1
|
Sier MAT, Gielen AHC, Tweed TTT, van Nie NC, Lubbers T, Stoot JHMB. Accelerated enhanced recovery after colon cancer surgery with discharge within one day after surgery: a systematic review. BMC Cancer 2024; 24:102. [PMID: 38233796 PMCID: PMC10795207 DOI: 10.1186/s12885-023-11803-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/27/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Recent studies have demonstrated that accelerated enhanced recovery after colorectal surgery is feasible for specific patient populations. The accelerated enhanced recovery protocols (ERP) tend to vary, and the majority of studies included a small study population. This hampers defining the optimal protocol and establishing the potential benefits. This systematic review aimed to determine the effect of accelerated ERPs with intended discharge within one day after surgery. METHODS PubMed (MEDLINE), Embase, Cochrane and Web of Science databases were searched using the following search terms: colon cancer, colon surgery, accelerated recovery, fast track recovery, enhanced recovery after surgery. Clinical trials published between January 2005 - February 2023, written in English or Dutch comparing accelerated ERPs to Enhanced Recovery After Surgery (ERAS) care for adult patients undergoing elective laparoscopic or robotic surgery for colon cancer were eligible for inclusion. RESULTS Thirteen studies, including one RCT were included. Accelerated ERPs after colorectal surgery was possible as LOS was shorter; 14 h to 3.4 days, and complication rate varied from 0-35.7% and readmission rate was 0-17% in the accelerated ERP groups. Risk of bias was serious or critical in most of the included studies. CONCLUSIONS Accelerated ERPs may not yet be considered the new standard of care as the current data is heterogenous, and data on important outcome measures is scarce. Nonetheless, the decreased LOS suggests that accelerated recovery is possible for selected patients. In addition, the complication and readmission rates were comparable to ERAS care, suggesting that accelerated recovery could be safe.
Collapse
Affiliation(s)
- Misha A T Sier
- Department of Surgery, Zuyderland Medical Centre, Heerlen, the Netherlands.
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands.
| | - Anke H C Gielen
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Thaís T T Tweed
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Noémi C van Nie
- Department of Surgery, Zuyderland Medical Centre, Heerlen, the Netherlands
| | - Tim Lubbers
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Jan H M B Stoot
- Department of Surgery, Zuyderland Medical Centre, Heerlen, the Netherlands
| |
Collapse
|
2
|
D’Souza J, Richards S, Eglinton T, Frizelle F. Incidence and risk factors for unplanned readmission after colorectal surgery: A meta-analysis. PLoS One 2023; 18:e0293806. [PMID: 37972100 PMCID: PMC10653493 DOI: 10.1371/journal.pone.0293806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 10/19/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Unplanned readmissions (URs) after colorectal surgery (CRS) are common, expensive, and result from failure to progress in postoperative recovery. These are considered preventable, although the true extent is yet to be defined. In addition, their successful prediction remains elusive due to significant heterogeneity in this field of research. This systematic review and meta-analysis of observational studies aimed to identify the clinically relevant predictors of UR after colorectal surgery. METHODS A systematic review was conducted using indexed sources (The Cochrane Database of Systematic Reviews, MEDLINE, and Embase) to search for published studies in English between 1996 and 2022. The search strategy returned 625 studies for screening of which, 150 were duplicates, and 305 were excluded for irrelevance. An additional 150 studies were excluded based on methodology and definition criteria. Twenty studies met the inclusion criteria and for the meta-analysis. Independent meta-extraction was conducted by multiple reviewers (JD & SR) in accordance with PRISMA guidelines. The primary outcome was defined as UR within 30 days of index discharge after colorectal surgery. Data were pooled using a random-effects model. Risk of bias was assessed using the Quality in Prognosis Studies tool. RESULTS The reported 30-day UR rate ranged from 6% to 22.8%. Increased comorbidity was the strongest preoperative risk factor for UR (OR 1.39, 95% CI 1.28-1.51). Stoma formation was the strongest operative risk factor (OR 1.54, 95% CI 1.38-1.72). The occurrence of postoperative complications was the strongest postoperative and overall risk factor for UR (OR 3.03, 95% CI 1.21-7.61). CONCLUSIONS Increased comorbidity, stoma formation, and postoperative complications are clinically relevant predictors of UR after CRS. These risk factors are readily identifiable before discharge and serve as clinically relevant targets for readmission risk-reducing strategies. Successful readmission prediction may facilitate the efficient allocation of healthcare resources.
Collapse
Affiliation(s)
- Joel D’Souza
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| | - Simon Richards
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| | - Timothy Eglinton
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| | - Frank Frizelle
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| |
Collapse
|
3
|
D’Souza J, Eglinton T, Frizelle F. Readmission prediction after colorectal cancer surgery: A derivation and validation study. PLoS One 2023; 18:e0287811. [PMID: 37384713 PMCID: PMC10309978 DOI: 10.1371/journal.pone.0287811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/13/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Unplanned readmissions after colorectal cancer (CRC) surgery are common, expensive, and result from failure to progress in postoperative recovery. The context of their preventability and extent of predictability remains undefined. This study aimed to define the 30-day unplanned readmission (UR) rate after CRC surgery, identify risk factors, and develop a prediction model with external validation. METHODS Consecutive patients who underwent CRC surgery between 2012 and 2017 at Christchurch Hospital were retrospectively identified. The primary outcome was UR within 30 days after index discharge. Statistically significant risk factors were identified and incorporated into a predictive model. The model was then externally evaluated on a prospectively recruited dataset from 2018 to 2019. RESULTS Of the 701 patients identified, 15.1% were readmitted within 30 days of discharge. Stoma formation (OR 2.45, 95% CI 1.59-3.81), any postoperative complications (PoCs) (OR 2.27, 95% CI 1.48-3.52), high-grade PoCs (OR 2.52, 95% CI 1.18-5.11), and rectal cancer (OR 2.11, 95% CI 1.48-3.52) were statistically significant risk factors for UR. A clinical prediction model comprised of rectal cancer and high-grade PoCs predicted UR with an AUC of 0.64 and 0.62 on internal and external validation, respectively. CONCLUSIONS URs after CRC surgery are predictable and occur within 2 weeks of discharge. They are driven by PoCs, most of which are of low severity and develop after discharge. Atleast 16% of readmissions are preventable by management in an outpatient setting with appropriate surgical expertise. Targeted outpatient follow-up within two weeks of discharge is therefore the most effective transitional-care strategy for prevention.
Collapse
Affiliation(s)
- Joel D’Souza
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| | - Timothy Eglinton
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| | - Frank Frizelle
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| |
Collapse
|
4
|
Wang S, Zhu X. Predictive Modeling of Hospital Readmission: Challenges and Solutions. IEEE/ACM TRANSACTIONS ON COMPUTATIONAL BIOLOGY AND BIOINFORMATICS 2022; 19:2975-2995. [PMID: 34133285 DOI: 10.1109/tcbb.2021.3089682] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Hospital readmission prediction is a study to learn models from historical medical data to predict probability of a patient returning to hospital in a certain period, e.g. 30 or 90 days, after the discharge. The motivation is to help health providers deliver better treatment and post-discharge strategies, lower the hospital readmission rate, and eventually reduce the medical costs. Due to inherent complexity of diseases and healthcare ecosystems, modeling hospital readmission is facing many challenges. By now, a variety of methods have been developed, but existing literature fails to deliver a complete picture to answer some fundamental questions, such as what are the main challenges and solutions in modeling hospital readmission; what are typical features/models used for readmission prediction; how to achieve meaningful and transparent predictions for decision making; and what are possible conflicts when deploying predictive approaches for real-world usages. In this paper, we systematically review computational models for hospital readmission prediction, and propose a taxonomy of challenges featuring four main categories: (1) data variety and complexity; (2) data imbalance, locality and privacy; (3) model interpretability; and (4) model implementation. The review summarizes methods in each category, and highlights technical solutions proposed to address the challenges. In addition, a review of datasets and resources available for hospital readmission modeling also provides firsthand materials to support researchers and practitioners to design new approaches for effective and efficient hospital readmission prediction.
Collapse
|
5
|
Muchiri S, Azadeh-Fard N, Pakdil F. The Analysis of Hospital Readmission Rates After the Implementation of Hospital Readmissions Reduction Program. J Patient Saf 2022; 18:237-244. [PMID: 34292263 DOI: 10.1097/pts.0000000000000883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study aims to analyze the impact of Hospital Readmissions Reduction Program (HRRP) on the nationwide optimization efforts of length of stay (LOS) and readmissions in the United States. METHODS We use the Nationwide Readmission Database between 2010 and 2016 provided in the Healthcare Cost and Utilization Project by the Agency for Healthcare Research and Quality. The study focuses on acute myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure (CHF), pneumonia monitored by the HRRP and 2 conditions, septicemia, and mood disorders that were not monitored by the HRRP but had among the highest readmissions. Patient demographics and readmissions were analyzed based on insurance type, LOS, and Charlson Comorbidity Index. RESULTS The readmissions vary by conditions, LOS, and insurance types. Congestive heart failure has the highest readmissions among the 6 analyzed conditions at approximately 25%. The readmission rate of CHF rises to 30% for the Medicaid patients and varies between 30% and 35% by LOS. Patients with CHF with higher Charlson Comorbidity Index demonstrates the highest readmissions among 6 conditions. The patients with longer LOSs had higher readmissions, and Medicare patients have a higher reduction in readmissions in acute myocardial infarction and mood disorders compared with the other forms of payments. CONCLUSIONS Our figures show that targeted programs, such as HRRP, may have a positive impact on readmission rates. We, however, observe some graphical evidence that nontargeted conditions could exhibit similar trends. Because of heterogeneity in hospital and patient characteristics, it is pivotal for researcher to consider them in formal analyses.
Collapse
Affiliation(s)
- Steve Muchiri
- From the Eastern Connecticut State University, Willimantic, Connecticut
| | - Nasibeh Azadeh-Fard
- Department of Industrial and Systems Engineering, Rochester Institute of Technology, Rochester, New York
| | - Fatma Pakdil
- From the Eastern Connecticut State University, Willimantic, Connecticut
| |
Collapse
|
6
|
Emond YEJJM, Calsbeek H, Peters YAS, Bloo GJA, Teerenstra S, Westert GP, Damen J, Wollersheim HC, Wolff AP. Increased adherence to perioperative safety guidelines associated with improved patient safety outcomes: a stepped-wedge, cluster-randomised multicentre trial. Br J Anaesth 2022; 128:562-573. [PMID: 35039174 DOI: 10.1016/j.bja.2021.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/23/2021] [Accepted: 12/15/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND National Dutch guidelines have been introduced to improve suboptimal perioperative care. A multifaceted implementation programme (IMPlementatie Richtlijnen Operatieve VEiligheid [IMPROVE]) has been developed to support hospitals in applying these guidelines. This study evaluated the effectiveness of IMPROVE on guideline adherence and the association between guideline adherence and patient safety. METHODS Nine hospitals participated in this unblinded, superiority, stepped-wedge, cluster RCT in patients with major noncardiac surgery (mortality risk ≥1%). IMPROVE consisted of educational activities, audit and feedback, reminders, organisational, team-directed, and patient-mediated activities. The primary outcome of the study was guideline adherence measured by nine patient safety indicators on the process (stop moments from the composite STOP bundle, and timely administration of antibiotics) and on the structure of perioperative care. Secondary safety outcomes included in-hospital complications, postoperative wound infections, mortality, length of hospital stay, and unplanned care. RESULTS Data were analysed for 1934 patients. The IMPROVE programme improved one stop moment: 'discharge from recovery room' (+16%; 95% confidence interval [CI], 9-23%). This stop moment was related to decreased mortality (-3%; 95% CI, -4% to -1%), fewer complications (-8%; 95% CI, -13% to -3%), and fewer unscheduled transfers to the ICU (-6%; 95% CI, -9% to -3%). IMPROVE negatively affected one other stop moment - 'discharge from the hospital' - possibly because of the limited resources of hospitals to improve all stop moments together. CONCLUSIONS Mixed implementation effects of IMPROVE were found. We found some positive associations between guideline adherence and patient safety (i.e. mortality, complications, and unscheduled transfers to the ICU) except for the timely administration of antibiotics. CLINICAL TRIAL REGISTRATION NTR3568 (Dutch Trial Registry).
