Readmissions after colorectal surgery cannot be predicted

Contemporary perioperative care strategies

Background

Historically, the preoperative and postoperative care of patients with gastrointestinal cancer was provided by surgeons. Contemporary perioperative care is a truly multidisciplinary endeavour with implications for cancer-specific outcomes.

Methods

A literature review was performed querying PubMed and the Cochrane Library for articles published between 1966 to 2012 on specific perioperative interventions with the potential to improve the outcomes of surgical oncology patients. Keywords used were: fast-track, enhanced recovery, accelerated rehabilitation, multimodal and perioperative care. Specific interventions included normothermia, hyperoxygenation, surgical-site infection, skin preparation, transfusion, non-steroidal anti-inflammatory drugs, thromboembolism and antibiotic prophylaxis, laparoscopy, radiotherapy, perioperative steroids and monoclonal antibodies. Included articles had to be randomized controlled trials, prospective or nationwide series, or systematic reviews/meta-analyses, published in English, French or German.

Results

Important elements of modern perioperative care that improve recovery of patients and outcomes in surgical oncology include accelerated recovery pathways, thromboembolism and antibiotic prophylaxis, hyperoxygenation, maintenance of normothermia, avoidance of blood transfusion and cautious use of non-steroidal anti-inflammatory drugs, promotion of laparoscopic surgery, chlorhexidine–alcohol skin preparation and multidisciplinary meetings to determine multimodal therapy.

Conclusion

Multidisciplinary management of perioperative patient care has improved outcomes.

Fast-track pathways in colorectal surgery

Enhanced recovery after surgery or "fast-track" pathways are a multimodal approach to the perioperative management of patients undergoing colorectal surgery designed to improve the overall quality of care. These pathways use existing evidence to streamline and standardize the perioperative management of patients to improve pain management, speed intestinal recovery, and ultimately facilitate a more rapid hospital discharge, thus minimizing complications, decreasing the use of hospital resources and health care costs, and improving overall patient care and satisfaction. Fast-track protocols are safe for patients and offer improvement in intestinal recovery and hospital discharge.

Criteria to determine readiness for hospital discharge following colorectal surgery: an international consensus using the Delphi technique

BACKGROUND

Standardized discharge criteria are considered valuable to reduce the risk of premature discharge and avoid unnecessary hospital stays. The most appropriate criteria to indicate readiness for discharge after colorectal surgery are unknown.

OBJECTIVE

The aim of this study is to achieve an international consensus on hospital discharge criteria for patients undergoing colorectal surgery.

DESIGN

Fifteen experts from different countries participated in a 3-round Delphi process. In round 1, experts determined which criteria best indicate readiness for discharge and described specific end points for each criterion. In rounds 2 and 3, experts rated their agreement with the use of a 5-point Likert scale.

MAIN OUTCOME MEASURES

Consensus was defined when criteria and end points were rated as agree or strongly agree by at least 75% of the experts in round 3.

RESULTS

Experts reached consensus that patients should be considered ready for hospital discharge when there is tolerance of oral intake, recovery of lower gastrointestinal function, adequate pain control with oral analgesia, ability to mobilize and self-care, and no evidence of complications or untreated medical problems. Specific end points were defined for each of the criteria. Experts also agreed that after these criteria are achieved, discharge may take place as soon as the patient has adequate postdischarge support and is willing to leave the hospital. If a stoma was constructed, the patient or the patient's family should have received training on stoma care or had outpatient training arranged.

LIMITATIONS

The panel comprised mostly experts from developed countries. This may restrict the applicability of these discharge criteria in countries where there are dissimilar health care resources.

CONCLUSION

This Delphi study has provided substantial consensus on discharge criteria for patients undergoing colorectal surgery. We recommend that these criteria be used in clinical practice to guide decisions regarding patient discharge and applied in future research to increase the comparability of study results.

Factors predicting hospital length-of-stay and readmission after colorectal resection: a population-based study of elective and emergency admissions

BACKGROUND

The impact of developments in colorectal cancer surgery on length-of-stay (LOS) and re-admission have not been well described. In a population-based analysis, we investigated predictors of LOS and emergency readmission after the initial surgery episode.

METHODS

Incident colorectal cancers (ICD-O2: C18-C20), diagnosed 2002-2008, were identified from the National Cancer Registry Ireland, and linked to hospital in-patient episodes. For those who underwent colorectal resection, the associated hospital episode was identified. Factors predicting longer LOS (upper-quartile, > 24 days) for elective and emergency admissions separately, and whether LOS predicted emergency readmission within 28 days of discharge, were investigated using logistic regression.

