Adherence to Guidelines May Boost Cost of Follow-up Care After Radical Cystectomy

A new analysis suggests that adherence to guidelines for follow-up care in patients who have undergone a radical cystectomy may standardize care but may also increase expenditures compared with the cost of most current approaches, which are more conservative and deviate from existing guidelines. The study, published recently in Urologic Oncology, examined the sources of variation in care and the cost associated with standardizing care to recommended guidelines.1

Until now, standard approaches to follow up with patients in the 2 years after they undergo a radical cystectomy have been poorly defined, noted lead investigator Seth A. Strope, MD, MPH, Assistant Professor of Surgery, Division of Urologic Surgery, Washington University School of Medicine, St. Louis, MO, and colleagues. To evaluate variations in follow-up care, the investigators performed a population-based study using Surveillance, Epidemiology, and End Results (SEER) Medicare data. The cost associated with standardizing care based on current guidelines was also evaluated.

All but 25% of patients with bladder cancer aged between 66 and 90 years undergoing radical cystectomy had less expensive follow-ups than would be incurred using even a low-intensity set of recommendations in the National Comprehensive Cancer Network (NCCN) guidelines. Patients also had less expensive follow-ups than if their physicians had used the European Association of Urology (EAU) guidelines for their postradical cystectomy care. The investigators also found that imaging accounted for most of the cost in both guideline-recommended care and actual clinical practice.

Deviating from Recommended Guidelines

“Despite the 2 prevailing recommendations for relatively intensive surveillance following extirpative surgery for bladder cancer, our analysis of current practice patterns suggests that providers are conducting a more conservative approach that is, for the most part, less costly than published guidelines,” the investigators wrote. “Greater compliance with current guidelines would actually increase expenditures for payers and patients. Additionally, strict adherence to follow-up protocols may restrict patients’ choice, potentially negatively affecting patient’s quality of life.”

However, Dr Strope noted that there is much more work that needs to be done to determine what is truly the best care for patients.

“Current research suggests the survival benefit of follow-up testing after definitive bladder cancer surgery is small,” Dr Strope told Urology Practice Management. “In the absence of stronger evidence to support intensive follow-up after surgery, more conservative approaches appear indicated.”

Evaluating Variability and Cost

The team modeled the variability in expenditures for follow-up care as well as how much of the variability could be explained by various factors, such as those specific to the patients or their surgeons. They found that patient-specific factors—primarily nodal status, use of chemotherapy, hospital readmissions, and final disease stage—represented the majority of variation in expenditures. Surgeon-specific factors also accounted for a significant amount of the variability.

In the second part of the study, Dr Strope and colleagues calculated what the patients’ cost of follow-up care would be if the physicians were using NCCN guidelines for high-intensity or low-intensity (ie, conservative) care, or the EAU guidelines, and compared it with the 25th, 50th, and 75th percentiles of cost of care among SEER-database patients.

The guideline-recommended care was more expensive than actual care in every comparison except one: the NCCN conservative follow-up versus the 75th percentile of actual-care cost ($1384 vs $1737). The highest estimated cost was for NCCN-recommended high-intensity follow-up, at $4833. The second-highest was for EAU-recommended follow-up for patients with bladder cancer staged at >2, at $4071. Imaging accounted for the majority of the cost in every category, both actual and estimated.

The team concluded that adherence to published guidelines may boost costs of follow-up care; however, adherence to conservative guidelines would facilitate standardization of care without producing large increases in cost.


  1. Vemana G, Vetter J, Chen L, et al. Sources of variation in follow-up expenditure after radical cystectomy. Urol Oncol. 2015 Apr 20 [Epub ahead of print].

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