Unplanned Readmission After Lung Resection: Complete Follow-Up in a 1-Year Cohort With Identification of Associated Risk Factors

Readmission after enhanced recovery video-assisted thoracoscopic surgery wedge resection

BACKGROUND

Despite the implementation of Enhanced Recovery After Surgery (ERAS) programs, surgical stress continues to influence postoperative rehabilitation, including the period after discharge. However, there is a lack of data available beyond the point of discharge following video-assisted thoracoscopic surgery (VATS) wedge resection. Therefore, the objective of this study is to investigate incidence and risk factors for readmissions after ERAS VATS wedge resection.

METHODS

A retrospective analysis was performed on data from prospectively collected consecutive VATS wedge resections from June 2019 to June 2022. We evaluated main reasons related to wedge resection leading to 90-day readmission, early (occurring within 0-30 days postoperatively) and late readmission (occurring within 31-90 days postoperatively). To identify predictors for these readmissions, we utilized a logistic regression model for both univariable and multivariable analyses.

RESULTS

A total of 850 patients (non-small cell lung cancer 21.5%, metastasis 44.7%, benign 31.9%, and other lung cancers 1.9%) were included for the final analysis. Median length of stay was 1 day (IQR 1-2). During the postoperative 90 days, 86 patients (10.1%) were readmitted mostly due to pneumonia and pneumothorax. Among the cohort, 66 patients (7.8%) had early readmissions primarily due to pneumothorax and pneumonia, while 27 patients (3.2%) experienced late readmissions mainly due to pneumonia, with 7 (0.8%) patients experiencing both early and late readmissions. Multivariable analysis demonstrated that male gender, pulmonary complications, and neurological complications were associated with readmission.

CONCLUSIONS

Readmission after VATS wedge resection remains significant despite an optimal ERAS program, with pneumonia and pneumothorax as the dominant reasons. Early readmission was primarily associated with pneumothorax and pneumonia, while late readmission correlated mainly with pneumonia.

Predictors of Readmission After Pulmonary Resection in Patients With Lung Cancer: A Systematic Review and Meta-analysis

Objective: Postoperative readmissions are considered an indicator of healthcare quality. The purpose of this study was to assess the factors associated with readmission following pulmonary resection for lung cancer. Methods: A comprehensive search was performed in PubMed, Web of science, the Cochrane Library, and databases of CNKI and Wanfang. We collected the factors associated with readmission following pulmonary resection from the included studies, and data analysis was conducted with STATA SE12.0 software. Results: A total of 11 studies (386 012 participants) were included. The meta-analysis results showed that age (standardized mean difference [SMD] = 0.093), male sex (odds ratio [OR] = 1.260), Charlson score (SMD = 1.408), forced expiratory volume in 1 second predicted (SMD = -0.203), congestive heart failure (OR = 1.708), peripheral vascular disease (OR = 1.436), and histology (OR = 0.804) were associated with readmission (P < .05), while hypertension was not. Patients with postoperative empyema, pneumonia, air leak, and arrhythmia (all P < .05) had higher odds of hospital readmission. Conclusion: The predictive factors for readmission can help in establishing individualized discharge and follow-up plans and programs for reducing hospital readmissions after pulmonary resection in patients with lung cancer.

[Patient outcomes after lung resection. The impact of unplanned readmission]

Unplanned readmissions after lung cancer surgery impair normal postoperative recovery and are associated with increased postoperative mortality. The objective of this review was to compile a detailed and comprehensive dataset on unplanned readmissions after pulmonary resection so as to better understand the associated factors and how they may be attenuated. Based on the identified risk factors, prevention involves improved preoperative preparation of at-risk patients and preoperative discharge planning so as to help prevent unscheduled readmissions, which are predictive of a poorer prognosis.

Standardized Postoperative Adverse Event Data Collection to Document, Inform, and Improve Patient Care

There is great potential for standardized postoperative adverse events data collection to document, inform, audit, and feedback, all to optimize patient care. Adverse events, defined as any deviation from expected recovery from surgery, have harmful implications for patients, their families, and clinicians. Postoperative adverse events occur frequently in thoracic surgery, predominately due to the high-stakes (ie, high potential for cure) and high-risk (ie, vital physiology and anatomy and preexisting disease) nature of the surgery. As discussed, engaging surgeons in audit and feedback practices informed by standardized data collection would generate consensus recommendations to reduce adverse events and improve patient outcomes.

