1
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Dugan MM, Ross S, Christodoulou M, Pattilachan TM, Flores JA, Rosemurgy A, Sucandy I. Hospital readmissions after robotic hepatectomy for neoplastic disease: Analysis of risk factors, survival, and economical impact. A logistical regression and propensity score matched study. Am J Surg 2024; 234:92-98. [PMID: 38519401 DOI: 10.1016/j.amjsurg.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/04/2024] [Accepted: 03/10/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND As the first comprehensive investigation into hospital readmissions following robotic hepatectomy for neoplastic disease, this study aims to fill a critical knowledge gap by evaluating risk factors associated with readmission and their impact on survival and the financial burden. METHODS The study analyzed a database of robotic hepatectomy patients, comparing readmitted and non-readmitted individuals post-operatively using 1:1 propensity score matching. Statistical methods included Chi-square, Mann-Whitney U, T-test, binomial logistic regression, and Kaplan-Meier analysis. RESULTS Among 244 patients, 44 were readmitted within 90 days. Risk factors included hypertension (p = 0.01), increased Child-Pugh score (p < 0.01), and R1 margin status (p = 0.05). Neoadjuvant chemotherapy correlated with lower readmission risk (p = 0.045). Readmissions didn't significantly impact five-year survival (p = 0.42) but increased fixed indirect hospital costs (p < 0.01). CONCLUSIONS Readmission post-robotic hepatectomy correlates with hypertension, higher Child-Pugh scores, and R1 margins. The use of neoadjuvant chemotherapy was associated with a lower admission rate due to less diffuse liver disease in these patients. While not affecting survival, readmissions elevate healthcare costs.
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Affiliation(s)
- Michelle M Dugan
- Florida Atlantic University Schmidt College of Medicine, USA; Digestive Health Institute AdventHealth Tampa, USA
| | - Sharona Ross
- Digestive Health Institute AdventHealth Tampa, USA
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2
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Yu S, Liu J, Reid J, Clarke J, Edwards S, Maddern G. Reoperation for post hepatectomy complications. ANZ J Surg 2024; 94:660-666. [PMID: 38054372 DOI: 10.1111/ans.18803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 11/16/2023] [Accepted: 11/18/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Reoperation for post hepatectomy complications is associated with high rates of morbidity and mortality. We aim to describe the frequency, indications, and risk factors for reoperation after liver resection in a single centre. METHODS Perioperative data of 464 patients, who underwent elective hepatectomy from 2001 to 2020 at The Queen Elizabeth Hospital in South Australia, were retrospectively analysed. The frequency and indications for reoperation for post hepatectomy complications were recorded. Binary logistic regression analysis was performed to determine variables associated with reoperation. RESULTS A total of seven patients (1.5%) underwent reoperation post hepatectomy. The most common indications for reoperation were intra-abdominal abscess, post-operative haemorrhage, bile leak, and ischaemic bowel. Three out of the seven patients died. Patients were more likely to require reoperation if an additional major non-hepatic procedure was performed. CONCLUSION Reoperation post hepatectomy is associated with morbidity and mortality and is more likely to occur in patients who have undergone a non-hepatic procedure at the same time as the primary hepatic resection. Surgeons should ensure these patients are appropriately monitored and be selective about performing complex, multiple procedures. When possible, procedures should be staged.
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Affiliation(s)
- Sam Yu
- Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Jianliang Liu
- Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Jessica Reid
- Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Jessie Clarke
- Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Suzanne Edwards
- Adelaide Health Technology Assessment (AHTA), School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Guy Maddern
- Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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3
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Smith SR, Blair CM, Lovasik BP, Little LA, Sweeney JF, Sarmiento JM. Use of Perioperative Advanced Practice Providers to Reduce Cost and Readmission in the Postoperative Hepatopancreatobiliary Population: Results of a Simulation Study. J Am Coll Surg 2024; 238:313-320. [PMID: 37930898 DOI: 10.1097/xcs.0000000000000907] [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: 11/08/2023]
Abstract
BACKGROUND Postoperative healthcare use and readmissions are common among the hepatopancreatobiliary (HPB) population. We evaluated the surgical volume required to sustain advanced practice providers (APPs) in the perioperative setting for cost reduction. STUDY DESIGN Using decision analysis modeling, we evaluated costs of employing dedicated perioperative APP navigators compared with no APPs navigators. Simulated subjects could: (1) present to an emergency department, with or without readmission, (2) present for direct readmission, (3) require additional office visits, or (4) require no additional care. We informed our model using the most current available published data and performed sensitivity analyses to evaluate thresholds under which dedicated perioperative APP navigators are beneficial. RESULTS Subjects within the APP navigator cohort accumulated $1,270 and a readmission rate of 6.9%, compared with $2,170 and 13.5% with no APP navigators, yielding a cost savings of $905 and 48% relative reduction in readmission. Based on these estimated cost savings and national salary ranges, a perioperative APPs become financially self-sustaining with 113 to 139 annual HPB cases, equating to 2 to 3 HPB cases weekly. Sensitivity analyses revealed that perioperative APP navigators were no longer cost saving when direct readmission rates exceeded 8.9% (base case 3.7%). CONCLUSIONS We show that readmissions are reduced by nearly 50% with an associated cost savings of $900 when employing dedicated perioperative APPs. This position becomes financially self-sufficient with an annual HPB case load of 113 to 139 cases. High-volume HPB centers could benefit from postdischarge APP navigators to optimize outcomes, minimize high-value resource use, and ultimately save costs.
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Affiliation(s)
- Savannah R Smith
- From the Department of Surgery (Smith, Blair, Lovasik, Sweeney, Sarmiento)
| | - Catherine M Blair
- From the Department of Surgery (Smith, Blair, Lovasik, Sweeney, Sarmiento)
| | - Brendan P Lovasik
- From the Department of Surgery (Smith, Blair, Lovasik, Sweeney, Sarmiento)
| | - Lori A Little
- Winship Cancer Institute (Little, Sarmiento), Emory University, Atlanta, GA
| | - John F Sweeney
- From the Department of Surgery (Smith, Blair, Lovasik, Sweeney, Sarmiento)
| | - Juan M Sarmiento
- From the Department of Surgery (Smith, Blair, Lovasik, Sweeney, Sarmiento)
- Winship Cancer Institute (Little, Sarmiento), Emory University, Atlanta, GA
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Luu T, Curran BP, Macias AA, Mehdipour S, Simpson S, Gabriel RA. A Point-Based Risk Calculator for Mortality After Hepatectomy. Anesth Analg 2023; 137:1039-1046. [PMID: 37307221 DOI: 10.1213/ane.0000000000006558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Preoperative risk stratification for hepatectomy patients can aid clinical decision making. The objective of this retrospective cohort study was to determine postoperative mortality risk factors and develop a score-based risk calculator using a limited number of preoperative predictors to estimate mortality risk in patients undergoing hepatectomy. METHODS Data were collected from patients that underwent hepatectomy from the National Surgical Quality Improvement Program dataset from 2014 to 2020. Baseline characteristics were compared between survival and 30-day mortality cohorts using the χ 2 test. Next, the data were split into a training set to build the model and a test set to validate the model. A multivariable logistic regression model modeling 30-day postoperative mortality was trained on the training set using all available features. Next, a risk calculator using preoperative features was developed for 30-day mortality. The results of this model were converted into a score-based risk calculator. A point-based risk calculator was developed that predicted 30-day postoperative mortality in patients who underwent hepatectomy surgery. RESULTS The final dataset included 38,561 patients who underwent hepatectomy. The data were then split into a training set from 2014 to 2018 (n = 26,397) and test set from 2019 to 2020 (n = 12,164). Nine independent variables associated with postoperative mortality were identified and included age, diabetes, sex, sodium, albumin, bilirubin, serum glutamic-oxaloacetic transaminase (SGOT), international normalized ratio, and American Society of Anesthesiologists classification score. Each of these features were then assigned points for a risk calculator based on their odds ratio. A univariate logistic regression model using total points as independent variables were trained on the training set and then validated on the test set. The area under the receiver operating characteristics curve on the test set was 0.719 (95% confidence interval, 0.681-0.757). CONCLUSIONS Development of risk calculators may potentially allow surgical and anesthesia providers to provide a more transparent plan to support patients planned for hepatectomy.
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Affiliation(s)
- Tiffany Luu
- From the Division of Perioperative Informatics, Department of Anesthesiology, University of California San Diego, La Jolla, California
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Xie J, Zhang B, Ma J, Zeng D, Lo-Ciganic J. Readmission Prediction for Patients with Heterogeneous Medical History: A Trajectory-Based Deep Learning Approach. ACM TRANSACTIONS ON MANAGEMENT INFORMATION SYSTEMS 2022. [DOI: 10.1145/3468780] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hospital readmission refers to the situation where a patient is re-hospitalized with the same primary diagnosis within a specific time interval after discharge. Hospital readmission causes $26 billion preventable expenses to the U.S. health systems annually and often indicates suboptimal patient care. To alleviate those severe financial and health consequences, it is crucial to proactively predict patients’ readmission risk. Such prediction is challenging because the evolution of patients’ medical history is dynamic and complex. The state-of-the-art studies apply statistical models which use static predictors in a period, failing to consider patients’ heterogeneous medical history. Our approach –
Trajectory-BAsed DEep Learning (TADEL)
– is motivated to tackle the deficiencies of the existing approaches by capturing dynamic medical history. We evaluate TADEL on a five-year national Medicare claims dataset including 3.6 million patients per year over all hospitals in the United States, reaching an F1 score of 87.3% and an AUC of 88.4%. Our approach significantly outperforms all the state-of-the-art methods. Our findings suggest that health status factors and insurance coverage are important predictors for readmission. This study contributes to IS literature and analytical methodology by formulating the trajectory-based readmission prediction problem and developing a novel deep-learning-based readmission risk prediction framework. From a health IT perspective, this research delivers implementable methods to assess patients’ readmission risk and take early interventions to avoid potential negative consequences.
