Patient Disposition Patterns following Transurethral Resection of Bladder Tumor Vary Widely: SEER-Medicare Analyses of Postoperative Discharge Practices

Introduction: Following transurethral resection of bladder tumor, patients can be discharged home, observed for 24 hours or admitted to the hospital. While disposition can impact care delivery value, little is known about postoperative management patterns. We examined national trends and predictors of disposition following transurethral resection of bladder tumor. Methods: We queried SEER (Surveillance, Epidemiology, and End Results)-Medicare for patients who underwent transurethral resection of bladder tumor between 1994 and 2009. HCPCS (Healthcare Common Procedure Coding System) observation codes and admission and discharge dates were used to classify disposition as inpatient, ambulatory or 24-hour observation. Multivariable logistic regression was used to test associations between patient, facility and tumor level covariates and disposition status. Results: We identified dispositions in 142,466 transurethral resections of bladder tumor, of which 107,784 (75.7%) were classified as ambulatory, 18,771 (13.2%) as inpatient and 15,911 (11.2%) as 24-hour observation. Patients with inpatient or 24-hour observation disposition were elderly (85 years old or older, OR 2.2), African American (OR 1.4) or Hispanic (OR 1.3), or infirm (Charlson comorbidity index 2 or higher, OR 1.5) or had large (greater than 5 cm, OR 1.6), high stage (3 OR 2.9 or 4, OR 3.5) tumors. Stent placement (OR 2.3) and restaging transurethral resection of bladder tumor (OR 1.8) were also associated with inpatient and 24-hour observation dispositions, while sequential resections were protective. Relative to 24-hour observation, individuals kept as inpatients were older (85 years old or older, OR 2.0), African American (OR 1.5) or Hispanic (OR 1.6), or infirm (Charlson comorbidity index 2 or higher, OR 1.7) or had large (greater than 5 cm, OR 1.1), high stage tumors (3 OR 2.1 or 4 OR 2.9). Temporal and geographic variations in disposition practice were identified. Conclusions: Disposition patterns are impacted by patient, tumor and treatment factors, and are heterogeneous following transurethral resection of bladder tumor. These data provide opportunities for care standardization and optimization in the value of care delivery for patients with bladder cancer.