RESULTS

8197 patients underwent resection, 63% (n = 5133) elective and 37% (n = 3063) emergency admissions. Median LOS was 14 days (inter-quartile range (IQR) = 11-20) for elective and 21 (15-33) for emergency admissions. For both emergency and elective admissions, likelihood of longer LOS was significantly higher in patients who were older, had co-morbidities and were unmarried; it was reduced for private patients. For emergency patients only the likelihood of longer LOS was lower for patients admitted to higher-volume hospitals. Longer LOS was associated with increased risk of emergency readmission.

CONCLUSIONS

One quarter of patients stay in hospital for at least 25 days following colorectal resection. Over one third of resected patients are emergency admissions and these have a significantly longer median LOS. Patient- and health service-related factors were associated with prolonged LOS. Longer LOS was associated with increased risk of emergency readmission. The cost implications of these findings are significant.

Dehydration is the most common indication for readmission after diverting ileostomy creation

BACKGROUND

Early readmission after discharge from the hospital is an undesirable outcome. Ileostomies are commonly used to prevent symptomatic anastomotic complications in colorectal resections.

OBJECTIVE

The aim of this study was to identify factors predictive of readmission after colectomy/proctectomy and diverting loop ileostomy.

DESIGN

This study is a retrospective review.

PATIENTS

Patients were included who underwent colon and rectal resections with ileostomy at our institution. Sex, age, type of disease, comorbidities, elective vs urgent procedure, type of ileostomy, operative method, steroid use, ASA score, and the use of diuretics were evaluated as potential factors for readmission.

MAIN OUTCOME MEASURES

The primary outcomes measured were the need for readmission and the presence of dehydration (ostomy output ≥1500 mL over 24 hours and a blood urea nitrogen/creatinine level ≥20, or physical findings of dehydration).

RESULTS

Six hundred three loop ileostomies were created mostly in white (95.3%), male (55.6%) patients undergoing colon or rectal resections. IBD was the most common indication at 50.9%, with rectal cancer at 16.1%, and other at 31.0%. The 60-day readmission rate was 16.9% (n = 102) with the most common cause dehydration (n = 44, 43.1%). Regression analysis demonstrated that the laparoscopic approach (p = 0.02), lack of epidural anesthesia (p = 0.004), preoperative use of steroids (p = 0.04), and postoperative use of diuretics (p = 0.0001) were highly predictive for readmission. Furthermore, regression analysis for readmission for dehydration identified the use of postoperative diuretics as the sole risk factor (p = 0.0001).

LIMITATIONS

This study is limited by the retrospective analysis of data, and it does not capture patients that were treated at home or in clinic.

CONCLUSION

Readmission after colon or rectal resection with diverting loop ileostomy was high at 16.9%. Dehydration was the major cause for readmission. Patients receiving diuretics are at increased risk for readmission for dehydration. High-risk patients should be treated more cautiously as inpatients and closely monitored in the outpatient setting to help reduce dehydration and readmission.

Patient readmission and mortality after colorectal surgery for colon cancer: impact of length of stay relative to other clinical factors

BACKGROUND

Data on readmission as well as the potential impact of length of stay (LOS) after colectomy for colon cancer remain poorly defined. The objective of the current study was to evaluate risk factors associated with readmission among a nationwide cohort of patients after colorectal surgery.

STUDY DESIGN

We identified 149,622 unique individuals from the Surveillance, Epidemiology, and End Results-Medicare dataset with a diagnosis of primary colorectal cancer who underwent colectomy between 1986 and 2005. In-hospital morbidity, mortality, LOS, and 30-day readmission were examined using univariate and multivariate logistic regression models.

RESULTS

Primary surgical treatment consisted of right (37.4%), transverse (4.9%), left (10.5%), sigmoid (22.8%), abdominoperineal resection (7.3%), low anterior resection (5.6%), total colectomy (1.2%), or other/unspecified (10.3%). Mean patient age was 76.5 years and more patients were female (52.9%). The number of patients with multiple preoperative comorbidities increased over time (Charlson comorbidity score ≥3: 1986 to 1990, 52.5% vs 2001 to 2005, 63.1%; p < 0.001). Mean LOS was 11.7 days and morbidity and mortality were 36.5% and 4.2%, respectively. LOS decreased over time (1986 to 1990, 14.0 days; 1991 to 1995, 12.0 days; 1996 to 2000, 10.4 days; 2001 to 2005, 10.6 days; p < 0.001). In contrast, 30-day readmission rates increased (1986 to 1990, 10.2%; 1991 to 1995, 10.9%; 1996 to 2000, 12.4%; 2001 to 2005, 13.7%; p < 0.001). Factors associated with increased risk of readmission included LOS (odds ratio = 1.02), Charlson comorbidities ≥3 (odds ratio = 1.27), and postoperative complications (odds ratio = 1.17) (all p < 0.01).