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Affiliation(s)
- Jiaheng Xie
- Lerner College of Business & Economics, University of Delaware, Newark, DE, USA
| | - Bin Zhang
- Eller College of Management, University of Arizona, Tucson, AZ, USA
| | - Jian Ma
- University of Colorado, Colorado Springs, Colorado Springs CO, USA
| | - Daniel Zeng
- Institute of Automation, Chinese Academy of Sciences, Beijing, China
| | - Jenny Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, University of Florida, FL
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Sindayigaya R, Tribillon E, Ghedira A, Beaussier M, Sarran A, Tubbax C, Bonnet S, Gayet B, Soubrane O, Fuks D. Predictors of discharge timing and unplanned readmission after laparoscopic liver resection. HPB (Oxford) 2022; 24:708-716. [PMID: 34674952 DOI: 10.1016/j.hpb.2021.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/17/2021] [Accepted: 09/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of the study was to determine the predictors of discharge timing and 90-day unplanned readmission after laparoscopic liver resection (LLR). METHODS Consecutive LLR performed at the "Institut Mutualiste Montsouris" between 2000 and 2019 were retrieved from a prospectively maintained database. Length of stay (LOS) was stratified according to surgical difficulty and was categorized as early (LOS<25th percentile), routine (25th percentile<75th percentile), and delayed discharge otherwise. Uni-and-multivariate analyses were conducted to determine the factors associated with the time of discharge and 90-day unplanned readmission. RESULTS Early discharge occurred in 15.7% patients whereas delayed discharge occurred in 20.6% patients. Concomitant pancreatic resections (OR 26.8, 95% CI 5.75-125, p < 0.0001) and removal of colorectal primary tumors (OR 7.14, 95% CI 3.98-12.8, p < 0.0001) were the strongest predictors of delayed discharge whereas ERP implementation was the strongest predictor of early discharge (OR 7.4, 95% CI 4.60-11.9, p < 0.0001). Unplanned readmission rate was lower among early discharged patients (7.4% vs. 23.8%, p < 0.0001). Bile leakage was the strongest predictor of 90-day unplanned readmission (OR 3.8, 95% CI 1.12-15.8, p = 0.045). CONCLUSION Concomitant colorectal or pancreatic resections were the strongest predictors of delayed discharge. Postoperative bile leakage was the strongest predictor of 90-day unplanned readmission following LLR.
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Affiliation(s)
- Rémy Sindayigaya
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France.
| | - Ecoline Tribillon
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Abdessalem Ghedira
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Marc Beaussier
- Department of Anesthesiology, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Anthony Sarran
- Department of Radiology, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Candice Tubbax
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Stéphane Bonnet
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Brice Gayet
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Olivier Soubrane
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
| | - David Fuks
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
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Watanabe G, Kawaguchi Y, Ichida A, Ishizawa T, Akamatsu N, Kaneko J, Arita J, Hasegawa K. Understanding conditional cumulative incidence of complications following liver resection to optimize hospital stay. HPB (Oxford) 2022; 24:226-233. [PMID: 34312059 DOI: 10.1016/j.hpb.2021.06.419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/14/2021] [Accepted: 06/18/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND After liver resection, the in-hospital observation periods associated with minimal risks for complications and unplanned readmission remains unclear. This study aimed to assess changes in risks of complications over time. METHODS Surgical complexity of liver resection was stratified into grades I (low complexity), II (intermediate), and III (high). The cumulative incidence rate and risk factors for complication ≥ Clavien-Dindo grade II (defined as treatment-requiring complications) were assessed. RESULTS Of 581 patients, grade I, II, and III resections were performed in 81 (13.9%), 119 (20.5%), and 381 patients (65.6%). Complexity grades (I vs. III, hazard ratio [HR] 0.45, P = 0.007; II vs. III, HR 0.60, P = 0.011) and background liver status (HR 1.76, P = 0.004) were risk factors for treatment-requiring complications. The cumulative incidence rate of treatment-requiring complications was higher after grade III resection than grade I resection (38.1% vs. 16.1%, P < 0.001) or grade II resection (38.1% vs. 25.2%, P = 0.019). Without cirrhosis/chronic hepatitis, the cumulative incidence rate of treatment-requiring complications decreased to less than 10% on postoperative day (POD) 3 after grade I resection, POD 5 after grade II resection, and POD 10 after grade III resection. CONCLUSION Conditional complication risk analysis stratified by surgical complexity may be useful for optimizing in-hospital observation.
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Affiliation(s)
- Genki Watanabe
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Akihiko Ichida
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeaki Ishizawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Kaneko
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Arita
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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Kang E, Shin JI, Griesemer AD, Lobritto S, Goldner D, Vittorio JM, Stylianos S, Martinez M. Risk Factors for 30-Day Unplanned Readmission After Hepatectomy: Analysis of 438 Pediatric Patients from the ACS-NSQIP-P Database. J Gastrointest Surg 2021; 25:2851-2858. [PMID: 33825121 DOI: 10.1007/s11605-021-04995-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/23/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hepatic resections are uncommon in children. Most studies reporting complications of these procedures and risk factors associated with unplanned readmissions are limited to retrospective data from single centers. We investigated risk factors for 30-day unplanned readmission after hepatectomy in children using the American College of Surgeons National Surgical Quality Improvement-Pediatric database. METHODS The database was queried for patients aged 0-18 years who underwent hepatectomy for the treatment of liver lesions from 2012 to 2018. Chi-squared tests were performed to evaluate for potential risk factors for unplanned readmissions. A multivariate regression analysis was performed to identify independent predictors for unplanned 30-day readmissions. RESULTS Among 438 children undergoing hepatectomy, 64 (14.6%) had unplanned readmissions. The median age of the hepatectomy cohort was 1 year (0-17); 55.5% were male. Patients readmitted had significantly higher rates of esophageal/gastric/intestinal disease (26.56% vs. 14.97%; p=0.022), current cancer (85.94% vs. 75.67%; p=0.012), and enteral and parenteral nutritional support (31.25% vs. 17.65%; p=0.011). Readmitted patients had significantly higher rates of perioperative blood transfusion (67.19% vs. 52.41%; p=0.028), organ/space surgical site infection (10.94% vs. 1.07%; p<.001), sepsis (15.63% vs. 3.74%; p<.001), and total parenteral nutrition at discharge (9.09% vs. 2.66%; p=0.041). Organ/space surgical site infection was an independent risk factor for unplanned readmission (OR=9.598, CI [2.070-44.513], p=0.004) by multivariable analysis. CONCLUSION Unplanned readmissions after liver resection are frequent in pediatric patients. Organ/space surgical site infections may identify patients at increased risk for unplanned readmission. Strategies to reduce these complications may decrease morbidity and costs associated with unplanned readmissions.
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Affiliation(s)
- Elise Kang
- Department of Pediatrics, NewYork Presbyterian Hospital, New York, NY, USA
| | - John Inho Shin
- Department of Orthopedic Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Adam D Griesemer
- Department of Surgery, Vagelos College of Physician and Surgeons, Columbia University, New York, NY, USA
| | - Steven Lobritto
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY, USA
| | - Dana Goldner
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY, USA
| | - Jennifer M Vittorio
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY, USA
| | - Steven Stylianos
- Department of Surgery, Vagelos College of Physician and Surgeons, Columbia University, New York, NY, USA
| | - Mercedes Martinez
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY, USA.
- Department of Pediatrics, Columbia University Irving Medical Center, 620 West 168th Street, PH17, Room 105B, New York, NY, 10032, USA.
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Woeste MR, Strothman P, Jacob K, Egger ME, Philips P, McMasters KM, Martin RCG, Scoggins CR. Hepatopancreatobiliary readmission score out performs administrative LACE+ index as a predictive tool of readmission. Am J Surg 2021; 223:933-938. [PMID: 34625205 DOI: 10.1016/j.amjsurg.2021.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/19/2021] [Accepted: 09/29/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND This study aims to compare the LACE + readmission index to a novel hepatopancreatobiliary readmission risk score (HRRS) in predicting post-operative hepatopancreatobiliary (HPB) cancer patient readmissions. METHODS A retrospective review of 104 postoperative HPB cancer patients from January 2017 to July of 2019 was performed. Univariable and multivariable analyses were utilized. RESULTS The LACE + index did not predict 30-day (OR 1.01, 95% CI, 0.97-1.05, p = 0.81, c-statistic = 0.52) or 90-day (OR 1.02, 95% CI, 0.98-1.05, p = 0.43) readmission. Patients readmitted within 30 days had significantly increased HRRS scores compared to those who were not (0 vs 34, p < 0.001). A single unit increase in HRRS corresponded to a 6.5% increased risk of readmission; (OR 1.065, 95% CI, 1.038-1.094, p < 0.0001). HRRS independently predicted 30-day (OR 1.07, 95% CI, 1.04-1.11, p < 0.0001) and 90-day postoperative readmission (OR 1.05, 95% CI 1.03-1.08, p < 0.0001). CONCLUSIONS HRRS better predicts postoperative readmissions for HPB surgical patients compared to LACE+. Accurate assessment of postoperative readmission must include readmission scores focused on clinically relevant perioperative parameters.