Collapse
Affiliation(s)
- Yvette E J J M Emond
- IQ Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands; Department of Anesthesiology, Pain and Palliative Care, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands.
| | - Hiske Calsbeek
- IQ Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Yvonne A S Peters
- IQ Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Gerrit J A Bloo
- IQ Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands; Department of Anesthesiology, Pain and Palliative Care, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Steven Teerenstra
- Department for Health Evidence, Section Biostatistics, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Gert P Westert
- IQ Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Johan Damen
- Department of Anesthesiology, Pain and Palliative Care, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Hub C Wollersheim
- IQ Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - André P Wolff
- Department of Anesthesiology, Pain Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
7
|
Yu D, Wu X, Li X, Liu X, Jiang K, Zhao Q, Nie H. Development and External Validation of Safe Discharge Criteria After Radical Gastrectomy. Cancer Manag Res 2021; 13:5251-5261. [PMID: 34234567 PMCID: PMC8257067 DOI: 10.2147/cmar.s305046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/14/2021] [Indexed: 11/23/2022] Open
Abstract
Aim Enhanced recovery after surgery (ERAS) gradually shortens the length of stay but increases the rate of unplanned readmission after discharge. Currently, objective discharge criteria for patients after radical gastrectomy is lacking. This study aimed to construct and validate a nomogram for estimation of the possibility of safe discharge on the fifth-day post radical gastrectomy. Methods We enrolled 496 consecutive patients undergoing radical gastrectomy as the development cohort. After the fifth day of surgery, patients were assigned to the postoperative complication group and no postoperative complication group. Multivariate logistic regression analyses were performed for both groups. Then, we constructed the risk prediction model of postoperative severe complications (PSCs) and applied it to evaluate whether the patient could be discharged safely. The external validation cohort comprised 245 patients, whom we used to evaluate the capability of our model to predict the risk of PSCs. The primary measure was the negative predictive rate (NPR) and the area under the curve (AUC). Results Through multivariate analysis, gender, maximum body temperature on the 4th postoperative day (POD4), oral intake and ambulatory duration on POD4, the proportion of neutrophils (≥75% or <75%) and pain score (≥4 or <4) on POD5, and defecation with 5 days after the procedure (yes or no) were identified as independent predictors for PSCs. Upon incorporation of these variables, the nomogram demonstrated a good NPR of 0.957 and 0.916 and AUC of 0.918 and 0.719 in the two cohorts, respectively. With a nomogram score of 110, patients were stratified into low and high risk of PSCs. Conclusion The nomogram demonstrated good predictive potential for low-risk patients. It could serve as an objective safe discharge approach for patients after the fifth day of radical gastrectomy.
Collapse
Affiliation(s)
- Deliang Yu
- Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, 710032, People's Republic of China
| | - Xiaoyong Wu
- Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, 710032, People's Republic of China
| | - Xuzhao Li
- Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, 710032, People's Republic of China
| | - Xiaonan Liu
- Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, 710032, People's Republic of China
| | - Kun Jiang
- Information Center, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
| | - Qingchuan Zhao
- Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, 710032, People's Republic of China
| | - Huang Nie
- Department of Anesthesiology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, People's Republic of China
| |
Collapse
|
8
|
What are the risk factors for readmission in patients with an ileostomy? JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2013.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Purpose the aim of this study was to identify the risk factors for readmission among patients submitted to colorectal surgery.
Methods a single-center colorectal quality-assessment database was queried for patients undergoing colorectal procedures with ileostomy during 2009. the sample was divided into readmitted vs. non-readmitted. readmission was defined as admission within the first 30 days after the index procedure. Groups were compared by pre, intra and postoperative characteristics. A multivariate analysis was performed to identify the risk factors for readmission.
Results the query returned 496 patients, [267 (54%) males, median age 48 years (iQr: 34-60)]. Eighty-three (17%) were readmitted; 296 patients (60%), were operated due to inflammatory bowel disease, 89 (18%) for cancer, 16 (3%) for diverticular disease and 95 (19%) for other diagnosis. the three most common procedures were total proctocolectomy with ileal pouch-anal anastomosis (iPAA) in 103 patients (21%), total colectomy with end ileostomy in 117 (24%) and small bowel resections (including enterocutaneous fistula takedown and J-pouch excision) in 149 (30%). the following variables were significantly more common in readmitted patients: current smoking (24% vs. 14%, p = 0.02), postoperative DVt/PE (10% vs. 4%, p = 0.04), wound infection (20% vs. 10% p = 0.01), sepsis (22% vs. 8% p < 0.001) and organ or space surgical site infection (orgSSi) (35% vs. 5%, p < 0.001). Postoperative orgSSi was the only independent factor associated with readmission in a multivariate analysis (p < 0.001).
Conclusion colorectal surgeons should be alert for orgSSi when facing an ileostomy patient readmitted after a colorectal procedure.
Collapse
|
9
|
Rubens M, Ramamoorthy V, Saxena A, Bhatt C, Das S, Veledar E, McGranaghan P, Viamonte-Ros A, Odia Y, Chuong M, Kotecha R, Mehta MP. A risk model for prediction of 30-day readmission rates after surgical treatment for colon cancer. Int J Colorectal Dis 2020; 35:1529-1535. [PMID: 32377912 DOI: 10.1007/s00384-020-03605-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to develop a risk model for the prediction of 30-day unplanned readmission rate after surgery for colon cancer. METHOD This study was a cross-sectional analysis of data from Nationwide Readmissions Database, collected during 2010-2014. Patients ≥ 18 years of age who underwent surgery for colon cancer were included in the study. The primary outcome of the study was 30-day unplanned readmission rate. RESULTS There were 141,231 index hospitalizations for surgical treatment of colon cancers and 16,551 had unplanned readmissions. Age, sex, primary payer, Elixhauser comorbidity index, node positive or metastatic disease, length of stay, hospital bedsize, teaching status, hospital ownership, presence of stoma, surgery types, surgery procedures, infectious complications, surgical complications, mechanical wounds, pulmonary complications, and gastrointestinal complications were selected for the risk analysis during backward regression model. Based on the estimated coefficients of selected variables, risk scores were developed and stratified as low risk (≤ 1.08), moderate risk (> 1.08 to ≤ 1.5), and high risk (> 1.5) for unplanned readmission. Validation analysis (n = 42,269) showed that 7.1% of low-risk individuals, 11.1% of moderate-risk individuals, and 17.1% of high-risk individuals experienced unplanned readmissions (P < 0.001). Pairwise comparisons also showed statistically significant differences between low-risk and moderate-risk participants (P < 0.001), between moderate-risk and high-risk participants (P < 0.001), and between low-risk and high-risk participants (P < 0.001). The area under the ROC curve was 0.622. CONCLUSIONS Our risk model could be helpful for risk-stratifying patients for readmission after surgical treatment for colon cancer. This model needs further validation by incorporating all possible clinical variables.
Collapse
Affiliation(s)
- Muni Rubens
- Miami Cancer Institute, Baptist Health South Florida, 8900 N. Kendall Dr. 1st Floor, Research Bldg, Radiation Oncology Executive Office, Miami, FL, 33176, USA
| | | | | | | | - Sankalp Das
- Baptist Health South Florida, Miami, FL, USA
| | | | - Peter McGranaghan
- Miami Cancer Institute, Baptist Health South Florida, 8900 N. Kendall Dr. 1st Floor, Research Bldg, Radiation Oncology Executive Office, Miami, FL, 33176, USA
| | | | - Yazmin Odia
- Miami Cancer Institute, Baptist Health South Florida, 8900 N. Kendall Dr. 1st Floor, Research Bldg, Radiation Oncology Executive Office, Miami, FL, 33176, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Michael Chuong
- Miami Cancer Institute, Baptist Health South Florida, 8900 N. Kendall Dr. 1st Floor, Research Bldg, Radiation Oncology Executive Office, Miami, FL, 33176, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Rupesh Kotecha
- Miami Cancer Institute, Baptist Health South Florida, 8900 N. Kendall Dr. 1st Floor, Research Bldg, Radiation Oncology Executive Office, Miami, FL, 33176, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Minesh P Mehta
- Miami Cancer Institute, Baptist Health South Florida, 8900 N. Kendall Dr. 1st Floor, Research Bldg, Radiation Oncology Executive Office, Miami, FL, 33176, USA. .,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
| |
Collapse
|
10
|
Operative Incision and Drainage for Perirectal Abscesses: What Are Risk Factors for Prolonged Length of Stay, Reoperation, and Readmission? Dis Colon Rectum 2020; 63:1127-1133. [PMID: 32251145 DOI: 10.1097/dcr.0000000000001653] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Perirectal abscess is a common problem. Despite a seemingly simple disease to manage, clinical outcomes of perirectal abscesses can vary significantly given the wide array of patients who are susceptible to this disease. OBJECTIVE Our aims were to evaluate the outcomes after operative incision and drainage for perirectal abscess and to examine factors associated with length of stay, reoperations, and readmissions. DESIGN This was a retrospective analysis of the National Surgical Quality Improvement Program database. SETTINGS The study was conducted with hospitals participating in the surgical database. PATIENTS Adult patients undergoing outpatient perirectal abscess procedures from 2011 through 2016 were included. MAIN OUTCOME MEASURES Study outcomes were length of stay, reoperation, and readmission. RESULTS We identified 2358 patients undergoing incision and drainage for perirectal abscesses. Approximately 35% of patients required hospital stay. Reoperations occurred in 3.4%, with median time to reoperation of 15.5 days. The majority of reoperations (79.7%) were performed for additional incision and drainage. Readmissions rate was 3.0%, with median time to readmission of 10.5 days. Common indications for readmissions included recurrent/persistent abscess (41.4%) and fever/sepsis (8.6%). Risk factors for hospitalization in multivariable analysis were preoperative sepsis, bleeding disorder, and non-Hispanic black and Hispanic races. For reoperations, risk factors included morbid obesity, preoperative sepsis, and dependent functional status. Lastly, for readmissions, female sex, steroid/immunosuppression, and dependent functional status were significant risk factors. LIMITATIONS The study was limited by its retrospective analysis and potential selection bias in decisions on hospital stay, reoperation, and readmission. CONCLUSIONS Suboptimal outcomes after outpatient operative incision and drainage for perirectal abscesses are not uncommon in the United States. In the era of value-based care, additional work is needed to optimize use outcomes for high-risk patients undergoing perirectal incision and drainage. Strategies to prevent inadequate drainage at the time of the initial operative incision and drainage (ie, use of imaging modalities and thorough examination under anesthesia) are warranted to improve patient outcomes. See Video Abstract at http://links.lww.com/DCR/B229. INCISIÓN Y DRENAJE QUIRÚRGICOS DE ABSCESOS PERIRRECTALES: CUALES SON LOS FACTORES DE RIESGO PARA UNA ESTADÍA PROLONGADA, REINTERVENCIÓN Y READMISION?: Los abscesos perirrectales son un problema frecuente. A pesar que parecen ser una afección aparentemente simple de manejar, los resultados clínicos de la incisión y drenaje quirúrgicos pueden variar significativamente dada la amplia variedad de pacientes susceptibles de sufrir esta afección.Evaluar los resultados después de la incisión y el drenaje quirúrgicos de un absceso perirrectal y analizar los factores asociados con la duración de la hospitalización, la reoperación y la readmisión.Análisis retrospectivo de la base de datos del Programa Americano de Mejora de la Calidad Quirúrgica.Hospitales que participan en la base de datos quirúrgica.Pacientes adultos sometidos a incisión y drenaje quirúrgico ambulatorio de un absceso perirrectal desde 2011 hasta 2016.Los resultados del estudio fueron la duración de la hospitalización, la reoperación y el reingreso.Fueron estudiados 2,358 pacientes sometidos a incisión y drenaje por abscesos perirrectales. Aproximadamente el 35% de los pacientes requirieron hospitalización. Las reoperaciones ocurrieron en 3.4% con una mediana de tiempo de reoperación de 15.5 días. La mayoría de las reoperaciones (79.7%) se realizaron para una incisión y drenaje adicionales. La tasa de reingreso fue del 3.0% con una mediana de tiempo de reingreso de 10.5 días. Las indicaciones comunes para los reingresos incluyeron abscesos recurrentes / persistentes (41.4%) y fiebre / sepsis (8.6%). Los factores de riesgo para la hospitalización en el análisis multivariable fueron sepsis preoperatoria, trastorno hemorrágico, raza negra no hispánica y raza hispana. Para las reoperaciones, los factores de riesgo incluyeron obesidad mórbida, sepsis preoperatoria y estado funcional dependiente. Por último, para los reingresos, el sexo femenino, uso de corticoides / inmunosupresores y un estadío funcional dependiente fueron factores de riesgo significativos.Análisis retrospectivo y posible sesgo de selección en las decisiones sobre hospitalización, reoperación y reingreso.Un resultado poco satisfactorio después de la incisión quirúrgica el drenaje de abscesos perirrectales ambulatoriamente no son infrecuentes en los Estados Unidos. En la era de la atención basada en los resultados, se necesita mucho más trabajo para optimizar los mismos en pacientes de alto riesgo sometidos a incisión y drenaje perirrectales. Las estrategias para prevenir el drenaje inadecuado en el momento de la incisión quirúrgica inicial y el drenaje (es decir, el uso de modalidades de imágenes, un examen completo bajo anestesia) son una garantía para mejorar los resultados en estos pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B229.