CONCLUSIONS

Readmission rates after colectomies have increased during the past 2 decades and mean LOS after this operation has declined. More research is needed to understand the balance and possible trade off between these hospital performance measures for all surgical procedures.

Readmission rates and cost following colorectal surgery

BACKGROUND

Hospital readmission is emerging as a quality indicator by the state, federal, and private payors with the goal of denying payment for select readmissions.

OBJECTIVE

We designed a study to measure the rate, cost, and risk factors for hospital readmission after colorectal surgery.

STUDY DESIGN/SETTING

We reviewed commercial health insurance records of 10,882 patients who underwent colorectal surgery over a 7-year period (2002-2008).

PATIENTS

All patients undergoing colon and/or rectal resection ages 18 to 64 were included.

MAIN OUTCOME MEASURE

The 30-day and 90-day readmission rates, the number of readmissions per patient, the median cost, length of stay, and risk factors for readmission were analyzed.

RESULTS

Thirty-day readmission occurred in 11.4% (1239/10,882) of patients. Readmission between 31 and 90 days occurred in an additional 11.9% (1027/10,882) of patients for a total 90-day readmission rate of 23.3%. Two or more readmissions occurred in 1.4% (155) and 5.2% (570) of patients in the first 30 and 90 days. Mean readmission length of stay was 8 days, and the median cost per stay was $8885. Initial hospitalization risk factors for readmission were the diagnosis of a surgical site infection (OR 1.2), creation of a stoma (OR 1.2), discharge to nursing home (OR 1.2), index admission length of stay >7 days (OR 1.2), proctectomy (OR 1.1), and severity of illness score (severity of illness 3 = OR 1.1; severity of illness 4 = OR 1.3).

CONCLUSIONS

Readmission after colorectal surgery occurs frequently and is associated with a cost of approximately $9000 per readmission. Nationwide these findings account for $300 million in readmission costs annually for colorectal surgery alone. Clinical and systems-based prevention strategies are needed to reduce readmission.

Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery

BACKGROUND

Health care systems provide care to increasingly complex and elderly patients. Colorectal surgery is a prime example, with high volumes of major procedures, significant morbidity, prolonged hospital stays, and unplanned readmissions. This situation is exacerbated by an exponential rise in costs that threatens the stability of health care systems. Enhanced recovery pathways (ERP) have been proposed as a means to reduce morbidity and improve effectiveness of care. We have reviewed the evidence supporting the implementation of ERP in clinical practice.

METHODS

Medline, Embase, and the Cochrane library were searched for randomized, controlled trials comparing ERP with traditional care in colorectal surgery. Systematic reviews and papers on ERP based on data published in major surgical and anesthesiology journals were critically reviewed by international contributors, experienced in the development and implementation of ERP.

RESULTS

A random-effect Bayesian meta-analysis was performed, including 6 randomized, controlled trials totalizing 452 patients. For patients adhering to ERP, length of stay decreased by 2.5 days (95% credible interval [CrI] -3.92 to -1.11), whereas 30-day morbidity was halved (relative risk, 0.52; 95% CrI, 0.36-0.73) and readmission was not increased (relative risk, 0.59; 95% CrI, 0.14-1.43) when compared with patients undergoing traditional care.

CONCLUSION

Adherence to ERP achieves a reproducible improvement in the quality of care by enabling standardization of health care processes. Thus, while accelerating recovery and safely reducing hospital stay, ERPs optimize utilization of health care resources. ERPs can and should be routinely used in care after colorectal and other major gastrointestinal procedures.

Determinants of preventable readmissions in the United States: a systematic review

BACKGROUND

Hospital readmissions are a leading topic of healthcare policy and practice reform because they are common, costly, and potentially avoidable events. Hospitals face the prospect of reduced or eliminated reimbursement for an increasing number of preventable readmissions under nationwide cost savings and quality improvement efforts. To meet the current changes and future expectations, organizations are looking for potential strategies to reduce readmissions. We undertook a systematic review of the literature to determine what factors are associated with preventable readmissions.