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Affiliation(s)
- Matthew R Woeste
- The Hiram C. Polk, Jr., MD Department of Surgery, Division of Surgical Oncology, University of Louisville School of Medicine, Louisville, KY, 40292, USA
| | - Phillip Strothman
- The Hiram C. Polk, Jr., MD Department of Surgery, Division of Surgical Oncology, University of Louisville School of Medicine, Louisville, KY, 40292, USA
| | - Kevin Jacob
- The Hiram C. Polk, Jr., MD Department of Surgery, Division of Surgical Oncology, University of Louisville School of Medicine, Louisville, KY, 40292, USA
| | - Michael E Egger
- The Hiram C. Polk, Jr., MD Department of Surgery, Division of Surgical Oncology, University of Louisville School of Medicine, Louisville, KY, 40292, USA
| | - Prejesh Philips
- The Hiram C. Polk, Jr., MD Department of Surgery, Division of Surgical Oncology, University of Louisville School of Medicine, Louisville, KY, 40292, USA
| | - Kelly M McMasters
- The Hiram C. Polk, Jr., MD Department of Surgery, Division of Surgical Oncology, University of Louisville School of Medicine, Louisville, KY, 40292, USA
| | - Robert C G Martin
- The Hiram C. Polk, Jr., MD Department of Surgery, Division of Surgical Oncology, University of Louisville School of Medicine, Louisville, KY, 40292, USA
| | - Charles R Scoggins
- The Hiram C. Polk, Jr., MD Department of Surgery, Division of Surgical Oncology, University of Louisville School of Medicine, Louisville, KY, 40292, USA.
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10
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Khan S, Chidi A, Hrebinko K, Kaltenmeier C, Nassour I, Hoehn R, Geller D, Tsung A, Tohme S. Readmission After Surgical Resection and Transplantation for Hepatocellular Carcinoma: A Retrospective Cohort Study. Am Surg 2020; 88:83-92. [PMID: 33369487 DOI: 10.1177/0003134820973739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a leading cause of cancer mortality worldwide. Liver resections and transplantations have increasingly become feasible options for potential cure. These complex surgeries are inherently associated with increased rates of readmission. In the meanwhile, hospital readmission rates are rapidly becoming an important quality of care metric. Therefore, it is very important to understand the effect of 30-day readmission on mortality and the factors associated with increased 30- and 90-day mortality rates. METHODS This is a retrospective cohort study utilizing data from the National Cancer Database. Patients included were 18 years or older who underwent liver resection or liver transplantation for HCC between 2003 and 2011. Our primary outcomes of interest were 30- and 90-day mortality rates. Our primary independent variable of interest was 30-day readmission. RESULTS 16 658 patients underwent either a liver resection or transplantation for HCC between 2003 and 2011. For patients with liver transplantations, increased readmission rates were associated with lower risks of 30-day mortality (P = .012) but a trend toward higher 90-day mortality (P = .057). Patients who underwent liver resection for HCC also demonstrated increased readmission rates to be associated with lower risk of 30-day mortality (P = .014) but higher 90-day mortality (P ≤ .001). CONCLUSION This is the only study to utilize a national database to investigate the association between readmission rates and mortality rates of both liver transplantations and resections for patients with HCC. We demonstrate 30-day readmission to show no increase in 30-day mortality, but rather higher 90-day mortality.
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Affiliation(s)
- Sidrah Khan
- Department of Surgery, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - Alexis Chidi
- Department of Surgery, 1466Johns Hopkins University, Baltimore, MA, USA
| | - Katherine Hrebinko
- Department of Surgery, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Ibrahim Nassour
- Department of Surgery, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - Richard Hoehn
- Department of Surgery, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - David Geller
- Department of Surgery, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - Allan Tsung
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Samer Tohme
- Department of Surgery, 6614University of Pittsburgh, Pittsburgh, PA, USA
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11
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Lovasik BP, Blair CM, Little LA, Sellers M, Sweeney JF, Sarmiento JM. Reduction in Post-Discharge Return to Acute Care in Hepatopancreatobiliary Surgery: Results of a Quality Improvement Initiative. J Am Coll Surg 2020; 231:231-238. [DOI: 10.1016/j.jamcollsurg.2020.03.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/15/2020] [Accepted: 03/17/2020] [Indexed: 10/24/2022]
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12
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de Klein GW, Brohet RM, Liem MSL, Klaase JM. Possible Preventable Causes of Unplanned Readmission After Elective Liver Resection, Results from a Non-academic Referral HPB Center. World J Surg 2019; 43:1802-1808. [PMID: 30843099 DOI: 10.1007/s00268-019-04970-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Unplanned readmission is a common event after liver resection, and it is a burden for both patients and healthcare policy makers. This study evaluates the incidence of and reasons for unplanned readmission after liver resection, in order to identify possible preventable causes. METHODS In this single-center cohort study, data from patients who underwent liver resection for both malignant and benign indications from 2001 to 2016 at our institute were collected from a database with prospective data. Readmissions were analyzed for their reasons and risk factors. Patients with general complaints with no specific complications were categorized as failure to thrive. RESULTS In 406 patients, the readmission rate was 11.6%. Most patients were readmitted because of failure to thrive (35%), deep and superficial surgical site infection (28%), or cardiopulmonary complications (15%). A multivariate analysis revealed that unplanned readmission was associated with the occurrence of complications during index admission-with an odds ratio of 4.69 (CI 2.41-9.12, p < 0.001). CONCLUSION Readmission occurs in more than 1 in 10 patients after liver resection, and it is associated with a complicated course during index admission. One-third of readmissions occur because of failure to thrive and might be preventable. Future research in strategies to reduce readmission rates should focus on both the prevention of complications during index admission and programs at the interface between primary and secondary care.
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Affiliation(s)
- G W de Klein
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands.
| | - R M Brohet
- Department of Research and Innovation, Isala, Zwolle, The Netherlands
| | - M S L Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - J M Klaase
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
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Mahvi DA, Pak LM, Fields AC, Urman RD, Gold JS, Whang EE. Prediction of Discharge Destination Following Major Hepatectomy. HPB (Oxford) 2019; 21:1462-1469. [PMID: 30956164 DOI: 10.1016/j.hpb.2019.03.354] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 02/24/2019] [Accepted: 03/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anatomic hepatectomies can be associated with complicated post-operative recoveries, often with discharge to post-acute care facilities. This study identifies preoperative and intraoperative factors associated with increased risk for non-home discharge destination after major hepatectomy. METHODS Patients undergoing major hepatectomy were identified in the NSQIP Targeted Hepatectomy Dataset (2014-2016). Multivariable logistic regression was performed. Patients from 2014 to 2015 were used for training cohort with nomogram generation and 2016 for validation cohort. RESULTS Overall, 226 of 3750 patients (6.0%) were discharged to rehab, skilled care, or acute care facilities. Preoperative factors associated with non-home discharge on multivariable analysis were outside patient transfers, older age, presence of ascites, ASA physical status 3 or higher, and low preoperative hematocrit (all p < 0.05). Intraoperative factors significantly predictive were concurrent lysis of adhesions, Pringle maneuver, and biliary reconstruction (all p < 0.05). Predictors from testing cohort were validated in validation cohort. Nomograms based on preoperative variables alone and both preoperative and intraoperative variables were generated. CONCLUSION We identify several preoperative and intraoperative factors that are associated with increased risk for non-home discharge after major hepatectomy. Preoperative anemia represents a potentially modifiable risk factor. Nomograms for preoperative planning as well as immediately following surgery were generated.
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Affiliation(s)
- David A Mahvi
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - Linda M Pak
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Adam C Fields
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason S Gold
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Department of Surgery, VA Boston Healthcare System, West Roxbury, MA, USA
| | - Edward E Whang
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Department of Surgery, VA Boston Healthcare System, West Roxbury, MA, USA
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Incidence and Long-term Outcomes of Patients Requiring Early Reoperation After HIPEC. J Surg Res 2019; 244:395-401. [PMID: 31325661 DOI: 10.1016/j.jss.2019.05.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/10/2019] [Accepted: 05/29/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) remains a formidable operation associated with considerable morbidity. It is unclear how often these patients require reoperation for postoperative complications and if the need for reoperations leads to worse long-term outcomes. METHODS The Peritoneal Surface Malignancy Database at a single center was retrospectively queried. Out of 149 entries, 141 HIPECs performed between 2012 and 2018 met inclusion criteria. Patients were categorized based on early reoperation (<60 d after HIPEC), and demographic and tumor factors were compared using univariate analyses. Recurrence was calculated for patients with complete cytoreduction and overall survival analyzed using the Kaplan-Meier method. RESULTS There were 15 reoperations after 141 HIPECs (10.6%). Median duration between HIPEC and reoperation was 18 d. Indications for reoperation included intra-abdominal infection (n = 5), bowel obstruction (n = 4), wound infection (n = 3), bleeding (n = 2), and evisceration (n = 1). There were no identified patient- or tumor-related risk factors for reoperation. Reoperations were associated with longer hospital length of stay (19 versus 9 d, P = 0.005) and 30-d readmissions (46.7% versus 12.8%, P = 0.003). There was no significant difference in 3-year recurrence-free survival, but there was a significant association between reoperation and 3-year overall survival (38.0% versus 71.9%, P = 0.03). CONCLUSIONS Complications requiring reoperation after HIPEC lead to increased short-term morbidity, longer hospital length of stay, and most importantly, reduced overall survival. Further studies investigating interventions to decrease complications and reduce reoperation rates are needed to improve outcomes after HIPEC.
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15
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Chacon E, Vilchez V, Eman P, Marti F, Morris-Stiff G, Dugan A, Turcios L, Gedaly R. Effect of critical care complications on perioperative mortality and hospital length of stay after hepatectomy: A multicenter analysis of 21,443 patients. Am J Surg 2018; 218:151-156. [PMID: 30528789 DOI: 10.1016/j.amjsurg.2018.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 10/31/2018] [Accepted: 11/19/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine predictors of critical care complications (CCC) in patients undergoing hepatectomy. METHODS All hepatectomy patients in NSQIP from 2012 to 2016 were analyzed. CCC included prolonged ventilation (>48 h), sepsis/septic shock, renal failure/insufficiency, cardiac arrest/AMI and pulmonary embolism. RESULTS A total of 21,443 patients underwent hepatectomy during the study period. Overall rate of CCC was 11%, with the most common being sepsis/septic shock (6.1%) and respiratory failure (4.9%). On multivariate analysis the preoperative risk factors associated with CCC included ASA Class IV-V (OR:2.04, p < 0.0001), diabetes (OR = 1.28, p = 0.0001), pre-operative ventilator use (OR: 17.75, p = 0.0003); COPD (OR: 1.65, p < 0.0001); pre-operative weight loss >10% (OR: 1.35, p = 0.0026); pre-operative sepsis (OR: 2.14, p < 0.0001). Propensity score matched analysis demonstrated a significant increased risk of mortality in patients with CCC (OR: 26.75, p < 0.0001) and a prolonged LOS of 10.5 days above the mean (β Estimate: 10.51, p < 0.0001). CONCLUSIONS ASA class, diabetes, COPD, pre-operative weight loss >10% and pre-operative sepsis are the strongest predictors of CCC after hepatectomy. The presence of CCC significantly increased the risk of peri-operative mortality 26-fold.