Harmonization of adverse events monitoring following thoracic surgery: Pursuit of a common language and methodology

Objective

Thoracic surgery carries significant risk of postoperative adverse events (AEs). Multiple international recording systems are used to define and collect AEs following thoracic surgery procedures. We hypothesized that a simple-yet-ubiquitous approach to AE documentation could be developed to allow universal data entry into separate international databases.

Methods

AE definitions of the Canadian Association of Thoracic Surgeons (CATS) system and 4 international databases were matched and compared. This consisted of reviewing the definition of each AE as described by their respective database and assessing compatibility with the CATS system. We developed a single set of 4 drop-down menus to enable clear classification and facilitated data entry, using 3 single-select mandatory lists and 1 multiselect optional list classifying type and severity of these events.

Results

The CATS data elements were harmonized (ie, perfect or good) with 100% (European Society of Thoracic Surgeons), 89% (Society of Thoracic Surgeons), 74% (Esophagectomy Complications Consensus Group), and 73% (National Surgical Quality Improvement Program) of respective data elements. The addition of 17 AEs and 2 complication modifiers to the CATS system was implemented to achieve complete harmonization. Consequently, 100% of AE data elements currently included in all 4 international databases are perfectly or well-harmonized with the revised 4-choice drop down menu.

Conclusions

We describe a framework for a ubiquitously applicable approach to AE monitoring following thoracic surgery harmonized with AE definitions of all major thoracic international associations. Use of this AE collection framework allows for comprehensive evaluation of both the incidence and severity of all AEs after thoracic surgery along with quality indicators.

Factors Associated with Unexpected Readmission Following Lung Resection

BACKGROUND

Identification of the predictors of readmission can facilitate appropriate perioperative management. The current study aimed to investigate the potential predictors of unexpected readmission after lung resection for primary lung cancers.

METHODS

This retrospective study enrolled 1000 patients who underwent pulmonary resection for lung cancer at our institution between January 2016 and December 2017. Unexpected readmission was defined as unscheduled readmission to our hospital within 30 days after discharge. Univariate and multivariate analyses were performed for identification of perioperative factors associated with readmission.

RESULTS

Forty-three patients (4.3%) required unexpected readmission, and the median interval between the day of discharge and readmission was 10 days (range 1-29 days). The reasons for readmission included empyema and pleural effusion (n = 11), acute exacerbation of idiopathic pulmonary fibrosis (n = 7), pneumothorax (n = 7), and others (n = 18). The median hospitalization length after readmission was 14 days (range 2-90 days). Four patients (9.3%) died in the hospital because of acute exacerbation of idiopathic pulmonary fibrosis after readmission. In multivariate logistic regression analysis, postoperative refractory air leakage, defined as prolonged air leakage lasting > 5 days or requiring reoperation, was identified as a significant predictor associated with an increased risk of readmission (odds ratio 2.87; 95% confidence interval 1.22-6.72; p = 0.015).

CONCLUSIONS

Unexpected readmission was an inevitable event following lung resection. Patients with readmission had an increased risk of death. Refractory air leakage after lung resection for primary lung cancer was strongly associated with unexpected readmission.

Frailty Is Independently Associated With Worse Outcomes After Elective Anatomic Lung Resection

BACKGROUND

Frailty has been widely recognized as a predictor of postoperative outcomes. Given the paucity of standardized frailty measurements in thoracic procedures, this study aimed to determine the impact of coding-based frailty on clinical outcomes and resource use after anatomic lung resection.

METHODS

All adults undergoing elective, anatomic lung resections (segmentectomy, lobectomy, pneumonectomy) from 2005 to 2014 were identified using the National Inpatient Sample. Patients were categorized as either frail or nonfrail on the basis of the presence of any frailty-defining diagnoses defined by the Johns Hopkins Adjusted Clinical Groups. Multivariable models were used to assess the independent association of frailty with in-hospital mortality, nonhome discharge, complications, duration of stay, and costs.

RESULTS

Of an estimated 366,357 hospitalizations for elective lung resection during the study period, 4.4% were in frail patients. Patients who underwent pneumonectomy or were treated at low-volume hospitals were more commonly frail. Relative to nonfrail patients, frailty was associated with increased unadjusted mortality (9.1% vs 1.7%; P < .001) and nonhome discharge (44.7% vs 10.5%; P < .001). Frail patients had 3.47 increased adjusted odds of mortality across resection types (95% confidence interval, 2.94 to 4.09). Frailty conferred the greatest increase in mortality, complications, and resource use after pneumonectomy relative to lobectomy or segmentectomy, although significant differences were evident for all 3 operations.

