Radical cystectomy (RC) is a very complex urologic procedure. Despite improvements in practice, technique and process of care, it is still associated with significant complications, including death, with reported postoperative mortality rates ranging from 0.8% to 8%. We examine the quality of surgical care indicators and document the mortality rates at 30, 60 and 90 days after RC across Quebec.
Within the Régie de l’assurance maladie du Québec (RAMQ) administrative database (this database provides prospectively collected universal data on all medical services) and the Institut de la statistique du Québec (ISQ) database (this provides vital status data), we used procedure codes to identify patients who underwent RC for bladder cancer in Quebec over 10 years (between 2000 and 2009), as well as RC outcomes and dates of death. Data obtained were retrospectively analyzed in relation to multiple parameters, including patient characteristics and health-care providers’ volumes. The outcomes analyzed included postoperative complications and mortality rates at 30, 60 and 90 days.
A total of 2778 RC were performed in 48 hospitals by 122 urologists across Quebec. Among them, 851 (30.6%) patients had at least one postoperative complication and 350 (12.6%) patients had more than one complication. The overall mortality rates at 30, 60 and 90 days were 2.8%, 5.3% and 7.5%, respectively, with significantly elevated 90-day mortality rates in some centres. In the multivariate analysis, increased age was associated with increased risk of post-RC complications and mortality. For example, patients over 75 had more chance of having at least one postoperative complication (odds ratio [OR] 1.66, 95% confidence interval [CI]: 1.31–2.11) and mortality at 90 days (OR 3.28, 95% CI: 2.05–5.26). Provider volume effect on outcomes was statistically significant, with large hospitals having decreased risk of 30-day mortality (OR 0.29, 95% CI: 0.12–0.70), 60-day mortality (OR 0.41, 95% CI: 0.26–0.82) and 90-day mortality (OR 0.52, 95% CI: 0.29–0.93) when compared to smaller hospitals. Surgeon volume showed weak, but not statistically significant, evidence of reduced odds of mortality for the high-volume surgeon. Limitations to our study include reliance on administrative data, which lack some relevant clinical information (such as patient functional status and tumour pathological characteristics) to perform risk adjustment analysis.
Our study demonstrates that postoperative outcomes after RC in Quebec varies based on several parameters. In addition, 30-day postoperative mortality after RC in Quebec appears acceptable. However, 90-day postoperative mortality rates remain significantly elevated in some centres, particularly in the elderly. This requires further research.