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Affiliation(s)
- Eduardo Chacon
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Valery Vilchez
- Section of Hepato-Pancreato-Biliary Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Pedro Eman
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Francesc Marti
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Gareth Morris-Stiff
- Section of Hepato-Pancreato-Biliary Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Adam Dugan
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Lilia Turcios
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Roberto Gedaly
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA.
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Cortolillo N, Patel C, Parreco J, Kaza S, Castillo A. Nationwide outcomes and costs of laparoscopic and robotic vs. open hepatectomy. J Robot Surg 2018; 13:557-565. [PMID: 30484059 DOI: 10.1007/s11701-018-0896-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 11/20/2018] [Indexed: 12/16/2022]
Abstract
The safety of hepatectomy continues to improve and it holds a key role in the management of benign and malignant hepatic lesions. Laparoscopic and robotic approaches to hepatectomy are increasingly utilized. The purpose of this study was to compare outcomes and costs of laparoscopic and robotic vs. open approaches to hepatectomy and to determine the national nonelective postoperative readmission rate, including readmission to other hospitals. The Nationwide Readmission Database from 2013 to 2014 was queried for all patients undergoing hepatectomy. Patients undergoing laparoscopic and robotic hepatectomies were compared to patients undergoing open hepatectomy. Multivariate logistic regression was implemented to determine the odds ratios (OR) for non-elective readmission within 45 days. There were 10,870 patients who underwent hepatectomy from 2013 to 2014 and 724 (6.7%) were approached with laparoscopic or robotic technique. The robotic cohort had lower mean cost of the index admission ($24,983 ± $18,329 vs. open $32,391 ± $31,983, p < 0.001, 95% CI - 18,292 to 534), shorter LOS (4.5 ± 3.8 vs. lap 6.8 ± 6.0 vs. open 7.6 ± 7.7 days, p < 0.01), and were less likely to be readmitted within 45 days (7.9% vs. 13.0% lap vs. 13.8% open, p = 0.05). The robotic cohort was slightly younger (mean age 57.5 ± 13.5 vs. lap 60.1 ± 13.8 vs. open 58.9 ± 13.7, p < 0.05), and no significant differences were seen by Charlson Comorbidity Index. Anastomosis of hepatic duct to GI tract carried higher odds of mortality (OR 2.87, p < 0.01) and higher odds of readmission (OR 1.40, p < 0.01). LOS above 7 days increased odds of readmission (OR 2.24, p < 0.01). Nearly one-fifth of patients readmitted after hepatectomy present to a different hospital. Robotic hepatectomy was associated with favorable cost and readmission outcomes compared to laparoscopic and open hepatectomy patients, despite similar patient comorbid burdens and patient's age. Length of stay over 7 days and anastomosis of hepatic duct to GI tract are strong risk factors for readmission and mortality.
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Affiliation(s)
- Nicholas Cortolillo
- Department of Surgery, University of Miami Miller School of Medicine, 5301 S. Congress Av, Atlantis, FL, 33462, USA.
| | - Chetan Patel
- Department of Surgery, University of Miami Miller School of Medicine, 5301 S. Congress Av, Atlantis, FL, 33462, USA
| | - Joshua Parreco
- Department of Surgery, University of Miami Miller School of Medicine, 5301 S. Congress Av, Atlantis, FL, 33462, USA
| | - Srinivas Kaza
- Department of Surgery, University of Miami Miller School of Medicine, 5301 S. Congress Av, Atlantis, FL, 33462, USA
| | - Alvaro Castillo
- Department of Surgery, University of Miami Miller School of Medicine, 5301 S. Congress Av, Atlantis, FL, 33462, USA
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Chen Q, Bagante F, Olsen G, Merath K, Idrees JJ, Beal EW, Akgul O, Cloyd J, Dillhoff M, Schmidt C, White S, Pawlik TM. Time to Readmission and Mortality Among Patients Undergoing Liver and Pancreatic Surgery. World J Surg 2018; 43:242-251. [PMID: 30109390 DOI: 10.1007/s00268-018-4766-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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18
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Tran AQ, Greene N, Cass I. The Impact of Annual Surgical Volume on Patient Outcomes in Laparoscopic Hysterectomy. J Gynecol Surg 2018. [DOI: 10.1089/gyn.2017.0113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Arthur-Quan Tran
- Department of Obstetrics and Gynecology, Cedars–Sinai Medical Center, Los Angeles, CA
| | - Naomi Greene
- Department of Obstetrics and Gynecology, Cedars–Sinai Medical Center, Los Angeles, CA
| | - Ilana Cass
- Department of Obstetrics and Gynecology, Cedars–Sinai Medical Center, Los Angeles, CA
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Lyu HG, Sharma G, Brovman EY, Ejiofor J, Urman RD, Gold JS, Whang EE. Unplanned reoperation after hepatectomy: an analysis of risk factors and outcomes. HPB (Oxford) 2018; 20:591-596. [PMID: 29331277 DOI: 10.1016/j.hpb.2017.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 12/04/2017] [Accepted: 12/09/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND/PURPOSE Reoperation is being increasingly utilized as a metric for surgical care quality. The aim of this study was to identify the incidence of and risk factors for unplanned reoperation following index hepatectomy. METHODS Pre, intra- and post-operative information of patients who underwent partial hepatectomy in 435 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2013 were analyzed. RESULTS 343 (4%) of 9195 patients required reoperation within 30 days of index hepatectomy. The index procedures with the highest incidence of reoperation (%) were trisectionectomy (7%) and right hepatectomy (5%). Patients who underwent reoperation had increased index operative duration (323 ± 174 min versus 243 ± 125 min, p < 0.001), postoperative transfusion (57% versus 23%, p < 0.001), wound complications, cardiorespiratory, renal, thromboembolic, and infectious events. Hemorrhage was the most common indication for reoperation (10%). Male gender, ASA class 4, and right hepatectomy or trisectionectomy were independent predictors of reoperation (OR 1.4 [1.1-1.7], p = 0.007; 2.0 [1.3-3.1], p = 0.003; 1.6 [1.2-2.0], p = 0.001 and 2.5 [1.8-3.4], p < 0.001, respectively). All reoperations occurred during index hospitalization and resulted in longer mean length of stay (19 ± 17 days versus 7 ± 7 days, p < 0.001). CONCLUSION Reoperation is associated with several patient characteristics and procedural factors in this national sample. Knowledge of these factors can increase awareness of patients at risk for reoperation.
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Affiliation(s)
- Heather G Lyu
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA; Center for Perioperative Research, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA.
| | - Gaurav Sharma
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA; Center for Perioperative Research, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Ethan Y Brovman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA; Center for Perioperative Research, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Julius Ejiofor
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA; Center for Perioperative Research, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA; Center for Perioperative Research, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Jason S Gold
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA; Department of Surgery, VA Boston Healthcare System, West Roxbury, MA, USA; Center for Perioperative Research, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Edward E Whang
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA; Department of Surgery, VA Boston Healthcare System, West Roxbury, MA, USA; Center for Perioperative Research, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
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Chen Q, Merath K, Olsen G, Bagante F, Idrees JJ, Akgul O, Cloyd J, Schmidt C, Dillhoff M, Beal EW, White S, Pawlik TM. Impact of Post-Discharge Disposition on Risk and Causes of Readmission Following Liver and Pancreas Surgery. J Gastrointest Surg 2018; 22:1221-1229. [PMID: 29569005 DOI: 10.1007/s11605-018-3740-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 03/05/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The relationship between the post-discharge settings and the risk of readmission has not been well examined. We sought to identify the association between discharge destinations and readmission rates after liver and pancreas surgery. METHODS The 2013-2015 Medicare-Provider Analysis and Review (MEDPAR) database was reviewed to identify liver and pancreas surgical patients. Patients were subdivided into three groups based on discharge destination: home/self-care (HSC), home with home health assistance (HHA), and skilled nursing facility (SNF). The association between post-acute settings, readmission rates, and readmission causes was assessed. RESULTS Among 15,141 liver or pancreas surgical patients, 60% (n = 9046) were HSC, 26.9% (n = 4071) were HHA, and 13.4% (n = 2024) were SNF. Older, female patients and patients with ≥ 2 comorbidities, ≥ 2 previous admissions, an emergent index admission, an index complication, and ≥ 5-day length of stay were more likely to be discharged to HHA or SNF compared to HSC (all P < 0.001). Compared to HSC, HHA and SNF patients had a 34 and a 67% higher likelihood of 30-day readmission, respectively. The HHA and SNF settings were also associated with a 33 and a 69% higher risk of 90-day readmission. There was no association between discharge destination and readmission causes. CONCLUSION Among liver and pancreas surgical patients, HHA and SNF patients had a higher risk of readmission within 30 and 90 days. There was no difference in readmission causes and discharge settings. The association between discharge setting and the higher risk of readmission should be further evaluated as the healthcare system seeks to reduce readmission rates after surgery.