Collapse
|
11
|
Postoperative outcomes in patients undergoing colorectal surgery with anastomotic leak before and after hospital discharge. Updates Surg 2020; 72:463-468. [PMID: 32285376 DOI: 10.1007/s13304-020-00754-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/20/2020] [Indexed: 10/24/2022]
Abstract
Anastomotic leak (AL) is the most feared complication after colorectal surgery and time to diagnosis is variable. The aim of this study was to analyze the outcomes of patient who had an AL during or after hospital discharge. A retrospective analysis of a prospectively collected database of all patients undergoing laparoscopic colorectal resections without proximal diversion during the period 2008-2018 was conducted. The sample was divided into two groups: patients who had AL during hospitalization (G1) and those who had AL after hospital discharge (G2). Demographics, operative variables and postoperative outcomes were compared between groups. A total of 853 patients were included; AL was diagnosed in 60 (7%) patients and was more frequent during initial hospitalization than after hospital discharge (G1: 49 (82%) vs. G2: 11 (18%), p < 0.001). Demographics were similar between groups. Most patients were treated with laparoscopic lavage and diverting ileostomy in both groups (G1: 92% vs. G2: 82%, p = 0.30). Severity of peritonitis at reoperation and length of hospital stay after AL were similar between groups (G1: 11 vs. G2: 9 days, p = 0.54). Overall postoperative morbidity (G1: 57% vs. G2: 36%, p = 0.31), mortality (G1: 10% vs. G2: 27%, p = 0.15) and intestinal reconstruction rate (G1: 92% vs. G2: 100%, p = 1) were similar between groups. Outpatient onset of anastomotic leak did not increase the severity of peritonitis, had no impact on the type of treatment performed, and showed similar postoperative morbidity and mortality as compared to those having AL during hospitalization.
Collapse
|
12
|
Chung JS, Kwak HD, Ju JK. Thirty-Day Readmission After Elective Colorectal Surgery for Colon Cancer: A Single-Center Cohort Study. Ann Coloproctol 2020; 36:186-191. [PMID: 32054242 PMCID: PMC7392574 DOI: 10.3393/ac.2019.11.04] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/04/2019] [Indexed: 12/20/2022] Open
Abstract
Purpose There is a concern that enhanced recovery after surgery may affect other proposed quality measures, including the rate of readmission due to early discharge. We examine the 30-day readmission rate, risk factors associated with readmission after elective colorectal surgery for colon cancer, causes of readmission, disease-free survival (DFS), and overall survival (OS) in a single institution. Methods We retrospectively investigated 292 patients who underwent elective colorectal surgery for colon cancer between 2010 and 2015. Baseline data including age, sex, body mass index, American Society of Anesthesiologists physical status classification, preoperative comorbidities, previous operation history, TNM stage, surgical approach, operation time, gas passage time, and length of hospital stay were obtained. Univariate and multivariate logistic regression analyses were performed to identify risk factors associated with 30-day readmission. Results A total of 229 patients who underwent elective colorectal surgery were enrolled. Twenty-four patients were readmitted 30 days after discharge. The most common readmission diagnoses were wound bleeding or surgical site infection. Multivariate analysis indicated that patients who had preoperative hepatic disease were at the highest risk of readmission (odds ratio [OR], 8.98; 95% confidence interval [CI], 7.35–10.61). Survival outcomes were significantly better in the nonreadmitted group (OS, P=0.00; DFS, P=0.04). Conclusion This study identified that preoperative comorbidities including hepatic and pulmonary diseases were associated with higher readmission rates after elective colorectal surgery. Moreover, the most common cause of readmission in patients who underwent elective colorectal surgery was wound bleeding or surgical site infection.
Collapse
Affiliation(s)
- Jun Seong Chung
- Department of Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Han Deok Kwak
- Department of Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Jae Kyun Ju
- Department of Surgery, Chonnam National University Hospital, Gwangju, Korea
| |
Collapse
|
13
|
Chen SY, Stem M, Gearhart SL, Safar B, Fang SH, Azad NS, Murphy AG, Narang AK, Wolfgang CL, Efron JE. Readmission Adversely Affects Survival in Surgical Rectal Cancer Patients. World J Surg 2019; 43:2506-2517. [PMID: 31222644 DOI: 10.1007/s00268-019-05053-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Readmission has received attention as a potential healthcare quality metric. No studies have investigated the relationship between readmission and survival in patients undergoing rectal cancer surgery. The aims of this study were to identify factors associated with 30-day readmission after rectal cancer surgery and to determine the impact of readmission on overall survival (OS). METHODS Patients who underwent surgical treatment for rectal/rectosigmoid adenocarcinoma stages I-IV were identified using the National Cancer Database (2004-2014). Multivariable logistic regression was used to identify factors for readmission. 2:1 nearest neighbor caliper matching without replacement was used to ensure similarity of patients being compared. Survival analyses were performed using Kaplan-Meier method along with log-rank test and Cox proportional hazards model. RESULTS Of 110,167 patients, 7045 (6.39%) were readmitted. Factors associated with readmission included higher Charlson comorbidity score, non-private or no insurance, procedure type, hospitals in the Northeast, South, and Midwest regions, and prolonged length of stay. Within the matched cohort (13,756 non-readmitted and 6878 readmitted), readmitted patients had worse 5- and 10-year OS regardless of cancer stage (p < 0.001) and procedure type. Five- and 10-year OS were 58.98% and 41.01% for readmitted patients, 64.96% and 43.50% for non-readmitted patients. Readmitted patients had shorter OS by 13.14 months and increased risk of mortality (HR 1.20, 95% CI 1.15-1.25, p < 0.001). CONCLUSIONS Thirty-day readmission after rectal cancer surgery is associated with decreased OS. Efforts to reduce readmissions should be considered to advance cancer care and enhance the potential for improved patient survival.
Collapse
Affiliation(s)
- Sophia Y Chen
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan L Gearhart
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sandy H Fang
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nilofer S Azad
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adrian G Murphy
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amol K Narang
- Department of Radiation Oncology & Molecular Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Mark M. Ravitch Professor of Surgery, The Johns Hopkins University School of Medicine, 733 North Broadway, Suite G-45, Baltimore, MD, 21205, USA.
| |
Collapse
|
14
|
Abstract
BACKGROUND Unplanned readmission after surgery negatively impacts surgical recovery. Few studies have sought to define predictors of readmission in a rectal cancer cohort alone. Readmission following rectal cancer surgery may be reduced by the identification and modification of factors associated with readmission. OBJECTIVES This study seeks to characterize the predictors of 30-day readmission following proctectomy for rectal cancer. DESIGN This study is a retrospective analysis of prospectively gathered cohort data. Outcomes were compared between readmitted and nonreadmitted patients. Multivariate analysis of factors association with readmission was performed by using binary logistic regression. SETTINGS This study was conducted at Beaumont Hospital, a nationally designated, publicly funded cancer center. PATIENTS Two hundred forty-six consecutive patients who underwent proctectomy for rectal cancer between January 2012 and December 2015 were selected. MAIN OUTCOME MEASURES The primary outcomes measured were readmission within 30 days of discharge and the variables associated with readmission, categorized into patient factors, perioperative factors, and postoperative factors. RESULTS Thirty-one (12.6%) patients were readmitted within 30 days of discharge following index rectal resection. The occurrence of anastomotic leaks, high-output stoma, and surgical site infections was significantly associated with readmission within 30 days (anastomotic leak OR 3.60, p = 0.02; high-output stoma OR 11.04, p = 0.003; surgical site infections OR 13.39, p = 0.01). Surgical site infections and high-output stoma maintained significant association on multivariate analysis (surgical site infections OR 10.02, p = 0.001; high-output stoma OR 9.40, p = 0.02). No significant difference was noted in the median length of stay or frequency of prolonged admissions (greater than 24 days) between readmitted and nonreadmitted patients. LIMITATIONS The institutional database omits a number of socioeconomic factors and comorbidities that may influence readmission, limiting our capacity to analyze the relative contribution of these factors to our findings. CONCLUSIONS An early postoperative care bundle to detect postoperative complications could prevent some unnecessary inpatient admissions following proctectomy. Key constituents should include early identification and management of stoma-related complications and surgical site infection. See Video Abstract at http://links.lww.com/DCR/A912.
Collapse
|
15
|
Orive M, Aguirre U, Gonzalez N, Lázaro S, Redondo M, Bare M, Anula R, Briones E, Escobar A, Sarasqueta C, Garcia-Gutierrez S, Quintana JM. Risk factors affecting hospital stay among patients undergoing colon cancer surgery: a prospective cohort study. Support Care Cancer 2019; 27:4133-4144. [PMID: 30793242 DOI: 10.1007/s00520-019-04683-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 09/26/2018] [Indexed: 02/03/2023]
Abstract
PURPOSE To identify and validate risk factors that contribute to prolonged length of hospital stay (LOS) in patients undergoing resection for colorectal cancer. METHODS This prospective cohort study included 1955 patients admitted to 22 hospitals for primary resection of colorectal cancer. Multivariate analyses were used to identify and validate risk factors, randomizing patients into a derivation and a validation cohort. Multiple correspondence and cluster analysis were performed to identify clinical subtypes based on LOS. RESULTS The strongest independent predictors of prolonged LOS were postoperative reintervention, surgical site infection, open surgery, and distant metastasis. The multiple correspondence and cluster analysis provided three groups of patients in relation to prolonged LOS: patients with the longest LOS included the highest percentage of patients with open surgery, distant metastasis, deep surgical site infections, emergency admissions, additional diagnostic factors, and highly contaminated surgical sites. Patients with prolonged LOS (> 14 days) were more likely to develop adverse outcomes within 30 days after discharge. CONCLUSIONS Patients undergoing resection of colorectal cancer cluster into different groups based on LOS of the index admission. Those with prolonged LOS were more likely to develop adverse outcomes within 30 days after discharge. Some of the strongest independent predictors of prolonged LOS, such as surgical infections or open surgery, could be modified to reduce LOS and, in turn, other adverse outcomes. TRIAL REGISTRATION NCT02488161.
Collapse
Affiliation(s)
- Miren Orive
- Research Unit, Hospital Galdakao-Usansolo, B° Labeaga s/n, 48960, Galdakao, Biscay, Spain.
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain.
| | - Urko Aguirre
- Research Unit, Hospital Galdakao-Usansolo, B° Labeaga s/n, 48960, Galdakao, Biscay, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain
| | - Nerea Gonzalez
- Research Unit, Hospital Galdakao-Usansolo, B° Labeaga s/n, 48960, Galdakao, Biscay, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain
| | - Santiago Lázaro
- General Surgery Service, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
| | - Maximino Redondo
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain
- Research Unit, Hospital Costa del Sol, Málaga, Spain
| | - Marisa Bare
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain
- Clinical Epidemiology Unit, Corporacio Parc Tauli, Barcelona, Spain
| | - Rocío Anula
- Colorectal Unit, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Antonio Escobar
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain
- Research Unit, Basurto University Hospital, Basurto, Bilbao, Bizkaia, Spain
| | - Cristina Sarasqueta
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain
- Research Unit, Donostia University Hospital, Donostia-San Sebastian, Gipuzkoa, Spain
| | - Susana Garcia-Gutierrez
- Research Unit, Hospital Galdakao-Usansolo, B° Labeaga s/n, 48960, Galdakao, Biscay, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain
| | - José M Quintana
- Research Unit, Hospital Galdakao-Usansolo, B° Labeaga s/n, 48960, Galdakao, Biscay, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain
| |
Collapse
|
16
|
Hyde LZ, Al-Mazrou AM, Kuritzkes BA, Suradkar K, Valizadeh N, Kiran RP. Readmissions after colorectal surgery: not all are equal. Int J Colorectal Dis 2018; 33:1667-1674. [PMID: 30167778 DOI: 10.1007/s00384-018-3150-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aims to assess factors associated with preventable readmissions after colorectal resection. METHODS All readmissions following colorectal resection from May 2013 to May 2016 at an academic medical center were reviewed. Readmissions that could be prevented were identified. Factors associated with preventable readmission were assessed using logistic regression. RESULTS Of 686 patients discharged during the study period, there were 75 patients (11%) with unplanned readmission. Twenty-nine readmissions (39%) were preventable-these readmissions were due to dehydration or acute kidney injury, pain, ostomy complications, and gastrointestinal bleeding. On regression analysis, the strongest preoperative risk factors associated with preventable readmission were urgent or emergent operation (OR 4.0, 95% CI 1.6-9.9), recent myocardial infarction (OR 2.9, 95% CI 1.0-9.0), total or subtotal colectomy (OR 2.8, 95% CI 1.1-7.3), and American Society of Anesthesiologist score ≥ 3 (OR 2.2, 95% CI 1.0-4.7). Intraoperative risk factors associated with preventable readmission included intraoperative stapler complication (OR 24.2, 95% CI 1.5-397). Postoperative risk factors associated with preventable readmission included postoperative arrhythmia (OR 5.6, 95% CI 2.0-16.1), and postoperative anemia (OR 2.6, 95% CI 1.2-5.7). On multivariable analysis while controlling for procedure type, urgent or emergent operation (OR 2.9, 95% CI 1.1-8.2), intraoperative stapler complication (OR 37.5, 95% CI 2.3-627.8), and postoperative arrhythmia (OR 4, 95% CI 1.3-12.8) remained statistically significant. CONCLUSION Approximately 40% of readmissions following colorectal surgery are potentially preventable. Since specific patients and factors that are associated with preventable readmission can be identified, resources should be targeted to factors associated with preventable readmissions.
