The volume–outcome relationship for radical cystectomy in England: an analysis of outcomes other than mortality


Erik K. Mayer, Department of Surgery and Cancer, 10th Floor QEQM Building, St Mary’s Hospital Campus, Imperial College London, London W2 1NY, UK. e-mail:


Study Type – Therapy (outcomes research) Level of Evidence 2c


  • • To evaluate the volume–outcome relationship for radical cystectomy in England using outcomes other than mortality.


  • • Patients undergoing an elective radical cystectomy were extracted from administrative hospital data for financial years 2000/1 to 2006/7.
  • • Institutional and surgeon volume was assessed against postoperative re-intervention, postoperative complications and emergency readmission within 28 days, using a set of models accounting for patient case-mix, the ‘clustered’ nature of the data and structural and process of care measures.


  • • In the final model, the odds of re-intervention within 14 and 30 days of operation for medium-volume institutions compared to low-volume institutions were found to be 63% (odds ratio, OR, 1.63; 95% CI 1.15–2.32; P= 0.01) and 52% (OR, 1.52; 95% CI, 1.13–2.04; P= 0.01) higher, respectively.
  • • In the summary of adjusted probabilities, low-volume institutions appeared to have a lower re-intervention rate than both medium- and high-volume institutions.
  • • By contrast, high-volume surgeons were associated with a reduced odds (OR, 0.68; 95% CI, 0.51–0.91; P= 0.01) of early re-intervention (within 14 days) compared to low-volume surgeons.
  • • This surgeon volume–outcome effect became apparent only after adjusting for the influence of the institution and structural and process of care confounders.
  • • There was no statistically significant relationship between volume and complication or readmission rates.


  • • Radical cystectomy measures of re-intervention rates can be used as outcome measures to discern differences across institutional or surgeon volume providers when the institutional and surgeon volume are co-examined and adjustment for structural and process of care confounders is performed.
  • • The finding of a lower risk of re-intervention in low-volume institutions needs to be explored further.