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Affiliation(s)
- Qinyu Chen
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Griffin Olsen
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
- Department of Surgery, University of Verona, Verona, Italy
| | - Jay J Idrees
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Ozgur Akgul
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Carl Schmidt
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Susan White
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Bagante F, Beal EW, Merath K, Paredes A, Chakedis J, Olsen G, Akgül O, Idrees J, Chen Q, Pawlik TM. The impact of a malignant diagnosis on the pattern and outcome of readmission after liver and pancreatic surgery: An analysis of the nationwide readmissions database. J Surg Oncol 2018; 117:1624-1637. [PMID: 29957864 DOI: 10.1002/jso.25065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 02/18/2018] [Indexed: 12/16/2023]
Abstract
BACKGROUND AND OBJECTIVES Reducing readmissions is an important quality improvement metric. We sought to investigate patterns of 90-day readmission after hepato-pancreatic (HP) procedures. METHODS The Nationwide Readmissions Database (NRD) was used to identify patients undergoing HP procedures between 2010 and 2014. Patients were stratified according to benign versus malignant HP diagnoses and as index (same hospital as operation) versus non-index (different hospital) readmissions. RESULTS Among the 41 059 patients who underwent HP procedures, 26 563 (65%) underwent a liver resection while 14 496 (35%) pancreatic resection. Among all patients, 11 902 (29%) had a benign diagnosis versus 29 157 (71%) who had a cancer diagnosis. Overall 90-day readmission was 22% (n = 8 998) with a slight increase in readmissions among patients with a malignant (n = 6 655;23%) versus benign (n = 2 343;20%) diagnosis (P < 0.001). Readmission to an index hospital was more common (n = 7 316 81%) versus a non-index hospital (n = 1 682 19%). Non-index hospital readmissions were more frequent among patients with malignant HP diagnoses (OR, 1.41;P = 0.001). CONCLUSIONS Up to one in four patients were readmitted after HP surgery. Late readmission was more common among patients with a cancer-diagnosis. While most readmissions occurred at the index hospital, 19% of all readmissions occurred at a non-index hospital and were more frequent among patients with malignant diagnoses.
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Affiliation(s)
- Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
- General and Hepatobiliary Surgery, Department of Surgery, University of Verona, School of Medicine, Verona, Italy
| | - Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Anghela Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jeffery Chakedis
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Griffin Olsen
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ozgür Akgül
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jay Idrees
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Quinu Chen
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Narula N, Kim BJ, Davis CH, Dewhurst WL, Samp LA, Aloia TA. A proactive outreach intervention that decreases readmission after hepatectomy. Surgery 2018; 163:703-708. [PMID: 29325786 DOI: 10.1016/j.surg.2017.08.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/30/2017] [Accepted: 08/30/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND After hepatectomy, 7%-19% of patients are readmitted within 30 days, accounting for substantial cost and poor patient experience. The purpose of this study was to analyze the impact of a proactive outreach intervention on readmissions. METHODS Consecutive patients undergoing hepatectomy by a single surgeon 2012-2016 were identified in a prospectively maintained database. In August 2013 a postoperative intervention was implemented; an advanced practice provider called each patient within 72 hours of discharge. Readmission rates were compared pre- and postintervention using standard statistics. RESULTS Two hundred thirty-one patients met the inclusion criteria and major hepatectomy was performed in 45.5% of patients. Although the complication rate was similar (25.0% preintervention and 19.4% postintervention, P = .324), readmissions within 30 days of operation decreased from 14.5% pre- to 6.5% postintervention (P = .046). Approximately 30% of outreach interactions required outpatient intervention. Factors associated with readmission on univariate analysis included increased operative time (P = .007), major hepatectomy (P = .012), hemi or extended hepatectomy (P = .032), second stage operation (P = .031), bile leak (P = 0.022), and any complication/modified Accordion complication ≥ 3 within 30 days (P <.0001). On multivariate analysis, lack of post-discharge intervention (P = .012) and bile leak (P = .031) were independently associated with readmission. CONCLUSION These data demonstrate the efficacy of a proactive communication intervention after discharge to decrease readmissions after hepatectomy. The additional work created by the intervention is likely offset by decreased inpatient care needs and costs. Identification of high-risk populations and application of technology are likely to lead to further improvements.
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Affiliation(s)
- Nisha Narula
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bradford J Kim
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Catherine H Davis
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Whitney L Dewhurst
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Leigh A Samp
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas A Aloia
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Douaiher J, Hussain T, Dhir M, Smith L, Are C. Preoperative Risk Factors for 30-Day Reoperation in Patients Undergoing Hepatic Resections for Malignancy. Indian J Surg Oncol 2017; 8:312-320. [DOI: 10.1007/s13193-016-0557-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/30/2016] [Indexed: 02/07/2023] Open
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Abstract
BACKGROUND Pancreatic resection is associated with a high incidence of postoperative complications, some of which require reoperation. AIMS To analyze the incidence of and risk factors for reoperation following pancreatectomy. METHODS Pre- and postoperative information and procedure characteristics of 15,549 patients having undergone pancreatectomy in 435 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2014 were analyzed. RESULTS A total of 773 (5.0%) patients required reoperation within 30 days of their index pancreatectomy. Patients requiring reoperation were more likely to be younger (mean ± standard deviation, 62.6 ± 13.2 vs. 64.1 ± 12.2 years, p < 0.001), male (60 vs. 49%, p < 0.001), to have respiratory comorbidities, lower preoperative serum albumin (3.7 ± 0.68 vs. 3.8 ± 0.62 mg/dl, p < 0.001), higher total bilirubin (1.7 ± 2.7 vs. 1.5 ± 2.4 mg/dl, p = 0.02), and higher American Society of Anesthesiologists (ASA) class than those who did not undergo reoperation. Other factors associated with increased incidence of reoperation included longer mean operative duration at the index procedure, postoperative transfusion requirement, wound complications, and cardiorespiratory, renal, thromboembolic, and infectious events. Multivariate regression analysis identified male sex, preoperative serum albumin <3.5 mg/dl, ASA class of 3 or 4, pancreaticoduodenectomy, and total pancreatectomy as the strongest predictors for reoperation after index pancreatic resection. Complication and readmission rates were significantly higher for those undergoing reoperation. CONCLUSION Patient characteristics and procedural factors contribute to reoperation after pancreatectomy in this largest and most diverse sample to date. Further investigation to identify perioperative strategies for mitigating this risk is required to improve the safety of pancreatic resection.
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Mollberg NM, Howell E, Vanderhoff DI, Cheng A, Mulligan MS. Health care utilization and consequences of readmission in the first year after lung transplantation. J Heart Lung Transplant 2017; 36:443-450. [DOI: 10.1016/j.healun.2016.09.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 09/22/2016] [Accepted: 09/28/2016] [Indexed: 11/26/2022] Open
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No Differences in Population-based Readmissions After Open and Robotic-assisted Radical Cystectomy: Implications for Post-discharge Care. Urology 2017; 104:77-83. [PMID: 28267606 DOI: 10.1016/j.urology.2017.01.042] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 01/05/2017] [Accepted: 01/18/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To inform whether readmission reduction strategies should consider surgical approach, we examined readmission differences between open and robotic-assisted radical cystectomy (RARC) using population-based data. METHODS We identified patients who underwent cystectomy between January 2010 and September 2013 based on International Classification of Diseases-9th edition codes and administrative claims from a large, national US health insurer (Clinformatics Data Mart Database, OptumInsight, Eden Prairie, MN). We assessed post-discharge health system utilization and tested for differences in readmissions after the 2 surgical approaches. RESULTS We identified 935 patients treated with cystectomy: open = 785 (84%) and RARC = 150 (16%). Patients undergoing RARC were slightly older, male, had more ileal conduit urinary reconstruction, and less need for intensive care. Index length of stay was shorter for RARC than for open surgery (7 days vs 8 days, P < .001). However, we found no differences in 30-day readmission rates (24% open vs 29% RARC, P = .26) or other readmission parameters, including readmission length of stay (5 days open vs 4 days RARC, P = .32), emergency department use (22% open vs 24% RARC, P = .86), reasons for readmission, or timing of first outpatient visits (11.5 days open vs 9 days RARC, P = .41). For both approaches, the majority of patients were readmitted within 2 weeks. CONCLUSION The surgical approach to cystectomy does not appear to impact readmissions. Strategies to reduce the readmission burden after cystectomy do not need to consider surgical approach but should focus on timing of medical contacts.
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Martínez-Mier G, Esquivel-Torres S, Alvarado-Arenas R, Ortiz-Bayliss A, Lajud-Barquín F, Zilli-Hernandez S. Liver resection morbidity, mortality, and risk factors at the departments of hepatobiliary surgery in Veracruz, Mexico. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2016. [DOI: 10.1016/j.rgmxen.2016.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Martínez-Mier G, Esquivel-Torres S, Alvarado-Arenas RA, Ortiz-Bayliss AB, Lajud-Barquín FA, Zilli-Hernandez S. Liver resection morbidity, mortality, and risk factors at the departments of hepatobiliary surgery in Veracruz, Mexico. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2016; 81:195-201. [PMID: 27527529 DOI: 10.1016/j.rgmx.2016.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 03/23/2016] [Accepted: 05/04/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Liver resection has been associated with high morbidity and mortality, and the most serious complication is liver failure. Patient evaluation is limited to risk scales. The 50-50 criteria and bilirubin peak>7mg/dl have been used as mortality predictors. AIM The aim of this study was to determine the risk factors associated with morbidity and mortality for liver resection in our population. MATERIAL AND METHODS A retrospective study was carried out on 51 patients that underwent liver resection. Sociodemographic variables, pathology, and the surgical act were analyzed, together with morbidity and mortality and their associated factors. RESULTS Fifty-one patients, 23 men and 28 women, were analyzed. They had a mean age of 51.4±19.13 years, 64.7% had concomitant disease, and their mean MELD score was 7.49±1.79. The mean size of the resected lesions was 7.34±3.47cm, 51% were malignant, and 34 minor resections were performed. The Pringle maneuver was used in 64.7% of the cases and the mean blood loss was 1,090±121.76ml. Morbidity of 25.5% was associated with viral hepatitis infection, greater blood loss, transfusion requirement, the Pringle maneuver, lower hemoglobin and PTT values, and higher MELD, INR, bilirubin, and glucose values. A total 3.9% mortality was associated with hyperbilirubinemia, hyperglycemia, and greater blood loss and transfusions. CONCLUSIONS The main risk factors associated with the morbidity and mortality of liver resection in our population were those related to the preoperative biochemical parameters of the patient and the factors that occurred during the surgical act.
