Predictors of the use of orthotopic bladder reconstruction after radical cystectomy for bladder cancer: Data from a pilot study of 1756 cases 2004-2011

Objective To examine variation in the use of orthotopic bladder reconstruction. Variability in the use of orthotopic reconstruction may indicate potential for quality improvement. Patients and Methods We analysed data from the British Association of Urological Surgeons Cancer Registry Complex Operations data set and Hospital Episode Statistics, covering the period 2004-2011. Three-level (patient, consultant and cancer network) mixed effect logistic regression models were used to examine sociodemographic and organizational variation in use of orthotopic reconstruction. The primary outcome was the odds ratio for use of orthotopic reconstruction for different patient groups. Results The final analysis sample included 1756 patients with bladder cancer who were treated by cystectomy by 121 consultants in 17 cancer networks. Of these, 120 (6.8%) were treated by orthotopic bladder reconstruction by 49 consultants in 14 cancer networks. In multivariable analysis, use of orthotopic surgery was higher in younger patients (odds ratio [OR] = 0.37 per increasing 10-year age group from 30-39 to ≥70, P ≤ 0.001) and men (OR = 2.31, P = 0.005). There was also some evidence of less frequent use among more deprived patients (OR per decreasing deprivation quintile 1.17, P = 0.037) and those with advanced disease (OR per increase in stage category 0.8, P = 0.037). After accounting for patient- and consultant-level variation, there was very limited variation in the use of orthotopic reconstruction between different cancer networks. Conclusions Within the study context, use of orthotopic surgery was relatively rare and variable between patients with different characteristics but not between different cancer networks. The extent by which this variation reflects variation in quality of care or patient choice is uncertain. Examining the dissemination of orthotopic surgery use using nationwide data is advisable.