Collapse
Affiliation(s)
- Laura Z Hyde
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA.,Department of Surgery, University of California San Francisco-East Bay, Oakland, CA, USA
| | - Ahmed M Al-Mazrou
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Ben A Kuritzkes
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Kunal Suradkar
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Neda Valizadeh
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA.
| |
Collapse
|
17
|
Predicting the Risk of Readmission From Dehydration After Ileostomy Formation: The Dehydration Readmission After Ileostomy Prediction Score. Dis Colon Rectum 2018; 61:1410-1417. [PMID: 30303886 PMCID: PMC6219896 DOI: 10.1097/dcr.0000000000001217] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND All-cause readmission rates in patients undergoing ileostomy formation are as high as 20% to 30%. Dehydration is a leading cause. No predictive model for dehydration readmission has been described. OBJECTIVE The purpose of this study was to develop and validate the Dehydration Readmission After Ileostomy Prediction scoring system to predict the risk of readmission for dehydration after ileostomy formation. DESIGN Patients who underwent ileostomy formation were identified using the American College of Surgeons National Surgical Quality Improvement Program data set (2012-2015). Predictors for dehydration were identified using multivariable logistic regression analysis and translated into a point scoring system based on corresponding β-coefficients using 2012-2014 data (derivation). Model discrimination was assessed with receiver operating characteristic curves using 2015 data (validation). SETTINGS This study used the American College of Surgeons National Surgical Quality Improvement Program. PATIENTS A total of 8064 (derivation) and 3467 patients (validation) were included from the American College of Surgeons National Surgical Quality Improvement Program. MAIN OUTCOME MEASURES Dehydration readmission within 30 days of operation was measured. RESULTS A total of 8064 patients were in the derivation sample, with 2.9% (20.1% overall) readmitted for dehydration. Twenty-five variables were queried, and 7 predictors were identified with points assigned: ASA class III (4 points), female sex (5 points), IPAA (4 points), age ≥65 years (5 points), shortened length of stay (5 points), ASA class I to II with IBD (7 points), and hypertension (9 points). A 39-point, 5-tier risk category scoring system was developed. The model performed well in derivation (area under curve = 0.71) and validation samples (area under curve = 0.74) and passed the Hosmer-Lemeshow goodness-of-fit test. LIMITATIONS Limitations of this study pertained to those of the American College of Surgeons National Surgical Quality Improvement Program, including a lack of generalizability, lack of ileostomy-specific variables, and inability to capture multiple readmission International Classification of Diseases, 9/10 edition, codes. CONCLUSIONS The Dehydration Readmission After Ileostomy Prediction score is a validated scoring system that identifies patients at risk for dehydration readmission after ileostomy formation. It is a specific approach to optimize patient factors, implement interventions, and prevent readmissions. See Video Abstract at http://links.lww.com/DCR/A746.
Collapse
|
18
|
Tebala GD, Gallucci A, Khan AQ. The impact of complications on a programme of enhanced recovery in colorectal surgery. BMC Surg 2018; 18:60. [PMID: 30115063 PMCID: PMC6097404 DOI: 10.1186/s12893-018-0390-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 08/02/2018] [Indexed: 01/22/2023] Open
Abstract
Background The advantages of Enhanced Recovery (ER) programmes are well known, in terms of improved overall experience of the patients, which associates with low morbidity and reduced length of stay. As a result, the pattern of morbidity is changing and some patients may develop complications after discharge. Aim of this work was to evaluate the impact of morbidity and related outcomes such as unplanned readmission and reoperation rate on an ER programme in colorectal surgery. Methods Prospectively collected clinical data of patients who underwent colorectal resection have been retrospectively analysed. Endpoints were: 90-day mortality and morbidity, length of hospital stay (LOS) and rate of unplanned readmissions and reoperations. Results Mortality and morbidity did not change in the analysed period, but LOS reduced significantly. Main determinant of postoperative LOS was the type of surgical approach, laparoscopy being associated with earlier discharge. LOS was longer in patients who developed complications. Morbidity and reoperation rate were significantly higher in patients discharged after day 4. Majority of complications happened in patients who were still in the hospital. However, the few patients who developed complications after discharge did not have a worse outcome if compared to those who had complications in hospital. Conclusions ER protocols must become integral part of the perioperative management of colorectal patients. ER and laparoscopy have a synergic effect to improve the postoperative recovery and reduce morbidity. Early discharge of patients does not affect the outcome of postoperative complications.
Collapse
Affiliation(s)
- Giovanni D Tebala
- Colorectal Team, Noble's Hospital, Douglas, Isle of Man, UK. .,East Kent Hospitals University NHS Foundation Trust, William Harvey Hospital, Kennington Rd, Willesborough, Ashford, Kent, TN24 0LZ, UK.
| | | | - Abdul Q Khan
- Colorectal Team, Noble's Hospital, Douglas, Isle of Man, UK
| |
Collapse
|
19
|
Lim S, Ghosh S, Niklewski P, Roy S. Laparoscopic Suturing as a Barrier to Broader Adoption of Laparoscopic Surgery. JSLS 2018; 21:JSLS.2017.00021. [PMID: 28694682 PMCID: PMC5491803 DOI: 10.4293/jsls.2017.00021] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Laparoscopic surgery is increasingly replacing the open procedure because of its many patient-related benefits that are well aligned with policies and programs that seek to optimize health system performance. However, widespread adoption of laparoscopic surgery has been slow, in part, because of the complexity of laparoscopic suturing. The objective of this study was to review the clinical and economic impacts of laparoscopic suturing in key procedures and to assess its role as a barrier to the broader adoption of laparoscopic surgery. DATABASE A medical literature search of MEDLINE, EMBASE, and BIOSIS from January 2010 through June 2016 identified 47 relevant articles. CONCLUSION Laparoscopic suturing and intracorporeal knot tying may result in extended surgical time, complications, and surgeon errors, while improving patient quality of life through improved cosmesis, diet toleration, and better bowel movements. Despite advancement in surgical techniques and the availability of newer surgical tools, the complexity of laparoscopic suturing continues to be a barrier to greater adoption of MIS. The results of the study underscore the need for development of proficiency in laparoscopic suturing, which may help improve patient outcomes and reduce healthcare costs.
Collapse
Affiliation(s)
- Sangtaeck Lim
- Franchise Health Economics and Market Access, Ethicon, Inc., Somerville New Jersey, USA
| | | | - Paul Niklewski
- Endomech Clinical Research, Ethicon, Inc., Cincinnati, Ohio, USA
| | - Sanjoy Roy
- Franchise Health Economics and Market Access, Ethicon, Inc., Somerville New Jersey, USA
| |
Collapse
|
20
|
Decreasing readmissions by focusing on complications and underlying reasons. Am J Surg 2017; 215:557-562. [PMID: 28760355 DOI: 10.1016/j.amjsurg.2017.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/06/2017] [Accepted: 07/16/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND To analyze demographics and outcomes of patients focusing on 30-day readmission status and identify procedure-specific risk factors. METHODS Patients undergoing abdominal colorectal surgery (2011-2013) were identified Demographics and outcomes including in-hospital complications were compared based on readmission status. RESULTS A total of 6637 patients were identified with a mean age of 51.2(±17.1) years. Seven hundred and seventy five(11.7%) patients were readmitted at least once within 30-day. The most common index procedures related to readmission were stoma closure (n = 127/775, 16.4%) and total colectomy (n = 105/775, 13.6%). Readmitted patients had longer length of index hospital stay (LOS)(8.2 ± 5.9 vs 7.9 ± 6.9 days,p < 0.001) and operative time(167 ± 104 vs 144 ± 95 min, p < 0.001), higher intraoperative(2% vs 1%,p = 0.04) and in-hospital complication rates(36% vs 28%,p < 0.001). Main reasons for readmissions were gastrointestinal-related causes(n = 222, 29%), small bowel obstruction (n = 133,17%), wound-related complications(n = 108,14%), and dehydration(n = 93,12%). Median readmission LOS was 4(1-71)days and 54%(n = 407) of readmissions occurred within 7 days of discharge. CONCLUSION Increased postoperative complications may be the main preventable underlying reason for increased risk of hospital readmission after colorectal surgery. Preventive measures to decrease complications and actions to identify high risk patients for complications would help to reduce readmissions.
Collapse
|
21
|
Horstman MJ, Mills WL, Herman LI, Cai C, Shelton G, Qdaisat T, Berger DH, Naik AD. Patient experience with discharge instructions in postdischarge recovery: a qualitative study. BMJ Open 2017; 7:e014842. [PMID: 28228448 PMCID: PMC5337662 DOI: 10.1136/bmjopen-2016-014842] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 01/12/2017] [Accepted: 01/16/2017] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES We examined the role of discharge instructions in postoperative recovery for patients undergoing colorectal surgery and report themes related to patient perceptions of discharge instructions and postdischarge experience. DESIGN Semistructured interviews were conducted as part of a formative evaluation of a Project Re-Engineered Discharge intervention adapted for surgical patients. SETTING Michael E. DeBakey VA Medical Center, a tertiary referral centre in Houston, Texas. PARTICIPANTS Twelve patients undergoing elective colorectal surgery. Interviews were conducted at the two-week postoperative appointment. RESULTS Participants demonstrated understanding of the content in the discharge instructions. During the interviews, participants reported several positive roles for discharge instructions in their postdischarge care: a sense of security, a reminder of inhospital education, a living document and a source of empowerment. Despite these positive associations, participants reported that the instructions provided insufficient information to promote access to care that effectively addressed acute issues following discharge. Participants noted difficulty reaching providers after discharge, which resulted in the adoption of workarounds to overcome system barriers. CONCLUSIONS Despite concerted efforts to provide patient-centred instructions, the discharge instructions did not provide enough context to effectively guide postdischarge interactions with the healthcare system. Insufficient information on how to access and communicate with the most appropriate personnel in the healthcare system is an important barrier to patients receiving high-quality postdischarge care. Tools and strategies from team training programmes, such as team strategies and tools to enhance performance and patient safety, could be adapted to include patients and provide them with structured methods for communicating with healthcare providers post discharge.
Collapse
Affiliation(s)
- Molly J Horstman
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- VA Quality Scholars Coordinating Center, IQuESt, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Whitney L Mills
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Levi I Herman
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Jesse H. Jones Graduate School of Business, Rice University, Houston, Texas, USA
| | - Cecilia Cai
- Internal Medicine Residency Program, Baylor College of Medicine, Houston, Texas, USA
| | - George Shelton
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Tareq Qdaisat
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas, USA
| | - David H Berger
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Aanand D Naik
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt); Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- VA Quality Scholars Coordinating Center, IQuESt, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| |
Collapse
|
22
|
Abstract
BACKGROUND Factors associated with readmission stratified by the day of postdischarge rehospitalization after colorectal surgery have not been characterized previously. OBJECTIVE The purpose of this study was to identify factors leading to readmission on a day-to-day basis after discharge from colorectal surgery. DESIGN This was a retrospective analysis of patients readmitted within 30-days after colorectal surgery. Reasons and factors associated with readmission each day after discharge were evaluated. Early readmitted patients (day 0-5 postdischarge) were compared with those readmitted later (day 6-29 postdischarge). SETTINGS The study was conducted at a tertiary center. PATIENTS Patients included those who had undergone primary colorectal resection from the American College of Surgeons National Surgical Quality Improvement Program (2012-2013). MAIN OUTCOME MEASURES The study intended to identify factors associated with any early versus late hospital readmission and to evaluate diagnoses for unplanned readmissions on a day-to-day basis after discharge. RESULTS For 69,222 elective colorectal procedures, 7476 patients (10.8%) were readmitted to the hospital within 30 days. Early (median, 3 days) and late (median, 11 days) readmissions were 3278 (43.8%) and 4198 (56.2%). Except for sex, patient demographics were similar between groups. Neurologic comorbidity; wound disruption; sepsis or septic shock; unplanned reintubation and reoperation; anastomotic leak and ileus; and neurological, cardiovascular, and pulmonary complications were significantly higher in the early readmission, whereas disseminated malignancy, stoma creation, and renal/urological complications were significantly higher in the late readmission group. On multivariable analysis, early readmission was significantly associated with male patients, wound disruption, sepsis or septic shock, reoperation, reintubation, and postoperative neurological complications. Disseminated malignancy, ostomy creation, and postoperative renal dysfunction/urological infection were associated with delayed readmission. LIMITATIONS Thirty-day readmissions and reasons for unplanned rehospitalizations were evaluated. CONCLUSIONS Differing factors are associated with early versus late readmission after colorectal resection. These data suggest that early readmission is intricately related to patient and operative complexity and hence may be inevitable, whereas delayed hospital presentation is associated with identifiable perioperative predictors at the time of discharge and hence more likely to be targetable.