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Affiliation(s)
- G Martínez-Mier
- Departamento de Cirugía Hepatobiliar, Unidad Médica de Alta Especialidad, Hospital de Especialidades No 14 Centro Médico Nacional "Adolfo Ruiz Cortinez", Instituto Mexicano del Seguro Social, Veracruz, México; Departamento de Cirugía Hepatobiliar, Hospital de Alta Especialidad de Veracruz, Veracruz, México.
| | - S Esquivel-Torres
- Departamento de Cirugía Hepatobiliar, Hospital de Alta Especialidad de Veracruz, Veracruz, México
| | - R A Alvarado-Arenas
- Departamento de Cirugía Hepatobiliar, Unidad Médica de Alta Especialidad, Hospital de Especialidades No 14 Centro Médico Nacional "Adolfo Ruiz Cortinez", Instituto Mexicano del Seguro Social, Veracruz, México
| | - A B Ortiz-Bayliss
- Departamento de Cirugía Hepatobiliar, Unidad Médica de Alta Especialidad, Hospital de Especialidades No 14 Centro Médico Nacional "Adolfo Ruiz Cortinez", Instituto Mexicano del Seguro Social, Veracruz, México
| | - F A Lajud-Barquín
- Departamento de Investigación, Unidad Médica de Alta Especialidad, Hospital de Especialidades No 14 Centro Médico Nacional "Adolfo Ruiz Cortinez", Instituto Mexicano del Seguro Social, Veracruz, México
| | - S Zilli-Hernandez
- Departamento de Investigación, Unidad Médica de Alta Especialidad, Hospital de Especialidades No 14 Centro Médico Nacional "Adolfo Ruiz Cortinez", Instituto Mexicano del Seguro Social, Veracruz, México
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Andrassy J, Wolf S, Hoffmann V, Rentsch M, Stangl M, Thomas M, Pratschke S, Frey L, Gerbes A, Meiser B, Angele M, Werner J, Guba M. Rescue management of early complications after liver transplantation-key for the long-term success. Langenbecks Arch Surg 2016; 401:389-96. [PMID: 26960592 DOI: 10.1007/s00423-016-1398-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 03/01/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE Postoperative complications may have not only immediate but also long-term effects on the outcomes. Here, we analyzed the effect of postoperative complications requiring a reoperation (grade 3b) within the first 30 days on patients' and graft survival following liver transplantation. METHODS Graft and patient survival in relation to donor and recipient variables and the need of reoperation for complications of 277 consecutive liver transplants performed from January 2007 to December 2012 were analyzed. RESULTS Two hundred seventy-seven liver transplants were performed in 252 patients. Overall patient and graft survival at 1, 2, and 3 years were significantly reduced in patients requiring a reoperation. The labMELD score was significantly elevated (p = 0.04) and cold ischemia time was prolonged (p = 0.03) in recipients undergoing reoperations. Kaplan-Meier curves indicate that complications impact the outcome primarily within the first 3 months after transplantation. In multivariate analyses, the actual need of reoperation (p < 0.001), the labMELD score (p = 0.05), cold ischemia time (p = 0.02), and the need for hemodialysis pre-transplant (p = 0.05) were the only variables which correlated with the overall survival. CONCLUSION Postoperative complications resulting in reoperations have a significant impact on the outcome primarily in the early phase after liver transplantation. Successful management of postoperative complications is key to every successful liver transplant program.
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Affiliation(s)
- Joachim Andrassy
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany.
| | - Sebastian Wolf
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Verena Hoffmann
- Institute of Medical Information Sciences, Biometry and Epidemiology (IBE), Ludwig Maximilian University, Munich, Germany
| | - Markus Rentsch
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Manfred Stangl
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Michael Thomas
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Sebastian Pratschke
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Lorenz Frey
- Department of Anesthesiology, Ludwig Maximilian University, Munich, Germany
| | - Alexander Gerbes
- Department of Medicine, MED II, Ludwig Maximilian University, Munich, Germany
| | - Bruno Meiser
- Transplant Center, Ludwig Maximilian University, Munich, Germany
| | - Martin Angele
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Markus Guba
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
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Abstract
Re-admission is a new concept in France, born with the advent of day-case surgery, and defined as any re-admission occurring within 30 days after surgery. The re-admission rate has increasingly come to be considered a criterion of the quality of medical care, by both the medical profession and by insurance companies. This report outlines the generalities and definitions related to re-admission after gastro-intestinal surgery, describes the current situation, rationalizes the value of re-admission rates as a measure of quality of care, details the risk factors for re-admission according to the type of intervention, exposes the possible means of prevention and what to do when a patient comes to the emergency room within 30 days after an operation.
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Egger ME, Ohlendorf JM, Scoggins CR, McMasters KM, Martin RCG. Assessment of the reporting of quality and outcome measures in hepatic resections: a call for 90-day reporting in all hepatectomy series. HPB (Oxford) 2015; 17:839-45. [PMID: 26228262 PMCID: PMC4557660 DOI: 10.1111/hpb.12470] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 06/02/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this paper is to assess the current state of quality and outcomes measures being reported for hepatic resections in the recent literature. METHODS Medline and PubMed databases were searched for English language articles published between 1 January 2002 and 30 April 2013. Two examiners reviewed each article and relevant citations for appropriateness of inclusion, which excluded papers of liver donor hepatic resections, repeat hepatectomies or meta-analyses. Data were extracted and summarized by two examiners for analysis. RESULTS Fifty-five studies were identified with suitable reporting to assess peri-operative mortality in hepatic resections. In only 35% (19/55) of the studies was the follow-up time explicitly stated, and in 47% (26/55) of studies peri-operative mortality was limited to in-hospital or 30 days. The time period in which complications were captured was not explicitly stated in 19 out of 28 studies. The remaining studies only captured complications within 30 days of the index operation (8/28). There was a paucity of quality literature addressing truly patient-centred outcomes. CONCLUSION Quality outcomes after a hepatic resection are inconsistently reported in the literature. Quality outcome studies for a hepatectomy should report mortality and morbidity at a minimum of 90 days after surgery.
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Affiliation(s)
- Michael E Egger
- The Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Joanna M Ohlendorf
- The Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Charles R Scoggins
- The Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Kelly M McMasters
- The Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Robert C G Martin
- The Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, KY, USA
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Spolverato G, Maqsood H, Vitale A, Alexandrescu S, Marques HP, Aldrighetti L, Gamblin TC, Pulitano C, Bauer TW, Shen F, Poultsides G, Maithel S, Marsh JW, Pawlik TM. Readmission After Liver Resection for Intrahepatic Cholangiocarcinoma: a Multi-Institutional Analysis. J Gastrointest Surg 2015; 19:1334-41. [PMID: 25903853 DOI: 10.1007/s11605-015-2826-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 04/08/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND The objective of the current study was to define the incidence of 30-day readmission after hepatic resection for intrahepatic cholangiocarcinoma (ICC). In particular, we sought to identify risk factors associated with a higher risk of readmission among patients undergoing resection for ICC. METHODS Patients who underwent hepatic resection for ICC at 12 major hepatobiliary centers in the USA, Europe, Australia, and Asia between 1990 and 2013 were identified. Thirty-day readmission and clinicopathologic characteristics associated with higher risk of readmission were examined. RESULTS Among 602 patients, 401 (68.3%) patients underwent a major hepatectomy and 256 (43.3%) experienced at least one post-operative complication. Overall 30-day readmission was 7.8% (n = 47). Risk factors associated with readmission included pre-operative jaundice (odds ratio (OR) 2.45) and the presence of a major complication (OR 3.38). In fact, 95.7% of readmitted patients had experienced a post-operative complication versus only 38.8% of non-readmitted patients (P < 0.001). Among patients who were readmitted, repeat hospitalization was associated with a median LOS of 6.5 days (interquartile range (IQR) 4.0-11.5) and one patient died during readmission. CONCLUSIONS Readmission after hepatic resection for ICC occurred in 1 in 13 patients. Patients with pre-operative jaundice and those who experienced a complication had over a threefold higher risk of being readmitted.
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Affiliation(s)
- Gaya Spolverato
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Costs of hepato-pancreato-biliary surgery and readmissions in privately insured US patients. J Surg Res 2015; 199:478-86. [PMID: 26026853 DOI: 10.1016/j.jss.2015.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/19/2015] [Accepted: 05/01/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgical costs are influenced by perioperative care, readmissions, and further therapies. We aimed to characterize costs in hepato-pancreato-biliary surgery in the United States. METHODS The MarketScan database (2008-2010) was used to identify privately insured patients undergoing pancreatectomy (n = 2254) or hepatectomy (n = 1702). Costs associated with the index surgery, readmissions, and total short-term costs were assessed from a third party payer perspective using generalized linear regression models. RESULTS Mean total costs of pancreatectomy and hepatectomy were $107,600 (95% confidence interval [CI], 101,200-114,000) and $81,300 (95% CI, 77,600-85,000), respectively, with corresponding surgical costs of 69.2% and 60.9%. Ninety-day readmission costs were $36,200 (95% CI, 32,000-40,400) and $34,100 (95% CI, 28,100-40,100), respectively. In multivariate analysis, readmissions were associated with an almost two-fold increase in total costs in both pancreatectomy (cost ratio = 1.98; P < 0.001) and hepatectomy (cost ratio = 1.92; P < 0.001). CONCLUSIONS Hepato-pancreato-biliary surgery is associated with significant economic burden in the privately insured population. Substantial costs are incurred beyond the index surgical admission, with readmissions representing a major source of potentially preventable health care spending. Sustained efforts in defining high-risk populations and decreasing the burden of postoperative complications through a combination of prevention and improved outpatient management offer promising strategies to reduce readmissions and control costs.