METHODS

We conducted a review of the English language medicine, health, and health services research literature (2000 to 2009) for research studies dealing with unplanned, avoidable, preventable, or early readmissions. Each of these modifying terms was included in keyword searches of readmissions or rehospitalizations in Medline, ISI, CINAHL, The Cochrane Library, ProQuest Health Management, and PAIS International. Results were limited to US adult populations.

RESULTS

The review included 37 studies with significant variation in index conditions, readmitting conditions, timeframe, and terminology. Studies of cardiovascular-related readmissions were most common, followed by all cause readmissions, other surgical procedures, and other specific-conditions. Patient-level indicators of general ill health or complexity were the commonly identified risk factors. While more than one study demonstrated preventable readmissions vary by hospital, identification of many specific organizational level characteristics was lacking.

CONCLUSIONS

The current literature on preventable readmissions in the US contains evidence from a variety of patient populations, geographical locations, healthcare settings, study designs, clinical and theoretical perspectives, and conditions. However, definitional variations, clear gaps, and methodological challenges limit translation of this literature into guidance for the operation and management of healthcare organizations. We recommend that those organizations that propose to reward reductions in preventable readmissions invest in additional research across multiple hospitals in order to fill this serious gap in knowledge of great potential value to payers, providers, and patients.

Readmission after colectomy for cancer predicts one-year mortality

OBJECTIVES

Early hospital readmission is a common and costly problem in the Medicare population. In 2009, the Centers for Medicaid and Medicare Services began mandating hospital reporting of disease-specific readmission rates. We sought to determine the rate and predictors of readmission after colectomy for cancer, as well as the association between readmission and mortality.

METHODS

Medicare beneficiaries who underwent colectomy for stage I to III colon adenocarcinoma from 1992 to 2002 were identified from the Surveillance, Epidemiology, and End Results-Medicare database. Multivariate logistic regression identified predictors of early readmission and 1-year mortality. Odds ratios were adjusted for multiple factors, including measures of comorbidity, socioeconomic status, and disease severity.

RESULTS

Of 42,348 patients who were discharged, 4662 (11.0%) were readmitted within 30 days. The most common causes of rehospitalization were ileus/obstruction and infection. Significant predictors of readmission included male gender, comorbidity, emergent admission, prolonged hospital stay, blood transfusion, ostomy, and discharge to nursing home. Readmission was inversely associated with hospital procedure volume, but not surgeon volume. After adjusting for potential confounding variables, the predicted probability of 1-year mortality was 16% for readmitted patients, compared with 7% for those not readmitted. This difference in mortality was significant for all stages of cancer.

CONCLUSIONS

Early readmission after colectomy for cancer is common and due in part to modifiable factors. There is a remarkable association between readmission and 1-year mortality. Early readmission is therefore an important quality-of-care indicator for colon cancer surgery. These findings may facilitate the development of targeted interventions that will decrease readmissions and improve patient outcomes.

The intraoperative Surgical Apgar Score predicts postdischarge complications after colon and rectal resection

BACKGROUND

We previously developed an intraoperative 10-point Surgical Apgar Score-based on blood loss, lowest heart rate, and lowest mean arterial pressure-to predict major complications after colorectal resection. However, because complications often arise after uncomplicated hospitalizations, we sought to evaluate whether this intraoperative metric would predict postdischarge complications after colectomy.

METHODS

We linked our institution's National Surgical Quality Improvement Program database with an Anesthesia Intraoperative Management System for all colorectal resections over 4 years. Using Chi-square trend tests and logistic regression, we evaluated the Surgical Apgar Score's prediction for major postoperative complications before and after discharge.

RESULTS

Among 795 colectomies, there were 230 (29%) major complications within 30 days; 45 (20%) after uncomplicated discharges. Surgical Apgar Scores predicted both inpatient complications and late postdischarge complications (both P < .0001). Late complications occurred from 0 to 27 (median, 11) days after discharge; the most common were surgical site infections (42%), sepsis (24%), and venous thromboembolism (16%). In pairwise comparisons against average-scoring patients (Surgical Apgar Scores, 7-8), the relative risk of postdischarge complications trended lower, to 0.6 (95% confidence interval [CI], 0.2-1.7) for those with the best scores (9-10); and were significantly higher, at 2.6 (95% CI, 1.4-4.9) for scores 5-6, and 4.5 (95% CI, 1.8-11.0) for scores 0-4.

CONCLUSION

The intraoperative Surgical Apgar Score remained a useful metric for predicting postcolectomy complications arising after uncomplicated discharges. Even late complications may thus be related to intraoperative condition and events. Surgeons could use this intraoperative metric to target low-scoring patients for intensive postdischarge surveillance and mitigation of postdischarge complications after colectomy.

