Regional differences in total hospital costs for radical cystectomy in the United States

To test for regional differences in total hospital costs (THC) across the United States in bladder cancer patients treated with open radical cystectomy (ORC) or robotic-assisted radical cystectomy (RARC).

We relied on the National Inpatient Sample (NIS) database (2016-2019) and stratified RC patients according to census region (Midwest, Northeast, South, West). Primary statistical analyses consisted of THC-trend analyses and multivariable log-link linear regression models, after adjustment for hospital clustering (Generalized Estimating Equation function) and discharge disposition weighting. Finally, sensitivity analysis, relying on most favorable patient cohort, was performed.

Of 5280 eligible patients, 1441 (27%), 1031 (20%), 1854 (35%) and 954 (18%) underwent RC in the Midwest, Northeast, South and West, respectively. Median THC was 28,915$ and differed significantly between regions (Midwest: 28,105$; Northeast: 28,886$; South: 26,096$; West: 38,809$; p < 0.001). After stratification between ORC and RARC, highest THC was invariably recorded in the West: ORC 36,137$ vs 23,941-28,850$ and RARC 43,119$ vs 28,425-29,952$ (both p < 0.05). In multivariable log-link linear regression models, surgery in the West was independently associated with higher THC: ORC (Exponent beta [Exp[β]]: 1.39; 95%-CI: 1.32-1.47; p < 0.001) and RARC (Exp[β]: 1.46; 95%-CI: 1.38-1.55; p < 0.001). Results remained unchanged when analyses were refitted in most favorable patient subgroup.

Important regional differences in ORC and RARC THC distinguish the West from other United States regions. The THC discrepancy clearly requires closer examination to identify underlying processes that contribute to inflated costs in the West.