Collapse
|
23
|
Yeo H, Mao J, Abelson JS, Lachs M, Finlayson E, Milsom J, Sedrakyan A. Development of a Nonparametric Predictive Model for Readmission Risk in Elderly Adults After Colon and Rectal Cancer Surgery. J Am Geriatr Soc 2016; 64:e125-e130. [PMID: 27650646 DOI: 10.1111/jgs.14448] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Primary objective: to use advanced nonparametric techniques to determine risk factors for readmission after colorectal cancer surgery in elderly adults. SECONDARY OBJECTIVE to compare this methodology with traditional parametric methods. DESIGN Using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), nonparametric techniques were used to evaluate the risk of readmission in elderly adults undergoing surgery for colorectal cancer in 2011 and 2012. SETTING More than 200 hospitals participating in the NSQIP database. PARTICIPANTS Individuals aged 65 and older who underwent surgery for colorectal cancer in 2011 and 2012 (N = 2,117). MEASUREMENTS Age-stratified robust nonparametric predictive model (classification and regression tree (CART) analysis) of 30-day readmission for elderly adults undergoing surgery for colorectal cancer. RESULTS Recent chemotherapy was the most important predictor of readmission in participants aged 65 to 74, with 20% of those with recent chemotherapy and 11% of with no recent chemotherapy being readmitted. Participants aged 75 to 84 who had recently undergone chemotherapy had a readmission rate of 23%, whereas those with no chemotherapy had a readmission rate of 9%. Being underweight was the greatest predictor of readmission (30%) in participants aged 85 and older. These methods were found to be more robust than traditional logistic regression. CONCLUSION Specific age-related preoperative factors help predict readmission in elderly adults undergoing colorectal cancer surgery. Results of the nonparametric CART analysis are better than traditional regression analysis and help physicians to clinically stratify based on age. This model may help identify individuals in whom intervention may be helpful in reducing readmission after surgery.
Collapse
Affiliation(s)
- Heather Yeo
- Department of Surgery, Weill Medical College, New York-Presbyterian Hospital, Cornell University, New York, New York.,Department of Healthcare Policy and Research, Weill Medical College, New York-Presbyterian Hospital, Cornell University, New York, New York
| | - Jialin Mao
- Department of Healthcare Policy and Research, Weill Medical College, New York-Presbyterian Hospital, Cornell University, New York, New York
| | - Jonathan S Abelson
- Department of Surgery, Weill Medical College, New York-Presbyterian Hospital, Cornell University, New York, New York
| | - Mark Lachs
- Department of Geriatric Medicine, Weill Medical College, New York-Presbyterian Hospital, Cornell University, New York, New York
| | - Emily Finlayson
- Department of Surgery, University of California San Francisco Medical Center, San Francisco, California.,Department of Medicine, University of California San Francisco Medical Center, San Francisco, California.,Department of Health Policy, University of California San Francisco Medical Center, San Francisco, California
| | - Jeffrey Milsom
- Department of Surgery, Weill Medical College, New York-Presbyterian Hospital, Cornell University, New York, New York
| | - Art Sedrakyan
- Department of Healthcare Policy and Research, Weill Medical College, New York-Presbyterian Hospital, Cornell University, New York, New York
| |
Collapse
|
24
|
Vargas López AJ, Fernández Carballal C. [Incidence and risk factors of 30-day readmission in neurosurgical patients]. Neurocirugia (Astur) 2016; 28:22-27. [PMID: 27640325 DOI: 10.1016/j.neucir.2016.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 06/12/2016] [Accepted: 06/15/2016] [Indexed: 10/21/2022]
Abstract
AIM The 30-day readmission rate has become an important indicator of health care quality. This study focuses on the incidence of 30-day readmission in neurosurgical patients and related risk factors. MATERIAL AND METHODS A retrospective review was performed on patients treated in a neurosurgery department between 1 January 2012 and the 31 December 2013. Patients requiring readmission within 30 days of discharge and the readmission diagnosis were identified, and the factors related to their readmission were analysed. RESULTS A total of 1,854 interventions were carried out on 1,739 patients during the aforementioned (study) period. Of the remaining patients, 174 (10.2%) required readmission within 30 days of discharge. The main causes of readmission were problems related to the surgical wound (21.2% of all readmissions), followed by respiratory processes (18.8%). A total of 73.9% of readmissions occurred in patients who had undergone cranial surgery. Multiple comorbidities estimated by Charlson comorbidity index and length of hospital stay were identified as factors related to a higher readmission rate. CONCLUSIONS The 30-day readmission rate observed in our series was 10.2%. Multiple comorbidity expressed by the Charlson comorbidity index and length of hospital stay were related to readmission.
Collapse
|
25
|
Park JH, Son YG, Kim TH, Huh YJ, Yang JY, Suh YJ, Suh YS, Kong SH, Lee HJ, Yang HK. Identification of Candidates for Early Discharge After Gastrectomy. Ann Surg Oncol 2016; 24:159-166. [DOI: 10.1245/s10434-016-5447-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Indexed: 12/30/2022]
|
26
|
Hospital Readmissions After Intestinal and Multivisceral Transplantation. Transplant Proc 2016; 48:2186-91. [DOI: 10.1016/j.transproceed.2016.03.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 03/30/2016] [Indexed: 12/14/2022]
|
27
|
Hardiman KM, Reames CD, McLeod MC, Regenbogen SE. Patient autonomy-centered self-care checklist reduces hospital readmissions after ileostomy creation. Surgery 2016; 160:1302-1308. [PMID: 27320065 DOI: 10.1016/j.surg.2016.05.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 04/27/2016] [Accepted: 05/07/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Patients who undergo a colorectal operation that includes a new ileostomy incur high rates of readmission. Ostomates face a steep learning curve to master the skills and knowledge needed for success at home. We designed and implemented a patient-centered checklist promoting independence and validating self-care knowledge and care skills and evaluated its effect on readmissions after ileostomy creation. METHODS On a single inpatient unit, new ileostomy patients were taught and evaluated using a novel postoperative self-care checklist, while perioperative care for ostomates remained unchanged elsewhere in the institution. In a retrospective cohort including all consecutive ileostomy patients from 2 years before (period 1) and 1 year after (period 2) the checklist implementation, we identified univariable predictors of readmission within 30 days of discharge and used a multivariable, difference-in-differences approach to compare trends in readmission between the intervention and control units. RESULTS Of the 430 patients in the study period, there were 116 with readmissions (26%). Readmitted patients had significantly greater all patient refined diagnosis related group weights (3.6 vs 3.3, P = .006) and longer initial duration of stay (13.3 vs 11.3 days, P = .006), and they were more likely to be emergency admissions (49% vs 38%, P = .04). The readmission rate on the intervention unit decreased from 28% in period 1 to 20% in period 2. The logistic regression-based difference-in-differences approach revealed that implementation of the checklist was an independent negative predictor of readmission (P = .04). CONCLUSION Implementation of a patient-centered, self-care-oriented postoperative education checklist was associated with significantly reduced odds of readmission after ileostomy creation.
Collapse
Affiliation(s)
- Karin M Hardiman
- Division of Colorectal Surgery, University of Michigan, Ann Arbor, MI.
| | | | | | | |
Collapse
|
28
|
Schlussel A, Steele SR. Statewide quality improvement initiatives in colorectal surgery. SEMINARS IN COLON AND RECTAL SURGERY 2016. [DOI: 10.1053/j.scrs.2016.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
29
|
Sutherland T, David-Kasdan JA, Beloff J, Mueller A, Whang EE, Bleday R, Urman RD. Patient and Provider-Identified Factors Contributing to Surgical Readmission After Colorectal Surgery. J INVEST SURG 2016; 29:195-201. [PMID: 26891195 DOI: 10.3109/08941939.2015.1124947] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Nearly one in seven surgical patients is readmitted to the hospital within 30 days of discharge. Few studies have identified patient-centric factors that raise the risk of both preventable and nonpreventable postoperative readmissions. MATERIALS AND METHODS Over 6 months in 2012, 48 colorectal surgical patients were identified on re-admission within 30 days of discharge. We prospectively obtained information on the patient's and primary surgeon's views on factors that contributed to readmission, and compiled data to produce an external list of contributing factors. A standard cost analysis was performed. RESULTS 48 colorectal surgery patients participated, and 47 were included in this patient-centric evaluation of factors leading to readmission. The three primary readmission diagnoses included dehydration, fever, and ileus or small bowel obstruction. Of all readmissions, 23% were considered to be preventable. 38% of patients had scheduled follow-up appointments that were documented in the medical record at the time of discharge. Providers identified several factors contributing to readmission including difficulty understanding discharge plan, medication management and premature discharge. Per patient, the cost of preventable readmission was $15,366 (±20%; $12,293-$18,439). Total preventable cost was $169,025 (±20%; $135,220-$202,829). CONCLUSIONS The ability to obtain an outpatient postoperative appointment and the understanding of their own postoperative care were the most commonly identified barriers. Interventions to help reduce unnecessary readmissions include a standard discharge process and coordinator, and routine (<7 days) postdischarge outpatient appointments. Successful reduction of preventable readmissions would result in approximately $3.6 million in cost savings per 1,000 colorectal readmissions.
Collapse
Affiliation(s)
- Tori Sutherland
- a Department of Anesthesia, Critical Care, and Pain Medicine , Beth Israel Deaconess Medical Center, Critical Care and Pain Medicine
| | | | - Jennifer Beloff
- b Department of Quality and Safety , Brigham and Women's Hospital
| | - Ariel Mueller
- a Department of Anesthesia, Critical Care, and Pain Medicine , Beth Israel Deaconess Medical Center, Critical Care and Pain Medicine
| | | | - Ronald Bleday
- c Department of Surgery , Brigham and Women's Hospital
| | - Richard D Urman
- d Department of Anesthesiology , Perioperative and Pain Medicine, Brigham and Women's Hospital
| |
Collapse
|
30
|
Pędziwiatr M, Pisarska M, Kisielewski M, Matłok M, Major P, Wierdak M, Budzyński A, Ljungqvist O. Is ERAS in laparoscopic surgery for colorectal cancer changing risk factors for delayed recovery? Med Oncol 2016; 33:25. [PMID: 26873739 PMCID: PMC4752577 DOI: 10.1007/s12032-016-0738-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 01/31/2016] [Indexed: 12/13/2022]
Abstract
There is evidence that implementation of enhanced recovery after surgery (ERAS) protocols into colorectal surgery reduces complication rate and improves postoperative recovery. However, most published papers on ERAS outcomes and length of stay in hospital (LOS) include patients undergoing open resections. The aim of this pilot study was to determine the factors affecting recovery and LOS in patients after laparoscopic colorectal surgery for cancer combined with ERAS protocol. One hundred and forty-three consecutive patients undergoing elective laparoscopic resection were prospectively evaluated. They were divided into two subgroups depending on their reaching the targeted length of stay—LOS (75 patients in group 1—≤4 days, 68 patients in group 2—>4 days). A univariate and multivariate logistic regression analysis was performed to assess for factors (demographics, perioperative parameters, complications and compliance with the ERAS protocol) independently associated with LOS of 4 days or longer. The median LOS in the entire group was 4 days. The postoperative complication rate was higher (18.7 vs. 36.7 %), and the compliance with ERAS protocol was lower (91.2 vs. 76.7 %) in group 2. There was an association between the pre- and postoperative compliance and the subsequent complications. In uni- and multivariate analysis, the lack of balanced fluid therapy (OR 3.87), lack of early mobilization (OR 20.74), prolonged urinary catheterization (OR 4.58) and use of drainage (OR 2.86) were significantly associated with prolonged LOS. Neither traditional patient risk factors nor the stage of the cancer was predictive of the duration of hospital stay. Instead, compliance with the ERAS protocol seems to influence recovery and LOS when applied to laparoscopic colorectal cancer surgery.