CONCLUSIONS

Frailty exhibits a strong association with inferior clinical outcomes and increased resource use after elective lung resection, particularly pneumonectomy. This readily available tool may improve preoperative risk assessment and allow for better selection of treatment modalities for frail patients with pulmonary disorders.

Impact of the integrated comprehensive care program post-thoracic surgery: A propensity score-matched study

OBJECTIVE

Thoracic surgery is associated with significant rates of postoperative morbidity and postdischarge return to the hospital or emergency department (ED). This study aims to assess the impact of a novel integrated patient-centered, hospital-based multidisciplinary community program (Integrated Comprehensive Care [ICC]) on postdischarge outcomes in patients undergoing thoracic surgery compared to routine care.

METHODS

This was a retrospective cohort study of patients who underwent surgical resection for lung malignancies at a tertiary care center from 2010 to 2014. Patients were divided into 2 cohorts based on their enrollment in the ICC program (intervention cohort; 2012-2014) or routine postoperative care (control cohort; 2010-2012). Propensity score matching was performed to match the 2 cohorts. The impact of the ICC program on postoperative length of stay (LOS), rate of ED visits, readmissions, and mortality within the first 60 days was assessed.

RESULTS

Of the 1288 patients included in this study, 658 (51.1%) were male patients with mean age of 64 years (standard deviation 14.1 years). After propensity score matching, 478 patients were enrolled in the ICC cohort and 592 were enrolled as controls. The ICC cohort had significantly shorter LOS (4 days, vs 5 days in controls, P = .001), lower rate of 60-day ED visits (9.8% vs 28.4% in controls, P < .001), and readmissions (6.9% vs 8.6% in controls, P < .001). The 60-day mortality was also significantly lower in the ICC cohort compared with the control group (0.6% vs 0.8% in controls, P < .001).

CONCLUSIONS

The ICC program is associated with shorter LOS, fewer ED visits and readmissions after discharge, and ultimately may decrease postoperative mortality.

Unplanned Readmission within 28 Days of Hospital Discharge in a Longitudinal Population-Based Cohort of Older Australian Women

This study aimed to estimate the incidence of 28-day unplanned readmission among older women, and associated factors. Data were used from the 1921–1926 birth cohort of the Australian Longitudinal Study on Women’s Health. Linkage of self-reported survey data with the Admitted Patient Data Collection allowed the identification of hospital admissions for each woman and the corresponding baseline characteristics. The Cox proportional-hazards model was used to identify factors associated with time to unplanned readmission, using SAS software V 9.4. (SAS Institute, Cary, NC, USA). Of 2056 women with index unplanned admission, 363 (17.5%) were readmitted within 28 days of discharge, and of these 229 (11.14%) had unplanned readmission. Among women with unplanned readmission, 24% were for the same condition as for the index hospitalisation. Cardiovascular diseases were the main diagnoses for the index admission and readmission. Unplanned readmission risk was higher if not partnered (hazard ratio (HR) = 1.43, 95% confidence interval (CI): 1.05–1.95), of non-English speaking background (HR = 1.62%, 95% CI: 1.07–2.47), more than three days length of stay on index admission (HR = 1.41%, 95% CI: 1.04–1.90) and one or two of the assessed chronic diseases (HR = 1.68, 95% CI: 1.19–2.36). At least one in ten women had unplanned readmission at some time between ages 75–95 years. Women who are not partnered, not of English-speaking background, with longer hospital stay and those with multi-morbidity, may need further efforts during their stay and on discharge to mitigate unplanned readmission.

Hospital readmissions after pulmonary resection: post-discharge nursing telephone assessment identifies high risk patients

Background

We previously reported that post-discharge nursing telephone assessments identified a frequent number of patient complaints. Our aim was to determine if telephone assessments can identify patients at risk for emergency room (ER) visits or hospital readmissions.

Methods

A single-institution, retrospective review was performed on all patients undergoing pulmonary resection over a 12-month period. Standardized nursing telephone calls were conducted and records were reviewed to determine postoperative issues. ER visits and readmissions within 30 and 90 days were recorded.

