Factors that Influence Selection of Urinary Diversion among Bladder Cancer Patients in Three Community-Based Integrated Health Care Systems

Objectives: To assess the relative contributions of patient and surgeon factors for predicting selection of ileal conduit (IC), neobladder (NB), or continent pouch (CP) urinary diversions (UD) for patients diagnosed with muscle-invasive/high-risk non-muscle invasive bladder cancer. This information is needed to enhance research comparing cancer survivors’ outcomes across different surgical treatment options. Methods: Bladder cancer patients age ≥21 years with cystectomy/UD performed from 1/2010 to 6/2015 in three Kaiser Permanente regions were included. All patient and surgeon data were obtained from electronic health records. A mixed effects logistic regression model was used treating surgeon as a random effect and region as a fixed effect. Results: Of 991 eligible patients, 794 (80%) received IC. 169 surgeons performed the surgeries and accounted for a sizeable proportion of the variability in patient receipt of UD (ICC=.26). The multilevel model with only patient factors showed good fit (AUC=.93, Hosmer-Lemeshow test p=. 44), and older age, female sex, eGFR<45, 4+ comorbidity index score, and stage III/IV tumors were associated with higher odds of receiving an IC vs. NB/CP. However, including surgeon factors (annual cystectomy volume, specialty training, clinical tenure) had no association (p=.29). Conclusions: In this community setting, patient factors were major predictors of UD received. Surgeons also played a substantial role, yet clinical training and experience were not major predictors. Surgeon factors such as beliefs about UD options and outcomes should be explored.