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Brudvik KW, Mise Y, Conrad C, Zimmitti G, Aloia TA, Vauthey JN. Definition of Readmission in 3,041 Patients Undergoing Hepatectomy. J Am Coll Surg 2015; 221:38-46. [PMID: 26047760 DOI: 10.1016/j.jamcollsurg.2015.01.063] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/15/2015] [Accepted: 01/16/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Readmission rates of 9.7% to 15.5% after hepatectomy have been reported. These rates are difficult to interpret due to variability in the time interval used to monitor readmission. The aim of this study was to refine the definition of readmission after hepatectomy. STUDY DESIGN A prospectively maintained database of 3,041 patients who underwent hepatectomy from 1998 through 2013 was merged with the hospital registry to identify readmissions. Area under the curve (AUC) analysis was used to determine the time interval that best captured unplanned readmission. RESULTS Readmission rates at 30 days, 90 days, and 1 year after discharge were 10.7% (n = 326), 17.3% (n = 526), and 31.9% (n = 971) respectively. The time interval that best accounted for unplanned readmissions was 45 days after discharge (AUC, 0.956; p < 0.001), during which 389 patients (12.8%) were readmitted (unplanned: n = 312 [10.3%]; planned: n = 77 [2.5%]). In comparison, the 30 days after surgery interval (used in the ACS-NSQIP database) omitted 65 (26.3%) unplanned readmissions. Multivariate analysis revealed the following risk factors for unplanned readmission: diabetes (odds ratio [OR] 1.6; p = 0.024), right hepatectomy (OR 2.1; p = 0.034), bile duct resection (OR 1.9; p = 0.034), abdominal complication (OR 1.8; p = 0.010), and a major postoperative complication (OR 2.4; p < 0.001). Neither index hospitalization > 7 days nor postoperative hepatobiliary complications were independently associated with readmission. CONCLUSIONS To accurately assess readmission after hepatectomy, patients should be monitored 45 days after discharge.
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Affiliation(s)
- Kristoffer W Brudvik
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yoshihiro Mise
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claudius Conrad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Giuseppe Zimmitti
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Kim S, Maynard EC, Shah MB, Daily MF, Tzeng CWD, Davenport DL, Gedaly R. Risk factors for 30-day readmissions after hepatectomy: analysis of 2444 patients from the ACS-NSQIP database. J Gastrointest Surg 2015; 19:266-71. [PMID: 25451735 DOI: 10.1007/s11605-014-2713-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 11/20/2014] [Indexed: 01/31/2023]
Abstract
AIMS The aim of this study was to identify risk factors associated with unplanned readmissions after hepatectomies. METHODS Patients who underwent hepatectomies between January and December of 2011 were identified using the ACS-NSQIP database. A multivariate logistic regression analysis was performed to determine predictors of unplanned readmissions related to the procedure within 30 days. RESULTS Unplanned readmissions occurred in 10.5 % of all patients who received a hepatectomy. On multivariate analysis, transfusion within 72 h after surgery (odds ratio [OR] 1.74, p < 0.001), complexity of procedure (extended, OR 1.84, p = 0.004; right hepatectomy, OR 1.66, p = 0.003), and longer operative time (>median 320 min, OR 2.43, p < 0.001) were independent perioperative predictors of unplanned readmissions. Independent preoperative risk factors included elevated alkaline phosphatase (OR 1.45, p = 0.017), bleeding disorders (OR 1.72, p = 0.051), and lower albumin levels (OR 1.30, p = 0.036). CONCLUSION Transfusion, complexity of procedure, and duration of operation were the strongest predictors of unplanned readmissions after liver resection.
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Affiliation(s)
- Sooyeon Kim
- Department of Surgery, Section of Transplant Surgery, University of Kentucky College of Medicine, 800 Rose Street, Room C453, Lexington, KY, 40508, USA
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Stitzenberg KB, Chang Y, Smith AB, Nielsen ME. Exploring the burden of inpatient readmissions after major cancer surgery. J Clin Oncol 2014; 33:455-64. [PMID: 25547502 DOI: 10.1200/jco.2014.55.5938] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Travel distances to care have increased substantially with centralization of complex cancer procedures at high-volume centers. We hypothesize that longer travel distances are associated with higher rates of postoperative readmission and poorer outcomes. METHODS SEER-Medicare patients with bladder, lung, pancreas, or esophagus cancer who were diagnosed in 2001 to 2007 and underwent extirpative surgery were included. Readmission rates and survival were calculated using Kaplan-Meier functions. Multivariable negative binomial models were used to examine factors associated with readmission. RESULTS Four thousand nine hundred forty cystectomies, 1,573 esophagectomies, 20,362 lung resections, and 2,844 pancreatectomies were included. Thirty- and 90-day readmission rates ranged from 13% to 29% and 23% to 43%, respectively, based on tumor type. Predictors of readmission were discharge to somewhere other than home, longer length of stay, comorbidities, higher stage at diagnosis, and longer travel distance (P < .001 for each). Patients who lived farther from the index hospital also had increased emergency room visits and were more likely to be readmitted to a hospital other than the index hospital (P < .001). Of readmitted patients, 31.9% were readmitted more than once. Long-term survival was worse and costs of care higher for patients who were readmitted (P < .001 for all). CONCLUSION The burden of readmissions after major cancer surgery is high, resulting in substantially poorer patient outcomes and higher costs. Risk of readmission was most strongly associated with length of stay and discharge destination. Travel distance also has an impact on patterns of readmission. Interventions targeted at higher risk individuals could potentially decrease the population burden of readmissions after major cancer surgery.
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Affiliation(s)
| | - YunKyung Chang
- All authors: University of North Carolina, Chapel Hill, NC
| | - Angela B Smith
- All authors: University of North Carolina, Chapel Hill, NC
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Egger ME, Squires MH, Kooby DA, Maithel SK, Cho CS, Weber SM, Winslow ER, Martin RCG, McMasters KM, Scoggins CR. Risk stratification for readmission after major hepatectomy: development of a readmission risk score. J Am Coll Surg 2014; 220:640-8. [PMID: 25667144 DOI: 10.1016/j.jamcollsurg.2014.12.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 12/15/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hospital readmission is becoming a quality measure, despite poor understanding of the risks of readmission. This study examines readmission risk factors after major hepatectomy and develops a predictive model. STUDY DESIGN A retrospective review was performed on patients who had undergone major hepatectomy at 1 of 3 academic centers between the years 2000 and 2012. Clinicopathologic and perioperative data were analyzed for risk factors of 90-day readmission using logistic regression. A readmission risk score was developed and validated in a separate validation set to determine its predictive value. RESULTS Of 1,184 hepatectomies performed, 17.3% of patients were readmitted within 90 days. Factors associated with readmission include operative blood loss (odds ratio [OR] = 1.00; 95% CI, 1.000-1.001), any postoperative complication (OR = 4.3; 95% CI, 1.8-10.4), a major postoperative complication (OR = 5.7; 95% CI, 3.2-10.2), postoperative pulmonary embolism (OR = 12.2; 95% CI, 1.9-78.4), no postoperative blood transfusion (OR = 3.3; 95% CI, 1.7-6.2), surgical site infection (OR = 5.3; 95% CI, 2.9-10.0), and post-hepatectomy hyperbilirubinemia (OR = 1.1; 95% CI, 1.1-1.2). A scoring system based on these risk factors accurately predicted readmission in the validation cohort. A score of >20 points had a positive predictive value of 30.8% and negative predictive value of 95.6%, and a score >50 had a positive predictive value of 50.9% and negative predictive value of 87.7%. This risk score accurately stratifies readmission risk. CONCLUSIONS The risk of hospital readmission within 90 days after major hepatectomy is high and is reliably predicted with a novel scoring system.
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Affiliation(s)
- Michael E Egger
- Hiram C Polk Jr, MD Department of Surgery, University of Louisville, Louisville, KY
| | | | - David A Kooby
- Department of Surgery, Emory University, Atlanta, GA
| | | | - Clifford S Cho
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Emily R Winslow
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Robert C G Martin
- Hiram C Polk Jr, MD Department of Surgery, University of Louisville, Louisville, KY
| | - Kelly M McMasters
- Hiram C Polk Jr, MD Department of Surgery, University of Louisville, Louisville, KY
| | - Charles R Scoggins
- Hiram C Polk Jr, MD Department of Surgery, University of Louisville, Louisville, KY.