Laparoscopic versus open colectomy for patients with American Society of Anesthesiology (ASA) classifications 3 and 4: the minimally invasive approach is associated with significantly quicker recovery and reduced costs

BACKGROUND

Conceivably, the benefits of earlier recovery associated with a minimally invasive technique used in laparoscopic colectomy (LC) may be amplified for patients with comorbid disease. The dearth of evidence supporting the safety of laparoscopy for these patients led to a comparison of outcomes between LC and open colectomy (OC) for patients with American Society of Anesthesiology (ASA) classifications 3 and 4.

METHODS

Data for all ASA 3 and 4 patients who underwent elective LC were reviewed from a prospectively maintained laparoscopic database. The patients who underwent LC were matched with OC patients by age, gender, diagnosis, year, and type of surgery. Estimated blood loss, operation time, time to return of bowel function, length of hospital stay, readmission rate, and 30-day complication and mortality rates were compared using chi-square, Fisher's exact, and Wilcoxon tests as appropriate. A p value <0.05 was considered statistically significant.

RESULTS

In this study, 231 LCs were matched with 231 OCs. The median age of the patients was 68 years, and 234 (51%) of the patients were male. There were 44 (19%) conversions from LC to OC. More patients in the OC group had undergone previous major laparotomy (5 vs. 15%; p < 0.001). Estimated blood loss, return of bowel function, length of hospital stay, and total direct costs were decreased in the LC group. Wound infection was significantly greater with OC (p = 0.02). When patients with previous major laparotomy were excluded, the two groups had similar overall morbidity. The other benefits of LC, however, persisted.

CONCLUSION

The findings show that LC is a safe option for patients with a high ASA classification. The LC approach is associated with faster postoperative recovery, lower morbidity rates, and lower hospital costs than the OC approach.

Early readmission after ileoanal pouch surgery

PURPOSE

This study was designed to evaluate factors that might be predictive of readmission and early and long-term outcomes for patients readmitted after ileal pouch-anal anastomosis.

METHODS

Data for patients readmitted within 30 days after ileal pouch-anal anastomosis were identified from a prospectively maintained database and compared with the remaining patients. Early and delayed outcomes for readmitted patients, including long-term functional outcomes and quality of life, were evaluated. Potential predictors of readmission were assessed using a multivariate analysis of factors.

RESULTS

Of 3,410 patients who underwent ileal pouch-anal anastomosis from 1984 to 2008, 410 (12%) were readmitted. Reasons for readmission included ileus, obstruction or dyselectrolytemia (54.9%), surgical site infection (19.8%), anastomotic problems (9.8%), and thrombotic (3.4%), hemorrhagic (3.2%), infectious (2.9%), cardiac (1.2%), and miscellaneous (4.3%) complications. Thirty-two (7.8%) patients underwent reoperation; 74 (18%) required invasive nonoperative interventions. Median hospital stay for readmission was four (range, 1-52) days. Readmitted patients had worse long-term functional results (P = 0.015) and social (P = 0.024), work (P = 0.008), and sexual (P = 0.046) restriction as compared with patients who were not readmitted. The Cleveland Global Quality of Life (P = 0.018) and physical SF-36 (P = 0.008) scores were also significantly lower for readmitted patients. On multivariate analysis, comorbid conditions (P = 0.014, odds ratio = 1.36), laparoscopic technique (P = 0.008, odds ratio = 1.8), proctocolectomy (rather than initial subtotal colectomy) at ileal pouch-anal anastomosis (P < 0.001, odds ratio = 1.55), and postoperative blood transfusion (P = 0.02, odds ratio = 1.54) were independently associated with readmission.

CONCLUSION

Early readmission after ileal pouch-anal anastomosis is common. Associated comorbidity, laparoscopic approach, reconstruction of the ileal pouch-anal anastomosis at the index surgery, and postoperative blood transfusion are associated with readmission.

Hospital readmission rates after ileal pouch-anal anastomosis

PURPOSE

The goal of this study was to determine the unplanned hospital readmission rate following ileal pouch-anal anastomosis, prior to loop ileostomy closure.

METHODS

Patients undergoing ileal pouch-anal anastomosis over a five-year period were included in this retrospective study. Unplanned readmissions and readmission diagnoses were compiled. Gender, age, type of disease, duration of illness, elective vs. urgent surgical indication, operative method, steroid use, American Society of Anesthesiologists score, and regional anesthesia use at initial ileal pouch-anal anastomosis were evaluated as potential factors for readmission. Total length of stay was compared between patients readmitted and not readmitted.

