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Editorial: Threading the cost–outcome needle after radical cystectomy




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I commend Borza et al. [1] on their timely study, which seeks to identify predictors of bounceback (≤3‐day) vs 30‐day readmissions after radical cystectomy. As the authors allude to in their paper, value‐based health reforms being undertaken in the USA seek to improve the quality of care delivery while simultaneously bending the healthcare cost curve [2]. For example, the Hospital Readmission and Reduction Program (HRRP), originally introduced in fiscal year 2013 for targeted medical conditions, has more recently been applied to a limited number of surgical procedures, whereby providers receive financial penalties for higher than expected 30‐day readmission rates [3]. While urological conditions/procedures are not currently targeted by programmes such as the HRRP, it is easy to envision a future where procedures with disproportionately high readmission rates, such as radical cystectomy, fall within the crosshairs of policy‐makers and insurers, alike.

The fact that nearly one in five patients undergoing cystectomy experiences a readmission within 3 days of index hospitalization discharge is staggering, and it is incumbent upon urologists as specialists to devise methods by which to improve the morbidity associated with cystectomy. For example, the findings of Borza et al. implicate postoperative infection as a major driver of early readmission. As evidenced by the work of Krasnow et al. [4], urologists have historically been poor stewards of peri‐operative antibiotic prophylaxis, and the development/implementation of strategies to improve guideline adherence represents a potentially simple yet effective means of reducing post‐cystectomy readmission rates. In a similar vein, there is an emerging body of literature demonstrating the important role that enhanced recovery after surgery (ERAS) protocols may play in improving peri‐operative complications and convalescence after radical cystectomy. However, there is inconsistency across the literature with regard to the precise components of ERAS, making cross‐institutional comparisons and adoption by other groups difficult [5]. Unless greater standardization and subsequent implementation of these enhanced recovery protocols occurs, progress in the field will remain incremental at best. Recent work by Mossanen et al. [6] further demonstrates the need for improving post‐cystectomy readmission rates, which, in addition to driving down healthcare costs/utilization, may actually reduce postoperative mortality. For example, they found that a readmission complication after cystectomy nearly doubled the predicted probability of postoperative mortality as compared to an initial complication (3.9% vs 7.4%; P < 0.001).

It is essential that urologists spearhead research such as that undertaken by Borza et al., which in turn can be used to develop strategies to develop value‐based reforms within the specialty that ‘thread the needle’ of physician autonomy, cost containment, and respect for the patient experience. In doing so, urologists will find themselves driving the conversation surrounding payment/quality reform rather than sitting on the figurative policy‐making sidelines while administrators/bureaucrats implement reforms with potentially profound effects on day‐to‐day clinical practice and the patient experience. Radical cystectomy is likely to fall within the crosshairs of the aforementioned reforms given the procedure’s high complication/readmission rate and the significant cost burden associated with these complications. An intuitive yet effective first step in combating the morbidity associated with radical cystectomy is the development, validation and implementation of standardized peri‐operative care pathways such as ERAS.

by David F. Friedlander

References

  1. Borza T, Kirk PS, Skolarus TA et al. Characterising ‘bounce‐back’ readmissions after radical cystectomy. BJU Int 2019;124:955-61
  2. Health Affairs (Millwood) Delivery Innovations 2017363923
  3. Boccuti CCCasillas GAiming for Fewer Hospital U‐turns: The Medicare Hospital Readmission Reduction Program2017. Accessed January 2019
  4. Krasnow REMossanen MKoo S et al. Prophylactic antibiotics and postoperative complications of radical cystectomy: a population based analysis in the United States. J Urol 2017198297– 304
  5. Chenam AChan KGEnhanced recovery after surgery for radical cystectomy. Cancer Treat Res. 2018175215– 39
  6. Mossanen MKrasnow REZlatev DV et al. Examining the relationship between complications and perioperative mortality following radical cystectomy: a population‐based analysis. BJU Int 201912440– 6

 

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