Health Literacy and Ethnicity as Predictors for Urinary Diversion Choice in Patients With Bladder Cancer

Objective: Continent urinary diversion is a quality-of-care metric for patients undergoing cystectomy for nonmetastatic muscle-invasive bladder cancer. However, Hispanic patients seem less likely to receive continent diversion than non-Hispanic patients, and the reasons for this remain unclear. This study aimed to identify the factors underlying this disparity in surgical decision-making. Methods: We conducted a single-institution, qualitative, prospective observational cohort study of 54 patients (31 non-Hispanic, 23 Hispanic) who underwent radical cystectomy between November 2019 and August 2024. Semistructured interviews explored decision-making, physician communication, and patient satisfaction. Health literacy was assessed using the Brief Health Literacy Screener (BHLS) and Newest Vital Sign (NVS). Qualitative data were analyzed using thematic analysis, and quantitative comparisons were performed using paired t tests and χ2 tests. Results: Although the mean age was similar between the Hispanic and non-Hispanic cohorts, patients with continent diversion were significantly younger than those who received an ileal conduit. Nearly one-third of those receiving continent diversion were Hispanic. The level of education did not differ by diversion type but was lower among Hispanic patients overall. Although the BHLS did not detect differences in health literacy, the NVS revealed that Hispanic patients scored lower than non-Hispanic patients, correlating with a higher likelihood of choosing an ileal conduit. Thematic analysis identified 5 main themes: understanding bladder cancer and urinary diversion, lifestyle implications, education and counseling, physician communication, and barriers to care. Hispanic patients more often reported limited autonomy in selecting a diversion and experienced gaps in the comprehension of surgical options, despite expressing high satisfaction with the care process. Conclusions: Lower health literacy, rather than the education level, emerged as a potential key factor associated with choosing incontinent urinary diversion in patients with bladder cancer. Hispanic patients were less likely to understand the difference between the procedures and more likely to choose the diversion decided by the treating physician. Improving health literacy screening and physician-patient dialogue may help at-risk populations better understand complex procedures and make autonomous decisions regarding urinary diversion.