RESULTS

One hundred and ninety-five patients underwent ileal pouch-anal anastomosis with diverting ileostomy. Fifty-nine patients (30 percent) required readmission. Forty-one patients had a single readmission, and 18 patients had at least 2 readmissions. Small bowel obstruction (28/86) and pelvic sepsis/ anastomotic leak (28/86) were the most common diagnoses upon readmission. Seventeen of 59 patients (28.8 percent) required surgical intervention following readmission and 42 patients were managed nonoperatively. Patients using systemic steroids at the time of surgery were more likely to be readmitted [47/116 (41 percent) vs. 12/79 (15 percent), P = 0.001). Length of stay (including initial admission for ileal pouch-anal anastomosis) for patients requiring readmission averaged 19.6 days vs. 9.6 days for patients not readmitted.

CONCLUSIONS

Hospital readmission after ileal pouch-anal anastomosis is common. We plan to institute a more intensive follow-up in an effort to prevent readmission of selected high-risk patients who might be effectively managed as outpatients.

Can We Predict Unplanned Hospital Readmission after Colectomy for Ulcerative Colitis and Indeterminate Colitis?

Unplanned readmission (UR) is considered to be an index of quality surgical care. We examined whether any perioperative factor was associated with UR after colectomy for ulcerative colitis (UC) or indeterminate colitis (IC). Patients undergoing a two-stage or three-stage ileal pouch-anal anastomosis were included. Patient, disease, and surgical factors were collected. UR occurring within 30 days of hospital discharge was assessed. The 202 study patients had a median age of 38 years. Median body mass index was 22. There were 130 (64%) UC patients and 72 (36%) IC patients. Indications for surgery were medically refractory disease (n = 176, 87%) and dysplasia/cancer (n = 26, 13%). Preoperative medical therapy included steroids alone in 25 patients and steroids combined with other immunomodulators in 151 patients. A two-stage and three-stage ileal pouch-anal anastomosis was used in 146 (72%) and 56 (28%) patients, respectively. Median white blood cell count before discharge was 8600 cells/mm3. Median length of stay after surgery was 7 days. Complications before discharge were observed in 28 patients (14%). Thirty-eight patients (19%) had a UR. No preoperative or surgical factor was associated with UR. Although UR occurs frequently (19%) after colectomy for UC or IC, it cannot be predicted.

Predictors and Outcome of Readmission after Laparoscopic Intestinal Surgery

BACKGROUND

Previous studies have failed to identify predictors of early readmission after major intestinal operations. The objectives of this study were to determine readmission rates, outcomes, and predictors of readmission for patients undergoing laparoscopic colon and rectal operations.

METHODS

Patients readmitted (PR) to the hospital within 30 days of discharge after laparoscopic colon and rectal operations were identified from a prospectively maintained database. The PR group was compared with patients that were not readmitted (NR). Outcomes and variables related to readmission were evaluated.

RESULTS

There were 820 consecutive elective laparoscopic colon and rectal operations performed over a 5-year period, with adequate follow-up data for 787 cases. Seventy-nine (10%) patients were readmitted. There was no difference in the age, sex, surgeon, or type of operation between the PR and NR groups. The most common causes for readmission were bowel obstruction (19%), ileus (18%), intra-abdominal abscess (14%), and anastomotic leak (9%). Overall mean (median) length of stay (LOS) for the index admission was 3.7 +/- 4.3 (3.0) days. Patients in the PR group had a trend toward a longer index admission LOS than the NR group (5.4 +/- 8.8 [3.0] versus 3.5 +/- 3.3 [3.0], p = 0.068). Univariate analysis demonstrated that patients with inflammatory bowel disease, pulmonary comorbidities, and steroid use were more likely to be readmitted. Multivariate analysis confirmed that inflammatory bowel disease and pulmonary comorbidity are independent risk factors for readmission.

CONCLUSIONS

Early readmission after laparoscopic colon and rectal operations is not associated with early discharge. Identification of specific patient characteristics indicating risk for early readmission may allow for selective changes in perioperative care or discharge criteria to avoid unexpected readmission.

Risk factors of unplanned readmission after colorectal surgery: a prospective, multicenter study

PURPOSE

Unplanned readmission after colorectal surgery is a relatively frequent event, knowledge of which often is inaccurate. This study was designed to examine the incidence and causes of readmissions and to determine the criteria that could predict them.