Results

In total, 521 patients underwent pulmonary resection and 245 (47%) were reached for telephone assessment. ER visits within 30/90 days were 8.1% (n=42) and 12.1% (n=63). Readmissions within 30/90 days were 3.1% (n=16) and 6% (n=31). For those reached by telephone assessment, patients with major issue demonstrated increased 30-day ER visits: 22.6% (n=7) vs. 8.0% (n=17), P=0.019. For all patients, those with 90-day ER visit and/or readmission were more likely to have pulmonary complications during initial admission (43.8% vs. 21.2%, P<0.001). Among patients who were reached by telephone, independent predictors of ER visit or readmission within 30 days were: major issue identified on telephone assessment (P=0.007), discharge with chest tube (<0.001), and reintubation postoperatively (P=0.047).

Conclusions

Standardized nursing telephone assessments were able to identify a high-risk population more likely to need ER visit or readmission. However, telephone assessments did not decrease ER visits or readmissions. Improved post-discharge protocols are needed for these high-risk patients in order to ensure patient safety, optimize patient experience, and limit unnecessary resource utilization.

Validation study of the dynamic parameters of pulse wave in pulmonary resection surgery

INTRODUCTION

In lung resection surgery, restrictive fluid therapy is recommended due to the risk of acute lung injury. In contrast, this recommendation increases the risk of hypoperfusion. Guided fluid therapy allows individualization of fluid intake. The use of dynamic volume response parameters is not validated during one-lung ventilation. The main objective is the validation of dynamic parameters, stroke volume variation (SVV) and pulse pressure variation (PPV), during lung resection surgery as fluid response predictors, after the administration of 250ml crystalloid volume loads, if IC<2.5ml/min/m² and if SVV≥8% and/or PPV≥10%.

MATERIAL AND METHODS

Pilot, prospective, observational and single centre study. Twenty-five patients monitored with the PiCCO system were included during open lung resection surgery with the patient in a lateral position, one lung ventilation with tidal volume (TV): 6ml/kg and open chest. Hemodynamic variables were collected before and after volume loading. The results were classified into two groups: volume responders (increase IC≥10% and/or VSI≥10% after volume loading) and non-responders (no increase or increase IC<10% and/or VSI<10% after volume loading). We assess the diagnostic efficacy of SVV and PPV by analyzing the AUC (area under curve) in the ROC curves.

RESULTS

In the analysis of ROC curves, SVV and PPV did not reach a discriminative value (AUCSVV: 0.47; AUCPPV: 0.50), despite the decrease in the threshold value of SVV and PPV to initiate an overload of volume during one-lung ventilation, in lateral position and open chest.

CONCLUSIONS

The results obtained show that the values of the dynamic parameters of volume response (SVV≥8% and PPV≥10%) do not discriminate against responders patients and non-responders during open lung resection surgery.

Delayed recovery following thoracic surgery: persistent issues and potential interventions

PURPOSE OF REVIEW

Lung and esophageal surgery remain a curative option for resectable cancers. However, despite advances in surgical and anesthesia practices, the inclusion of patients with comorbidities that would have previously not been offered curative resection presents additional concerns and challenges.

RECENT FINDINGS

Perioperative complication rates remain high and prolonged and/or painful recovery are common. Further, many patients face a permanent decline in their functional status, which negatively affects their quality of life. Examination of the variables associated with high complications following thoracic surgery reveals patient, physician, and institutional factors in the forefront. Anesthesiologist training, Enhanced Recovery After Surgery protocols, and preparations to minimize "failure to rescue" when a complication does arise are key strategies to address adverse outcomes.

SUMMARY

Delayed and complicated recovery after thoracic noncardiac surgery persist in current practice. This review analyzes the diverse factors that can impact complications and quality of life after lung surgery and the interventions that can help decrease length of stay and improve return to baseline conditions.

Unplanned readmission after lung resection surgery: A systematic review

Urgent readmissions have a major impact on outcomes in patient health and healthcare costs. The associated risk factors have generally been infrequently studied. The main objective of the present work is to identify pre- and perioperative determinants of readmission; the secondary aim was to determine readmission rate, identification of readmission diagnoses, and impact of readmissions on survival rates in related analytical studies. The review was performed through a systematic search in the main bibliographic databases. In the end, 19 papers met the selection criteria. The main risk factors were: sociodemographic patient variables; comorbidities; type of resection; postoperative complications; long stay. Despite the great variability in the published studies, all highlight the importance of reducing readmission rates because of the significant impact on patients and the healthcare system.

Identifying Drivers of Multiple Readmissions After Pulmonary Lobectomy

BACKGROUND

Readmissions after pulmonary lobectomy for lung cancer are important markers of healthcare quality for surgeons and hospitals. The implications on resources and quality are magnified when examining patients who require multiple readmissions within the perioperative period.

