urological cancer therapy. J Urol. 2005 Aug;174(2):432-8.

4. Isbarn H, Jeldres C, Zini L, Perrotte P, Baillargeon-Gagne S, Capitanio
U, Shariat SF, Arjane P, Saad F, McCormack M, Valiquette L, Peloquin F,
Duclos A, Montorsi F, Graefen M, Karakiewicz PI.A population based
assessment of perioperative mortality after cystectomy for bladder cancer.
J Urol. 2009 Jul;182(1):70-7. Epub 2009 May 17.

5. www.nice.org.uk/nicemedia/live/10889/28771/28771.pdf. Improving
Outcomes in Urological Cancers

Competing interests:
Professor John Kelly is Chair of the NCRI Bladder Clinical Studies Group.