METHODS

From June to September 2002, 1,421 patients were enrolled in a prospective, multicenter study performed by the Association Francaise de Chirurgie. The goal of the study was to determine mortality and morbidity after colorectal surgery for elective or emergency surgical management of diverticular disease or cancer. In the study, readmissions within three months after discharge were assessed.

RESULTS

Of 1,421 patients, 342 patients (27 percent) were readmitted once after a mean period of 53 days. Among the readmissions, 248 (19.5 percent) were planned and 94 (7.5 percent) were unplanned (mainly for septic complications). With the multivariate logistic regression analysis, five independent factors were significantly associated with a higher risk of unplanned readmission (in order of importance): surgical field contamination, long duration of operation, need for an associated surgical procedure, hemoglobin level <12 g/dl, and absence of air testing after colorectal anastomosis.

CONCLUSIONS

The study permitted to individualize several factors significantly associated with a higher risk of unplanned readmission after colorectal surgery.

Readmission rates after a planned hospital stay of 2 versus 3 days in fast-track colonic surgery

Background

Initial programmes of fast-track open colonic surgery with a planned 2-day postoperative hospital stay have had a high readmission rate (about 20 per cent). The aim of this large, consecutive series was to compare readmission rates after a fast-track open colonic surgery programme with a planned hospital stay of 2 versus 3 days.

Methods

The study included 541 consecutive colonic resections from one surgical department with a structured care programme, including well defined discharge criteria, between April 1997 and December 2005. The planned hospital stay was increased from 2 to 3 days from August 2004. All patients were examined 8 and 30 days after surgery.

Results

Readmission rates fell from 20·1 per cent in 408 patients with a planned 2-day hospital stay (period 1) to 11·3 per cent in 133 patients with a planned 3-day hospital stay (period 2) (P &lt; 0·020). Median length of primary hospital stay was 2 and 3 days, median stay after readmission was 5 and 5·5 days, and median (mean) total stay was 3 (5·6) and 3 (5·7) days in periods 1 and 2 respectively. The readmission rate in period 2 was lower because there were fewer readmissions for short-term observation or social reasons. There was no difference in type and incidence of morbidity between the two periods.

Conclusion

Readmission after fast-track open colonic resection was reduced by planning discharge 3 instead of 2 days after surgery, with the same discharge criteria.

Multivariable analysis of factors associated with hospital readmission after intestinal surgery

BACKGROUND

Readmission rates after major abdominal surgery have a significant impact on hospital costs and quality of care. Identification of risk factors for readmission may improve postoperative care and discharge plans.

METHODS

One hundred fifty consecutive patients readmitted within 30 days of discharge after intestinal surgery (RD) were compared with matched nonreadmitted patients. Patient-related (demographic, comorbidity, medications), disease-related (diagnosis, type of surgery), and perioperative course variables were collected for logistic regression analysis.

RESULTS

RD was associated with chronic obstructive pulmonary disease (odds ratio [OR] 7.12 and 95% confidence interval [CI] 1.4-37.6), worse functional capacity class (OR 2.02 and CI 1.15-3.56), previous anticoagulant therapy (OR 4.85 and CI 1.2-19.7), steroid treatment, and discharge to a facility other than home (OR 4.35 and CI 0.97-20.0, P = .055). In patients with intestinal perforation, RD rate was decreased (OR 0.3 and CI 0.1-0.9), but this was associated with a longer primary hospital stay (median 8 vs. 6 days, P = .12). RD causes included surgical site septic complications (33%), ileus and/or small-bowel obstruction (23%), medical complications (24%), and others (20%).

CONCLUSIONS

Functional capacity, chronic obstructive pulmonary disease, previous anticoagulant therapy, perioperative steroids, and discharge destination are independent predictors of RD. Disease-related factors have minor impact on RD rates. Improving functional status before surgery, decreasing the adverse impact of steroids, and/or stratifying perioperative anticoagulant use may decrease unexpected readmissions in this patient population.

Phase III trial of alvimopan, a novel, peripherally acting, mu opioid antagonist, for postoperative ileus after major abdominal surgery

PURPOSE

Postoperative ileus presents significant clinical challenges that potentially prolong hospital stay, contribute to readmission, and increase morbidity. There is no approved treatment for postoperative ileus. Alvimopan is a novel, peripherally acting, mu opioid receptor antagonist currently in development for the management of postoperative ileus.