METHODS

The Nationwide Readmission Database between 2013 and 2014 was investigated for patients with a primary diagnosis of lung cancer who underwent pulmonary lobectomy. Using adjusted hierarchical regression models, demographic and clinical factors during the index hospitalization were investigated for associations with single and multiple readmissions during the 90-day postoperative period. First and second readmissions during this period were compared for the primary diagnosis at the time of readmission using Clinical Classification Software codes.

RESULTS

Of the 41,576 lobectomies during the study period 7,030 patients (16.9%) were readmitted. Among this group 1,554 patients (3.7%) had at least two readmissions. After adjustment for other factors, postoperative arrhythmia (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.25-1.83; p < 0.0001), postoperative infection (OR, 1.55; 95% CI, 1.11-2.17; p = 0.01), and postoperative sepsis (OR, 1.70; 95% CI, 1.08-2.67; p = 0.02) during the index hospitalization were associated with an increased risk of at least two readmissions. The most frequent Clinical Classification Software diagnosis for first readmissions was "postoperative complications" (892, 12.7%) and for second readmissions was heart disease (173, 11.2%).

CONCLUSIONS

Approximately one-fifth of patients readmitted after pulmonary lobectomy would go on to be readmitted two or more times within 90 days. Although first readmissions were most likely to present with postoperative infection or complication, second readmissions were most likely to present with heart disease.

Perioperative Outcomes for Stage I Non-Small Cell Lung Cancer: Differences Between Men and Women

BACKGROUND

Previous studies have highlighted important biologic and survival-related differences among men and women with non-small cell lung cancer (NSCLC). However, differences in perioperative or short-term outcomes have not been as well characterized. In this study, we investigated differences in the perioperative period and postoperative emergency department (ED) visits among men and women after lobectomy for stage I NSCLC.

METHODS

A retrospective review was performed of patients who underwent a lobectomy for clinical stage I NSCLC at a single institution from 2010 to 2015.

RESULTS

We identified 559 patients for inclusion, including 293 women (52%) and 266 men (48%). Women were more likely to present with clinical T1 status (p = 0.005) and to undergo a minimally invasive operation (p = 0.058). To reduce confounding, 206 case-matched pairs were identified. After matching, no differences were found in length of stay (p = 0.551) or pulmonary complications (p = 0.509); however, men experienced more cardiac complications (18% versus 7%, p = 0.001). Of importance, although rates of 30- and 90-day ED visits between sexes were similar (p = 0.531, p = 0.890, respectively) and no sex-related differences were found in presenting symptom on return to the ED (p = 0.478), women were more likely to be readmitted after presenting to the ED within 30 days (p = 0.038).

CONCLUSIONS

Women demonstrated an increased likelihood of being admitted after presenting to the ED within 30 days after discharge, indicating important differences between men and women in the short-term period after lobectomy. Further research will be required to further understand the cause for these differences.

Impact of major video-assisted thoracoscopic surgery on care quality

Background

The objective of this study was to investigate the impact of a program of major video-assisted surgery on care quality in a Unit of Thoracic Surgery.

Methods

A descriptive comparative study was conducted of 793 major thoracic procedures performed between 2009 and 2012. Quality indicators and hospital performance before [2009-2010] and after (2011 and 2012) the implementation of the program.

Results

The incidence of surgical complications decreased significantly from 6.32%/7.88% (2009/2010, respectively) to 1.87%/1.67% (2011/2012, respectively) [95% CI for 7.08% (4.20-9.96%); 95% CI for 1.76% (0.44-3.08%) P<0.001, respectively]. The mean hospital stay was reduced from 8.5/7.8 days in 2009/2010, respectively, to 6.3/5.8 days in 2011/2012, respectively. Mortality rates were 0.57%, 0.60%, 0.93% and 0.43% in 2009, 2010, 2011, and 2012, respectively (P=0.624, 95% CI: -0.6, 0.7). The percentages of emergency readmissions in 2009/2010 were 1.16%/1.23%, respectively vs. 2.80%/0.84% in 2011/2012.

Conclusions

The implementation of the video-assisted thoracic surgery (VATS) program in the unit of Thoracic Surgery Care resulted in a significant improvement in care quality, with a reduction of length of hospital stay, but without any changes in mortality or the percentage of readmissions at 30 post-operative days.