Collapse
Affiliation(s)
- Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland. .,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland.
| | - Magdalena Pisarska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Michał Kisielewski
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Maciej Matłok
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Mateusz Wierdak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| |
Collapse
|
31
|
King EA, Kucirka LM, McAdams-DeMarco MA, Massie AB, Al Ammary F, Ahmed R, Grams ME, Segev DL. Early Hospital Readmission After Simultaneous Pancreas-Kidney Transplantation: Patient and Center-Level Factors. Am J Transplant 2016; 16:541-9. [PMID: 26474070 PMCID: PMC6116541 DOI: 10.1111/ajt.13485] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 07/20/2015] [Accepted: 08/09/2015] [Indexed: 01/25/2023]
Abstract
Early hospital readmission is associated with increased morbidity, mortality, and cost. Following simultaneous pancreas-kidney transplantation, rates of readmission and risk factors for readmission are unknown. We used United States Renal Data System data to study 3643 adult primary first-time simultaneous pancreas-kidney recipients from December 1, 1999 to October 31, 2011. Early hospital readmission was any hospitalization within 30 days of discharge. Modified Poisson regression was used to determine the association between readmission and patient-level factors. Empirical Bayes statistics were used to determine the variation attributable to center-level factors. The incidence of readmission was 55.5%. Each decade increase in age was associated with an 11% lower risk of readmission to age 40, beyond which there was no association. Donor African-American race was associated with a 13% higher risk of readmission. Each day increase in length of stay was associated with a 2% higher risk of readmission until 14 days, beyond which each day increase was associated with a 1% reduction in the risk of readmission. Center-level factors were not associated with readmission. The high incidence of early hospital readmission following simultaneous pancreas-kidney transplant may reflect clinical complexity rather than poor quality of care.
Collapse
Affiliation(s)
- Elizabeth A. King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lauren M. Kucirka
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Mara A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Fawaz Al Ammary
- Department of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rizwan Ahmed
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Morgan E. Grams
- Department of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| |
Collapse
|
32
|
Martin TD, Lorenz T, Ferraro J, Chagin K, Lampman RM, Emery KL, Zurkan JE, Boyd JL, Montgomery K, Lang RE, Vandewarker JF, Cleary RK. Newly implemented enhanced recovery pathway positively impacts hospital length of stay. Surg Endosc 2015; 30:4019-28. [PMID: 26694181 DOI: 10.1007/s00464-015-4714-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 12/01/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Enhanced recovery pathways (ERPs) are thought to improve surgical outcomes by standardizing perioperative patient care established in evidence-based literature. The objective of this study was to determine the impact of a colorectal surgery ERP on hospital length of stay (LOS) and other patient outcomes. METHODS This is a comparative effectiveness study of patients undergoing elective colorectal surgery 2 years prior (pre-ERP group) and 2 years after (ERP group) implementation of an ERP program. The primary outcome was hospital LOS. Secondary outcomes included postoperative complications, 30-day readmissions, and 30-day reoperations. Multivariable regression analyses were utilized to control for patient factors, general health factors, diagnosis, surgeon, colon versus rectal operations, and open versus minimally invasive operations-laparoscopic and robotic. An ERP checklist was developed to track adherence to components of the pathway. RESULTS The study population included 1036 patients: 523 in the pre-ERP group and 513 in the ERP group. Unadjusted LOS was significantly shorter in the ERP group than the control pre-ERP group [3 (IQR 3.5) vs 5 days (IQR 4.6); p < 0.0001]. Multivariable regression analysis confirmed the reduction in LOS, controlling for age, colon/rectum procedure, open/laparoscopic/robotic approach, primary diagnosis, and alvimopan use. Postoperative outcomes were not significantly different between groups except for 30-day readmissions, which were unexpectedly higher in the ERP group (14.6 vs 8.7 %, p = 0.04). CONCLUSIONS A newly implemented ERP on a dedicated colorectal surgery service in an academic non-university hospital setting resulted in shorter hospital LOS, but increased readmissions, for patients undergoing elective open and minimally invasive colon and rectal surgery. Future multi-institutional studies are needed to understand the impact of ERP on postoperative complications and readmissions.
Collapse
Affiliation(s)
- Thomas D Martin
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Talya Lorenz
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Jane Ferraro
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Kevin Chagin
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Richard M Lampman
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Karen L Emery
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Joan E Zurkan
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Jami L Boyd
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Karin Montgomery
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Rachel E Lang
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - James F Vandewarker
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA
| | - Robert K Cleary
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5325 Elliott Dr MHVI #104, Ann Arbor, MI, 48106, USA.
| |
Collapse
|
33
|
Orcutt ST, Li LT, Balentine CJ, Albo D, Awad SS, Berger DH, Anaya DA. Ninety-day readmission after colorectal cancer surgery in a Veterans Affairs cohort. J Surg Res 2015; 201:370-7. [PMID: 27020821 DOI: 10.1016/j.jss.2015.11.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 11/06/2015] [Accepted: 11/18/2015] [Indexed: 01/25/2023]
Abstract
BACKGROUND Readmissions following colorectal surgery are common. However, there are limited data examining unplanned readmissions (URs) after colorectal cancer (CRC) surgery. The goal of this study was to identify reasons and predictors of UR, and to examine their clinical impact on CRC patients. METHODS A retrospective cohort study using a prospective CRC surgery database of patients treated at a VA tertiary referral center was performed (2005-2011). Ninety-day URs were recorded and classified based on reason for readmission. Clinical impact of UR was measured using a validated classification for postoperative complications. Multivariate logistic regression analyses were performed to identify predictors of UR. RESULTS 487 patients were included; 104 (21%) required UR. Although the majority of UR were due to surgical reasons (n = 72, 69%), medical complications contributed to 25% of all readmission events. Nearly half of UR (n = 44, 40%) had significant clinical implications requiring invasive interventions, intensive care unit stays, or led to death. After multivariate logistic regression, the following independent predictors of UR were identified: African-American race (odds ratio [OR] 0.47 [0.27-0.88]), ostomy creation (OR 2.50 [1.33-4.70]), and any postoperative complication (OR 4.36 [2.48-7.68]). CONCLUSIONS Ninety-day URs following colorectal cancer surgery are common, and represent serious events associated with worse outcomes. In addition to postoperative complications, surgical details that can be anticipated (i.e., ileostomy creation) and medical events unrelated to surgery, both contribute as important and potentially preventable reasons for UR. Future studies should focus on developing and examining interventions focused at improving the process of perioperative care for this high-risk population.
Collapse
Affiliation(s)
- Sonia T Orcutt
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Linda T Li
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Courtney J Balentine
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Daniel Albo
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Samir S Awad
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, Texas; Houston Veterans Affairs Health Services Research and Development, Center for Innovations in Quality, Effectiveness and Safety (IQUEST), Houston, Texas; Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - David H Berger
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, Texas; Houston Veterans Affairs Health Services Research and Development, Center for Innovations in Quality, Effectiveness and Safety (IQUEST), Houston, Texas; Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Daniel A Anaya
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida; Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, Texas.
| |
Collapse
|
34
|
Ang CW, Seretis C, Wanigasooriya K, Mahadik Y, Singh J, Chapman MAS. The most frequent cause of 90-day unplanned hospital readmission following colorectal cancer resection is chemotherapy complications. Colorectal Dis 2015; 17:779-86. [PMID: 25765143 DOI: 10.1111/codi.12945] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 02/10/2015] [Indexed: 12/13/2022]
Abstract
AIM NHS England deems 90-day readmission rates as a marker of quality of care. The causes of readmission have not been previously reported in the UK. The aim of this study was to examine the factors associated with 90-day readmission following colorectal cancer surgery at a hospital trust with a catchment population 1.2 million. METHOD A retrospective review was performed of all patients undergoing resection for colorectal cancer between January 2012 and December 2013. Unplanned readmission was defined as an emergency admission to the trust for any cause within 90 days of surgery. Readmission analyses were restricted to patients discharged from hospital within 28 days of resection. RESULTS A total of 570 patients underwent surgery, of whom 522 were discharged within 28 days and are included for readmission analysis. The readmission rate was 24.3% (127 patients with a total of 163 episodes of hospital readmissions) within 90 days following surgery. The most frequent cause for readmission was complications related to adjuvant chemotherapy (18.4%) followed by wound-related complications (14.1%). Most patients presenting with wound-related complications were admitted within 60 days and patients with chemotherapy-related complications after 61 days; 13/127 (10.2%) patients who were readmitted underwent emergency surgery, and one patient died following readmission. Multivariate analysis demonstrated that comorbidity was the only independent risk factor. CONCLUSION Ninety-day readmissions include a high number of readmissions secondary to chemotherapy-related complications, whereas most surgical-related readmission present within 60 days.
Collapse
Affiliation(s)
- C W Ang
- Department of General and Colorectal Surgery, Good Hope Hospital, Heart of England NHS Foundation Trust, Sutton Coldfield, UK
| | - C Seretis
- Department of General and Colorectal Surgery, Good Hope Hospital, Heart of England NHS Foundation Trust, Sutton Coldfield, UK
| | - K Wanigasooriya
- Department of General and Colorectal Surgery, Good Hope Hospital, Heart of England NHS Foundation Trust, Sutton Coldfield, UK
| | - Y Mahadik
- Department of General and Colorectal Surgery, Good Hope Hospital, Heart of England NHS Foundation Trust, Sutton Coldfield, UK
| | - J Singh
- Department of General and Colorectal Surgery, Good Hope Hospital, Heart of England NHS Foundation Trust, Sutton Coldfield, UK
| | - M A S Chapman
- Department of General and Colorectal Surgery, Good Hope Hospital, Heart of England NHS Foundation Trust, Sutton Coldfield, UK
| |
Collapse
|
35
|
Abstract
BACKGROUND Currently, the predictors of readmission after colectomy specifically for ulcerative colitis (UC) are poorly investigated. We sought to determine the rates and predictors of 30-day readmissions after colectomy for UC. METHODS Patients undergoing total proctocolectomy and end ileostomy, abdominal colectomy with end ileostomy, proctocolectomy with ileoanal pouch anastomosis (IPAA) formation and diverting ileostomy, one stage IPAA, or abdominal colectomy with ileorectal anastomosis at a tertiary care center between January 2002 and January 2012 for UC were included. Patients were identified using ICD-9 code 556.x. Each record was manually reviewed. The electronic record system was reviewed for demographic information, medical histories, UC history, medications, and data regarding the admission and discharge. Charts were reviewed for readmissions within 30 days of surgery. Univariate and multivariate analyses were performed using Stata v.13. RESULTS Two hundred nine patients with UC underwent a colectomy. Forty-three percent had a proctocolectomy with IPAA and diverting ileostomy and 32% had abdominal colectomy with end ileostomy. Seventy-six percent of surgeries were due to failure of medical therapy and 68% of patients were electively admitted for surgery. Thirty-two percent (n = 67/209) of the cohort was unexpectedly readmitted within 30 days. In multivariate model, proctocolectomy with IPAA and diverting ileostomy (odds ratio [OR] = 2.11; 95% CI, 1.06-4.19; P = 0.033) was the only significant predictor of readmission. Hospital length of stay >7 days (OR = 1.82; 95% CI, 0.98-3.41; P = 0.060), presence of limited UC (OR = 2.10; 95% CI, 0.93-4.74; P = 0.074), and steroid before admission (OR = 1.69; 95% CI, 0.90-3.2; P = 0.100) trended toward significance. CONCLUSIONS Surgery for UC is associated with a high rate of readmission. Further prospective studies are necessary to determine the means to reduce these readmissions.