METHODS

Patients undergoing partial colectomy or simple or radical hysterectomy were randomized to receive alvimopan 6 mg (n = 152), alvimopan 12 mg (n = 146), or placebo (n = 153) orally 2 hours before surgery and twice daily thereafter until discharge or for up to seven days. The primary efficacy end point, time to return of gastrointestinal function, was a composite measure of passage of flatus or stool and tolerating solid food. Secondary end points included time to the hospital discharge order written. Adverse events were monitored throughout the study.

RESULTS

Mean time to gastrointestinal recovery was significantly reduced in patients treated with alvimopan 6 mg vs. placebo (hazard ratio = 1.45; P = 0.003), with a smaller reduction seen with alvimopan 12 mg (hazard ratio = 1.28; P = 0.059). Mean time to the hospital discharge order written was significantly accelerated in patients treated with alvimopan 6 mg (hazard ratio = 1.50; P < 0.001). The most common treatment-emergent adverse events across all treatment groups were nausea, vomiting, and hypotension; the incidence of nausea and vomiting was reduced by 53 percent in the alvimopan 12-mg group.

CONCLUSIONS

In patients undergoing major abdominal surgery, alvimopan accelerated gastrointestinal recovery and time to the hospital discharge order written compared with placebo and was well tolerated.

Alvimopan, a novel, peripherally acting mu opioid antagonist: results of a multicenter, randomized, double-blind, placebo-controlled, phase III trial of major abdominal surgery and postoperative ileus

OBJECTIVE

To demonstrate that alvimopan (6 or 12 mg) accelerates recovery of gastrointestinal (GI) function in patients undergoing laparotomy for bowel resection or radical hysterectomy.

SUMMARY BACKGROUND DATA

Postoperative ileus (POI) following laparotomy may increase morbidity and extend hospitalization. Opioids can contribute to the duration of POI. Alvimopan is a novel opioid receptor antagonist in development for the management of POI.

METHODS

A total of 510 patients scheduled for bowel resection or radical hysterectomy were randomized (1:1:1) to receive alvimopan 6 mg, alvimopan 12 mg, or placebo orally > or =2 hours before surgery, then twice a day (b.i.d.) until hospital discharge or for up to 7 days. The primary efficacy end point was a composite of time to recovery of upper and lower GI function. An associated secondary end point was time to hospital discharge order written.

RESULTS

The modified intent-to-treat population included 469 patients (451 bowel resection and 18 radical hysterectomy patients). Time to recovery of GI function was accelerated for the alvimopan 6 mg (hazard ratio [HR] = 1.28; P < 0.05) and 12 mg (HR = 1.54; P < 0.001) groups with a mean difference of 15 and 22 hours, respectively, compared with placebo. The time to hospital discharge order written was also accelerated in the alvimopan 12 mg group (HR = 1.42; P = 0.003) with a mean difference of 20 hours compared with placebo. The incidence of adverse events was similar among treatment groups.

CONCLUSIONS

Alvimopan accelerated GI recovery and time to hospital discharge order written compared with placebo in patients undergoing laparotomy and was well tolerated.

Outcomes and prediction of hospital readmission after intestinal surgery1 1No competing interests declared

BACKGROUND

Clinical care pathways reduce postoperative stay after major bowel operations. Concerns about unexpected early readmissions and delays in diagnosis of complications remain unanswered. The objectives of this study were determination of readmission rate and outcomes for patients undergoing intestinal operations.

STUDY DESIGN

Patients readmitted (PR) within 30 days of discharge after intestinal operations were compared with patients who were not readmitted (NR). Variables that might predict readmission were evaluated.

RESULTS

Of 553 patients, 56 (10.1%) were readmitted after 10 days (interquartile range [IQR] 4.5 to 15.5 days). PR and NR groups had similar age, gender, diagnosis, preoperative comorbidities, and index operations. Discharge hemoglobin level, white cell count, antibiotic use, or presence of stoma did not affect readmission. PR had a greater frequency of steroid use (p = 0.03) during index admission. Median length of stay for the index hospitalization was 5 days (IQR 4 to 8 days) for the NR and 6 days (IQR 4.8 to 9 days) for the PR group (p = 0.049). Duration of readmission was 4 days (IQR 2 to 9 days) in the PR group, with equal total median length of stay identical for PR and NR patients with complications (median 12 days). Clinical outcomes for PR patients and NR patients with complications were similar.

CONCLUSIONS

Early readmission is an unpredictable sequel of major bowel operations; it does not correlate with shorter hospital stay. Identification of unpredictable complications after discharge that require later invasive intervention does not adversely affect clinical outcomes. Readmission within 30 days of a patient who has attained standardized discharge criteria may not be a valid indicator of poor quality of care.