Collapse
|
36
|
Dziegielewski PT, Boyce B, Manning A, Agrawal A, Old M, Ozer E, Teknos TN. Predictors and costs of readmissions at an academic head and neck surgery service. Head Neck 2015; 38 Suppl 1:E502-10. [DOI: 10.1002/hed.24030] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 12/12/2014] [Accepted: 03/04/2015] [Indexed: 11/09/2022] Open
Affiliation(s)
- Peter T. Dziegielewski
- Department of Otolaryngology-Head and Neck Surgery; The Ohio State University Wexner Medical Center; Columbus Ohio
- Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Columbus Ohio
- Department of Otolaryngology; University of Florida; Gainesville Florida
| | - Brian Boyce
- Department of Otolaryngology-Head and Neck Surgery; The Ohio State University Wexner Medical Center; Columbus Ohio
- Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Columbus Ohio
| | - Amy Manning
- Department of Otolaryngology-Head and Neck Surgery; The Ohio State University Wexner Medical Center; Columbus Ohio
- Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Columbus Ohio
| | - Amit Agrawal
- Department of Otolaryngology-Head and Neck Surgery; The Ohio State University Wexner Medical Center; Columbus Ohio
- Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Columbus Ohio
| | - Matthew Old
- Department of Otolaryngology-Head and Neck Surgery; The Ohio State University Wexner Medical Center; Columbus Ohio
- Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Columbus Ohio
| | - Enver Ozer
- Department of Otolaryngology-Head and Neck Surgery; The Ohio State University Wexner Medical Center; Columbus Ohio
- Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Columbus Ohio
| | - Theodoros N. Teknos
- Department of Otolaryngology-Head and Neck Surgery; The Ohio State University Wexner Medical Center; Columbus Ohio
- Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Columbus Ohio
| |
Collapse
|
37
|
A validated, risk assessment tool for predicting readmission after open ventral hernia repair. Hernia 2015; 20:119-29. [PMID: 26286089 DOI: 10.1007/s10029-015-1413-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 07/29/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND/PURPOSE To present a validated model that reliably predicts unplanned readmission after open ventral hernia repair (open-VHR). STUDY DESIGN A total of 17,789 open-VHR patients were identified using the 2011-2012 ACS-NSQIP databases. This cohort was subdivided into 70 and 30% random testing and validation samples, respectively. Thirty-day unplanned readmission was defined as unexpected readmission for a postoperative occurrence related to the open-VHR procedure. Independent predictors of 30-day unplanned readmission were identified using multivariable logistic regression on the testing sample (n = 12,452 patients). Subsequently, the predictors were weighted according to β-coefficients to generate an integer-based Clinical Risk Score (CRS) predictive of readmission, which was validated using receiver operating characteristics (ROC) analysis of the validation sample (n = 5337 patients). RESULTS The rate of 30-day unplanned readmission was 4.7%. Independent risk factors included inpatient status at time of open-VHR, operation time, enterolysis, underweight, diabetes, preoperative anemia, length of stay, chronic obstructive pulmonary disease, history of bleeding disorders, hernia with gangrene, and panniculectomy (all P < 0.05). ROC analysis of the validation cohort rendered an area under the curve of 0.71, which demonstrates the accuracy of this prediction model. Predicted incidence within each 5 risk strata was statistically similar to the observed incidence in the validation sample (P = 0.18), further highlighting the accuracy of this model. CONCLUSION We present a validated risk stratification tool for unplanned readmissions following open-VHR. Future studies should determine if implementation of our CRS optimizes safety and reduces readmission rates in open-VHR patients.
Collapse
|
38
|
Sun SX, Leung AN, Dillon PW, Hollenbeak CS. Length of Stay and Readmissions in Mastectomy Patients. Breast J 2015; 21:526-32. [DOI: 10.1111/tbj.12442] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Susie X. Sun
- Department of Surgery; Penn State Milton S. Hershey Medical Center; Hershey Pennsylvania
| | - Anna N. Leung
- Section of Surgical Oncology; Penn State Milton S. Hershey Medical Center; Hershey Pennsylvania
| | - Peter W. Dillon
- Department of Surgery; Penn State Milton S. Hershey Medical Center; Hershey Pennsylvania
| | - Christopher S. Hollenbeak
- Division of Outcomes Research and Quality; Penn State Milton S. Hershey Medical Center; Hershey Pennsylvania
| |
Collapse
|
39
|
Rossi G, Vaccarezza H, Alvarez A. Two-day hospital stay after laparoscopic colorectal surgery, is enhanced recovery program a healthcare system specific issue? Reply. World J Surg 2015; 39:1331-2. [PMID: 25651967 DOI: 10.1007/s00268-015-3000-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Gustavo Rossi
- Section of Colorectal Surgery, Department of Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
| | | | | |
Collapse
|
40
|
Abstract
OBJECTIVE To investigate the frequency of and the risk factors for hospital readmission within the first year after liver transplantation (LT). MATERIALS AND METHODS Between January 1999 and August 2013, LTs were performed in 890 adult patients at our center. We collected medical data from the Chinese Liver Transplant Registry and performed a retrospective review of the medical records of these patients. We aimed to identify the factors that contribute toward readmission during the first year after LT. We also first investigated the relationship between the number and severity of post-transplant complications and the risk of readmission. The survival outcomes of patients with and without readmission were also studied. RESULTS A total of 165 rehospitalizations occurred in 142 patients (18.0%) within 1 year after discharge from their index admissions. The risk factors included hepatic malignancy as an indication for LT (P=0.01), previous abdominal surgery (P=0.03), the occurrence of any complications (P<0.001), biliary complications (P<0.001), vascular complications (P=0.005), rejection (P<0.001), pulmonary complications (P<0.001), infection (P<0.001), returning to the operating room (P<0.001), and other complications (P<0.001). First-year readmission rates increased as the number (P<0.01) and severity (P<0.01) of post-LT complications increased. Patients requiring readmission had decreased survival compared with those not requiring readmission during the first year of discharge after LT (P<0.001). CONCLUSION Our study identified the factors that place LT recipients at a high risk for readmission. This knowledge could help prevent and minimize rehospitalizations during the first year after LT.
Collapse
|
41
|
Kelly KN, Iannuzzi JC, Aquina CT, Probst CP, Noyes K, Monson JRT, Fleming FJ. Timing of discharge: a key to understanding the reason for readmission after colorectal surgery. J Gastrointest Surg 2015; 19:418-27; discussion 427-8. [PMID: 25519081 DOI: 10.1007/s11605-014-2718-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 11/27/2014] [Indexed: 01/31/2023]
Abstract
PURPOSE There is a growing interest in surgery regarding the balance between appropriate hospital length of stay (LOS) and prevention of unnecessary readmissions. This study examines the relationship between postoperative LOS and unplanned readmission after colorectal resection, exploring whether patients discharged earlier have different readmission risk profiles. METHODS Patients undergoing colorectal resection were selected by Common Procedural Terminology (CPT) code from the 2012 ACS National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified by LOS quartile. Kaplan-Meier analysis was used to examine characteristics associated with 30-day unplanned readmission. Factors with a p < 0.1 were included in the Cox proportional hazards model. Subsequently, chi-square analysis compared LOS, patient, and perioperative factors with the primary reason for readmission. Factors with a p < 0.2 were included in a multivariable logistic regression for each readmission reason. RESULTS For 33,033 patients undergoing colorectal resection, the overall 30-day unplanned readmission rate was 11 %. After adjusting for patient and perioperative factors, a postoperative LOS ≥8 days was associated with a 55 % increase in the relative hazard of readmission. Patients with a ≤3-day LOS were more likely to be readmitted with ileus/obstruction (odds ratio (OR): 1.8, p = 0.001) and pain (OR: 2.2, p = 0.007). LOS was not significantly associated with readmission for intraabdominal infection or medical complications. CONCLUSIONS Patients with longer LOS and complicated hospital courses continue to be high risk post-discharge, while straightforward early discharges have a different readmission risk profile. More targeted readmission prevention strategies are critical to focusing resource utilization for colorectal surgery patients.
Collapse
Affiliation(s)
- Kristin N Kelly
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, 601 Elmwood Ave., Box SURG, Rochester, NY, 14642, USA,
| | | | | | | | | | | | | |
Collapse
|
42
|
Valero V, Grimm JC, Kilic A, Lewis RL, Tosoian JJ, He J, Griffin JF, Cameron JL, Weiss MJ, Vollmer CM, Wolfgang CL. A novel risk scoring system reliably predicts readmission after pancreatectomy. J Am Coll Surg 2015; 220:701-13. [PMID: 25797757 DOI: 10.1016/j.jamcollsurg.2014.12.038] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 12/17/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative readmissions have been proposed by Medicare as a quality metric and can impact provider reimbursement. Because readmission after pancreatectomy is common, we sought to identify factors associated with readmission to establish a predictive risk scoring system. STUDY DESIGN A retrospective analysis of 2,360 pancreatectomies performed at 9 high-volume pancreatic centers between 2005 and 2011 was performed. Forty-five factors strongly associated with readmission were identified. To derive and validate a risk scoring system, the population was randomly divided into 2 cohorts in a 4:1 fashion. A multivariable logistic regression model was constructed and scores were assigned based on the relative odds ratio (OR) of each independent predictor. A composite Readmission after Pancreatectomy (RAP) score was generated and then stratified to create risk groups. RESULTS Overall, 464 (19.7%) patients were readmitted within 90 days. Eight pre- and postoperative factors, including earlier MI (OR = 2.03), American Society of Anesthesiologists class ≥ 3 (OR = 1.34), dementia (OR = 6.22), hemorrhage (OR = 1.81), delayed gastric emptying (OR = 1.78), surgical site infection (OR = 3.31), sepsis (OR = 3.10), and short length of stay (OR = 1.51) were independently predictive of readmission. The 32-point RAP score generated from the derivation cohort was highly predictive of readmission in the validation cohort (area under the receiver operating curve = 0.72). The low-risk (0 to 3), intermediate-risk (4 to 7), and high-risk (>7) groups correlated with 11.7%, 17.5%, and 45.4% observed readmission rates, respectively (p < 0.001). CONCLUSIONS The RAP score is a novel and clinically useful risk scoring system for readmission after pancreatectomy. Identification of patients with increased risk of readmission using the RAP score will allow efficient resource allocation aimed to attenuate readmission rates. It also has potential to serve as a new metric for comparative research and quality assessment.
Collapse
Affiliation(s)
- Vicente Valero
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joshua C Grimm
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Arman Kilic
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Russell L Lewis
- Department of Surgery, The University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Jeffrey J Tosoian
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin He
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - James F Griffin
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - John L Cameron
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew J Weiss
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Charles M Vollmer
- Department of Surgery, The University of Pennsylvania School of Medicine, Philadelphia, PA
| | | |
Collapse
|
43
|
Hartney M, Liu Y, Velanovich V, Fabri P, Marcet J, Grieco M, Huang S, Zayas-Castro J. Bounceback branchpoints: using conditional inference trees to analyze readmissions. Surgery 2014; 156:842-7. [PMID: 25239331 DOI: 10.1016/j.surg.2014.07.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 07/18/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND We sought to identify risks for 30-day readmission in patients undergoing colorectal surgery. METHODS We reviewed 2011 American College of Surgery National Surgical Quality Improvement Program data to identify patients readmitted after colorectal surgery. We found 3,228 readmissions from 30,412 records. Using statistically suggestive variables from logistic regression (P < .1), we built conditional inference trees (CTREES) with subsampled records to identify combined risks. RESULTS Logistic regression identified 27 potentially significant variables. Using these in new logistic regression and CTREES, we found classification accuracies of 0.70 and 0.63, respectively. CTREES predicted that the majority of patients who required reoperation during their hospitalization were predicted to require readmission (n = 496), along with the majority of patients who developed organ space infection (n = 671). Patients with deep infections discharged ≤10 days from their index operation required readmission in 443 of 459 of records; this approach predicted a >99% risk of readmission in patients with these infections who were discharged ≤5 days (220/222). Additionally, >90% (253/271) of patients who returned to the operating room and were discharged ≤8 days from the first operation are predicted to return. CONCLUSION Subgroups identified using the CTREES model demonstrate that patients with deep space infections or who return to the operating room have a greater readmission rate if they are discharged early. Modeled patients found to have organ space infections and who returned to the operating room had 30-day readmission risks of >50%, with those discharged a rate of >90%. We show herein that CTREES can be used with retrospective data on surgery populations to bring hidden patterns into relief.
Collapse
Affiliation(s)
- Mark Hartney
- Department of Surgery, University of South Florida, Tampa, FL.
| | - Yazhuo Liu
- Department of Surgery, University of South Florida, Tampa, FL
| | - Vic Velanovich
- Department of Surgery, University of South Florida, Tampa, FL
| | - Peter Fabri
- Department of Surgery, University of South Florida, Tampa, FL
| | - Jorge Marcet
- Department of Surgery, University of South Florida, Tampa, FL
| | - Michael Grieco
- Department of Surgery, University of South Florida, Tampa, FL
| | - Shuai Huang
- Department of Surgery, University of South Florida, Tampa, FL
| | | |
Collapse
|
44
|
Fischer C, Lingsma HF, Marang-van de Mheen PJ, Kringos DS, Klazinga NS, Steyerberg EW. Is the readmission rate a valid quality indicator? A review of the evidence. PLoS One 2014; 9:e112282. [PMID: 25379675 PMCID: PMC4224424 DOI: 10.1371/journal.pone.0112282] [Citation(s) in RCA: 189] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 10/03/2014] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Hospital readmission rates are increasingly used for both quality improvement and cost control. However, the validity of readmission rates as a measure of quality of hospital care is not evident. We aimed to give an overview of the different methodological aspects in the definition and measurement of readmission rates that need to be considered when interpreting readmission rates as a reflection of quality of care. METHODS We conducted a systematic literature review, using the bibliographic databases Embase, Medline OvidSP, Web-of-Science, Cochrane central and PubMed for the period of January 2001 to May 2013. RESULTS The search resulted in 102 included papers. We found that definition of the context in which readmissions are used as a quality indicator is crucial. This context includes the patient group and the specific aspects of care of which the quality is aimed to be assessed. Methodological flaws like unreliable data and insufficient case-mix correction may confound the comparison of readmission rates between hospitals. Another problem occurs when the basic distinction between planned and unplanned readmissions cannot be made. Finally, the multi-faceted nature of quality of care and the correlation between readmissions and other outcomes limit the indicator's validity. CONCLUSIONS Although readmission rates are a promising quality indicator, several methodological concerns identified in this study need to be addressed, especially when the indicator is intended for accountability or pay for performance. We recommend investing resources in accurate data registration, improved indicator description, and bundling outcome measures to provide a more complete picture of hospital care.
Collapse
Affiliation(s)
- Claudia Fischer
- Department of Public Health, Centre for Medical Decision Making, Erasmus MC, Rotterdam, the Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Centre for Medical Decision Making, Erasmus MC, Rotterdam, the Netherlands
| | | | - Dionne S. Kringos
- Department of Public Health, Amsterdam Medical Centre, Amsterdam, the Netherlands
| | - Niek S. Klazinga
- Department of Public Health, Amsterdam Medical Centre, Amsterdam, the Netherlands
| | - Ewout W. Steyerberg
- Department of Public Health, Centre for Medical Decision Making, Erasmus MC, Rotterdam, the Netherlands
| |
Collapse
|
45
|
Kheir MM, Clement RC, Derman PB, Flynn DN, Speck RM, Levin LS, Fleisher LA. Are there identifiable risk factors and causes associated with unplanned readmissions following total knee arthroplasty? J Arthroplasty 2014; 29:2192-6. [PMID: 25081513 DOI: 10.1016/j.arth.2014.06.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 06/24/2014] [Accepted: 06/29/2014] [Indexed: 02/01/2023] Open
Abstract
We conducted a retrospective review of 3218 primary total knee arthroplasties (TKA) performed over two years at an urban academic hospital network using clinical and administrative data. Increased length of stay (LOS) was associated with readmission (P < 0.001). Readmission was not associated with age (P = 0.100), gender (P = 0.608), body mass index (P = 0.329), or staged bilateral procedures (P = 0.420). The most common readmitting diagnoses were post-operative infection (22.5%), hematoma (10.1%), pulmonary embolus (7.9%) and deep vein thrombosis (5.6%). Of readmissions, 53.9% were for surgical reasons and 46.1% were for medical reasons. Certain interventions described in previous literature may be more successful in minimizing unplanned readmissions by focusing on patients with extended LOS, elevated infection risk and low socioeconomic status.
Collapse
Affiliation(s)
- Michael M Kheir
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - David N Flynn
- Department of Anesthesiology & Critical Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Rebecca M Speck
- Department of Anesthesiology & Critical Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - L Scott Levin
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lee A Fleisher
- Department of Anesthesiology & Critical Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| |
Collapse
|
46
|
Improving outcomes and cost-effectiveness of colorectal surgery. J Gastrointest Surg 2014; 18:1944-56. [PMID: 25205538 DOI: 10.1007/s11605-014-2643-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 08/25/2014] [Indexed: 02/08/2023]
Abstract
In order to truly make an impact on improving the cost effectiveness, and most importantly, the outcomes of patients undergoing colorectal surgery, all aspects of care need to be scrutinized, re-evaluated, and refined. To accomplish this, everything from the way we train surgeons to the adoption of a minimally invasive approach for colorectal disease, along with the use of adjunct intraoperative measures to decrease morbidity and mortality, may all need to be incorporated within an ERAS program. Only then will this approach lead the provider to a patient-centric care plan which can successfully reduce metrics such as morbidity, mortality, and length of stay (even with the obligatory readmission rate) and provide it all at a lower cost of care.
Collapse
|
47
|
Postdischarge occurrences after colorectal surgery happen early and are associated with dramatically increased rates of readmission. Dis Colon Rectum 2014; 57:1309-16. [PMID: 25285699 DOI: 10.1097/dcr.0000000000000212] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Postoperative occurrences have been associated with an increased risk of readmission, yet these occurrences and their timing have not been well characterized. OBJECTIVE We sought to analyze patients undergoing colorectal surgery as a model for general surgical readmissions. DESIGN In a retrospective analysis, the impact of a postoperative occurrence on readmission was examined in a multivariable model with adjustment for potential confounders. The timing and type of postoperative occurrence were further characterized. SETTINGS This study was conducted at a tertiary care hospital. PATIENTS Patients undergoing colorectal surgery in the American College of Surgeons National Surgical Quality Improvement Program database (fiscal year 2011-2012) were analyzed. MAIN OUTCOME MEASURES The main outcome measure was admission within 30 days of operation. RESULTS A total of 54,823 patients undergoing colorectal surgery were identified, with 24% of patients experiencing a postoperative occurrence, and 12% of patients readmitted. The readmission rate in those who experienced an occurrence was 30% compared with 6% in those without an occurrence (p < 0.0001). After an occurrence during the index admission, the readmission rate was 18% compared with 57% if the occurrence happened postdischarge (p < 0.0001). In a multivariable analysis, postdischarge occurrence (risk ratio, 7.5 [95% CI, 7.3-7.8]) was associated with the largest risk of readmission. The median time to postdischarge occurrence was 8 days for organ space infection and wound complication and 7 days for sepsis. By day 14 postdischarge, 74% of organ space infections, 79% of wound complications, and 81% of sepsis had already occurred. LIMITATIONS This analysis was limited to the variables available in the American College of Surgeons National Surgical Quality Improvement Program. Most significantly, readmission is captured for 30 days postoperatively rather than for 30 days postdischarge. CONCLUSIONS Readmission occurs frequently (12%) after colorectal surgery and is strongly associated with a postdischarge occurrence. The most frequent postdischarge occurrences are infectious in nature and happen early postdischarge. The majority of postdischarge occurrences have already occurred by day 14, a standard time for the postoperative appointment.
Collapse
|
48
|
Identification of process measures to reduce postoperative readmission. J Gastrointest Surg 2014; 18:1407-15. [PMID: 24912913 DOI: 10.1007/s11605-013-2429-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 12/02/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Readmission rates after intestinal surgery have been notably high, ranging from 10 % for elective surgery to 21 % for urgent/emergent surgery. Other than adherence to established strategies for decreasing individual postoperative complications, there is little guidance available for providers to work toward reducing their postoperative readmission rates. STUDY DESIGN Processes of care that may affect postoperative readmissions were identified through a systematic literature review, assessment of existing guidelines, and semi-structured interviews with individuals who have expertise in hospital readmissions and surgical quality improvement. Eleven experts ranked potential process measures for validity on the basis of the RAND/University of California, Los Angeles Appropriateness Methodology. RESULTS Of 49 proposed process measures, 34 (69 %) were rated as valid. Of the 34 valid measures, two measures addressed care in the preoperative period. These included evaluation of patient's comorbidities, providing written instruction detailing the anticipated perioperative course, and communication with the patient's referring or primary care doctor. A measure addressing perioperative care stated that institutions should have a standardized perioperative care protocol. Additional measures focused on discharge instructions and communication. CONCLUSIONS An expert panel identified several aspects of care that are considered essential to quality patient care and important to reducing postoperative readmissions.
Collapse
|
49
|
Schneider EB, Calkins KL, Weiss MJ, Herman JM, Wolfgang CL, Makary MA, Ahuja N, Haider AH, Pawlik TM. Race-based differences in length of stay among patients undergoing pancreatoduodenectomy. Surgery 2014; 156:528-37. [PMID: 24973128 DOI: 10.1016/j.surg.2014.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 04/02/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Race-based disparities in operative morbidity and mortality have been demonstrated for various procedures, including pancreatoduodenectomy (PD). Race-based differences in hospital length-of-stay (LOS), especially related to provider volume at the surgeon and hospital level, remain poorly defined. METHODS Using the 2003-2009 Nationwide Inpatient Sample, we determined year-specific PD volumes for surgeons and hospitals and grouped them into terciles. Patient race (white, black, or Hispanic), age, sex, and comorbidities were examined. Median length of stay was calculated, and multivariable logistic regression was used to examine factors associated with increased LOS. RESULTS Among 4,319 eligible individuals, 3,502 (81.1%) were white, 423 (9.8%) were black, and 394 (9.1%) were Hispanic. Overall median LOS was 12 days (range, 0-234). Median annual surgeon volume was 8 (interquartile range [IQR], 2-19; range, 1-54). Annual hospital volume ranged from 1 to 129 (median, 19; IQR, 7-55). White patients were more likely to have been treated at medium- to high-volume hospitals (odds ratio [OR] 1.53, P < .001) and by medium- to high-volume surgeons (OR 1.62, P < .001) than black or Hispanic patients. After PD, white, black, and Hispanic patients demonstrated similar in-hospital mortality (5.1%, 5.7% and 7.2% respectively P = .250). After adjustment, black (OR 1.36, P = .010) and Hispanic (OR 1.68, P < .001) patients were more likely to have a greater LOS after PD. CONCLUSION Black and Hispanic PD patients were less likely than white patients to be treated at higher-volume hospitals and by higher-volume surgeons. Proportional mortality and LOS after PD were greater among black and Hispanic patients.
Collapse
Affiliation(s)
- Eric B Schneider
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Keri L Calkins
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Matthew J Weiss
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Joseph M Herman
- Department of Radiation Oncology, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Martin A Makary
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Nita Ahuja
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Adil H Haider
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Timothy M Pawlik
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD.
| |
Collapse
|
50
|
Cologne KG, Hwang GS, Senagore AJ. Cost of practice in a tertiary/quaternary referral center: is it sustainable? Tech Coloproctol 2014; 18:1035-9. [PMID: 24938394 DOI: 10.1007/s10151-014-1175-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 05/30/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Third-party payers are moving toward a bundled care payment system. This means that there will need to be a warranty cost of care-where the cost of complexity and complication rates is built into the bundled payment. The theoretical benefit of this system is that providers with lower complication rates will be able to provide care with lower warranty costs and lower overall costs. This may also result in referring riskier patients to tertiary or quaternary referral centers. Unless the payment model truly covers the higher cost of managing such referred cases, the economic risk may be unsustainable for these centers. METHODS We took the last seven patients that were referred by other surgeons as "too high risk" for colectomy at other centers. A contribution margin was calculated using standard Medicare reimbursement rates at our institution and cost of care based on our administrative database. We then recalculated a contribution margin assuming a 3 % reduction in payment for a higher than average readmission rate, like that which will take effect in 2014. Finally, we took into account the cost of any readmissions. RESULTS Seven patients with diagnosis related group (DRG) 330 were reviewed with an average age of 66.8 ± 16 years, American Society of Anesthesiologists score 2.3 ± 1.0, body mass index 31.6 ± 9.8 kg/m(2) (range 22-51 kg/m(2)). There was a 57 % readmission rate, 29 % reoperation rate, 10.8 ± 7.7 day average initial length of stay with 14 ± 8.6 day average readmission length of stay. Forty-two percent were discharged to a location other than home. Seventy-one percent of these patients had Medicare insurance. The case mix index was 2.45. Average reimbursement for DRG 330 was $17,084 (based on Medicare data) for our facility in 2012, with the national average being $12,520. The total contribution margin among all cases collectively was -$19,122 ± 13,285 (average per patient -$2,731, range -$21,905-$12,029). Assuming a 3 % reimbursement reduction made the overall contribution margin -$22,122 ± 13,285 (average -$3,244). Including the cost of readmission in the variable cost made the contribution margin -$115,741 ± 16,023 (average -$16,534). CONCLUSIONS Care of high-risk patients at tertiary and quaternary referral centers is a very expensive proposition and can lead to financial ruin under the current reimbursement system.
Collapse
Affiliation(s)
- K G Cologne
- Keck School of Medicine of the University of Southern California, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA, 90033, USA,
| | | | | |
Collapse
|