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Kawaguchi Y, Sugawara Y, Akamatsu N, Kaneko J, Hamada T, Tanaka T, Ishizawa T, Tamura S, Aoki T, Sakamoto Y, Hasegawa K, Kokudo N. Impact of early reoperation following living-donor liver transplantation on graft survival. PLoS One 2014; 9:e109731. [PMID: 25396413 PMCID: PMC4232253 DOI: 10.1371/journal.pone.0109731] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 09/04/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The reoperation rate remains high after liver transplantation and the impact of reoperation on graft and recipient outcome is unclear. The aim of our study is to evaluate the impact of early reoperation following living-donor liver transplantation (LDLT) on graft and recipient survival. METHODS Recipients that underwent LDLT (n = 111) at the University of Tokyo Hospital between January 2007 and December 2012 were divided into two groups, a reoperation group (n = 27) and a non-reoperation group (n = 84), and case-control study was conducted. RESULTS Early reoperation was performed in 27 recipients (24.3%). Mean time [standard deviation] from LDLT to reoperation was 10 [9.4] days. Female sex, Child-Pugh class C, Non-HCV etiology, fulminant hepatitis, and the amount of intraoperative fresh frozen plasma administered were identified as possibly predictive variables, among which females and the amount of FFP were identified as independent risk factors for early reoperation by multivariable analysis. The 3-, and 6- month graft survival rates were 88.9% (95%confidential intervals [CI], 70.7-96.4), and 85.2% (95%CI, 66.5-94.3), respectively, in the reoperation group (n = 27), and 95.2% (95%CI, 88.0-98.2), and 92.9% (95%CI, 85.0-96.8), respectively, in the non-reoperation group (n = 84) (the log-rank test, p = 0.31). The 12- and 36- month overall survival rates were 96.3% (95%CI, 77.9-99.5), and 88.3% (95%CI, 69.3-96.2), respectively, in the reoperation group, and 89.3% (95%CI, 80.7-94.3) and 88.0% (95%CI, 79.2-93.4), respectively, in the non-reoperation group (the log-rank test, p = 0.59). CONCLUSIONS Observed graft survival for the recipients who underwent reoperation was lower compared to those who did not undergo reoperation, though the result was not significantly different. Recipient overall survival with reoperation was comparable to that without reoperation. The present findings enhance the importance of vigilant surveillance for postoperative complication and surgical rescue at an early postoperative stage in the LDLT setting.
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Affiliation(s)
- Yoshikuni Kawaguchi
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yasuhiko Sugawara
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Junichi Kaneko
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Tomohiro Tanaka
- Organ Transplantation Service, University of Tokyo, Tokyo, Japan
| | - Takeaki Ishizawa
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Sumihito Tamura
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Taku Aoki
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Norihiro Kokudo
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Spolverato G, Ejaz A, Kim Y, Weiss M, Wolfgang CL, Hirose K, Pawlik TM. Readmission incidence and associated factors after a hepatic resection at a major hepato-pancreatico-biliary academic centre. HPB (Oxford) 2014; 16:972-8. [PMID: 24712690 PMCID: PMC4487747 DOI: 10.1111/hpb.12262] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 03/05/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Reducing readmission is a key quality improvement target for policymakers. The purpose of the present study was to define incidence and identify factors associated with readmission after a hepatic resection. METHODS Thirty-day readmission after discharge and factors associated with a higher risk of readmission were examined among patients undergoing a hepatic resection at Johns Hopkins Hospital between 2008 and 2012. RESULTS Among the 338 patients, the median age was 57.9 years and 173 (51.2%) were men. Indications for surgery included colorectal cancer liver metastasis (38.2%), primary hepatic tumours (25.7%) and benign disease (3.3%). Surgical resection consisted of less than a hemi-hepatectomy in the majority of patients (n = 224, 66.3%). The median index hospitalization length-of-stay (LOS) was 5 days; 68.7% patients experienced at least one inpatient complication. Overall 30-day readmission was 14.2% (n = 48). The majority of readmitted patients (n = 46, 95.8%) had a complication prior to readmission. The median LOS for readmission was 4 [interquartile range (IQR) 2-6] days. On multivariable analysis, the strongest independent predictor of readmission was the presence of a major complication [odds ratio (OR) 5.30, 95% confidence interval (CI) 2.38-11.78, P < 0.001]. CONCLUSIONS Readmission after a hepatic resection occurs in approximately one out of every seven patients. Patients who experience a post-operative complication are greater than five times more likely to be readmitted. Prospective studies are needed to evaluate methods to reduce unplanned readmissions.
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Affiliation(s)
- Gaya Spolverato
- Department of Surgery, The Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - Aslam Ejaz
- Department of Surgery, The Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - Yuhree Kim
- Department of Surgery, The Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - Mattew Weiss
- Department of Surgery, The Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - Christopher L Wolfgang
- Department of Surgery, The Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - Kenzo Hirose
- Department of Surgery, The Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of MedicineBaltimore, MD, USA,Correspondence, Timothy M. Pawlik, Department of Surgery, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA. Tel: +1 410 502 2387. Fax: +1 410 502 2388. E-mail:
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Abstract
Readmission is a large problem after both medical and surgical admissions. Recent policy changes that include substantial financial penalties have made readmission an important, if not the most important, pay-for-performance program for health care in the United States. The CMS Hospital Readmissions Reduction Program currently applies only to patients with certain medical diagnoses, but it is expanding into orthopedic surgery in 2014, and will likely involve more surgical procedures in the future. Accordingly, hospitals and researchers will increasingly be focused on understanding and preventing readmission. Definitions of readmission must be standardized between organizations to allow for comparison. The accepted definition for any organization tracking rehospitalization should be 30-day all-cause readmission. In addition, any hospital profiling applications or studies comparing readmission rates between hospitals should use hierarchical rather than standard logistic regression modeling. Rather than relying on findings from medical patients, further studies on the specific causes of readmission after surgery should be conducted. Predictive modeling has some utility in focusing readmission prevention efforts on high-risk patients, but understanding the underlying causes of readmission is key to designing effective prevention interventions. Current evidence suggests that postoperative complications play a key role in surgical readmission, but efforts on improving discharge planning and coordination of care developed in medical patients will also be critical in decreasing unnecessary readmissions in the future.
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Kimbrough CW, Agle SC, Scoggins CR, Martin RC, Marvin MR, Davis EG, McMasters KM, Jones CM. Factors predictive of readmission after hepatic resection for hepatocellular carcinoma. Surgery 2014; 156:1039-46. [DOI: 10.1016/j.surg.2014.06.057] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 06/24/2014] [Indexed: 12/12/2022]
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Paterno F, Wilson GC, Wima K, Quillin RC, Abbott DE, Cuffy MC, Diwan TS, Kaiser T, Woodle ES, Shah SA. Hospital utilization and consequences of readmissions after liver transplantation. Surgery 2014; 156:871-8. [DOI: 10.1016/j.surg.2014.06.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 06/20/2014] [Indexed: 02/09/2023]
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Preventable Readmissions to Surgical Services: Lessons Learned and Targets for Improvement. J Am Coll Surg 2014; 219:382-9. [DOI: 10.1016/j.jamcollsurg.2014.03.046] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 03/10/2014] [Accepted: 03/11/2014] [Indexed: 12/22/2022]
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A composite index for predicting readmission following emergency general surgery. J Trauma Acute Care Surg 2014; 76:1467-72. [PMID: 24854317 DOI: 10.1097/ta.0000000000000223] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Preventable readmission has become a national focus. It is clear that surgical patients present specific challenges to those interested in preventing readmission. Little is known about this outcome in the emergent population. We are interested in determining if there are readily available data variables to predict risk of readmission. The surgical Apgar score (SAS) is calculated from objective intraoperative variables and has been shown to be predictive of postoperative mortality in the nonemergent setting. The objectives of this study were to characterize 30-day readmissions in emergent general surgery and to determine whether certain variables were associated with readmissions. We hypothesized that the SAS correlates with the risk for readmission in emergency general surgery patients. PATIENTS AND METHODS Variables of interest were obtained from a retrospective analysis of the American College of Surgeons' National Surgical Quality Improvement Program database at an academic institution, paired with the electronic medical record. We identified adult general surgery patients who underwent an emergency procedure from 2006 to 2012. Univariate analysis identified factors associated with 30-day readmission. Factors with p < 0.1 were included in the multivariate analysis to reveal potential risk factors. SPSS version 20 was used for the statistical analysis, with p < 0.05 considered to be significant on multivariate analysis. RESULTS As compared with nonemergency surgery patients, emergency surgery patients had a higher readmission rate (11.1% vs. 15.2%, p = 0.004). The SAS (odds ratio, 3.297; 95% confidence interval, 1.074-10.121; p = 0.037) and the combined variable of the American Society of Anesthesiologists Physical Status Classification and length of stay (odds ratio, 4.370; 95% confidence interval, 2.251-8.486; p < 0.001) were associated with elevated risk for readmission in emergency general surgery patients. CONCLUSION We have identified readily available measures that allow for the stratification of patients into low- and high-risk groups for 30-day readmission. The stratification of patients will enable the study of prospective interventions designed to decrease unplanned readmissions in emergency surgery patients. LEVEL OF EVIDENCE Prognostic study, level II.
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Guo JY, Li DW, Liao R, Huang P, Kong XB, Wang JM, Wang HL, Luo SQ, Yan X, Du CY. Outcomes of simple saline-coupled bipolar electrocautery for hepatic resection. World J Gastroenterol 2014; 20:8638-8645. [PMID: 25024620 PMCID: PMC4093715 DOI: 10.3748/wjg.v20.i26.8638] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 02/14/2014] [Accepted: 04/03/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the application of bipolar coagulation (BIP) in hepatectomy by comparing the efficacy of BIP alone, cavitron ultrasonic surgical aspirator (CUSA) + BIP and conventional clamp crushing (CLAMP).
METHODS: Based on our database of patient records, a total of 380 consecutive patients who underwent hepatectomy at our hospital were retrospectively studied for the efficacy of BIP alone, CUSA + BIP and CLAMP. Of all the patients, 75 received saline-coupled BIP (Group A), 53 received CUSA + BIP (Group B), and 252 received CLAMP (Group C). The pre-, mid-, and postoperative clinical manifestations were compared, and the effects of those maneuvers were evaluated.
RESULTS: There was no obvious difference among the preoperative indexes between the different groups. The operative time was longer in Groups A and B than in Group C (P < 0.001 for both). The amount of bleeding and the rate of transfusion during the operation were significantly higher in Group C than in Groups A and B (P < 0.001 for all). The incidence of postoperative complications in Group C (46.43%) was higher than that in Groups A (30.67%, P = 0.015) and B (28.30%, P = 0.016). The patients’ liver function recovery and postoperative hospital stay were not significantly different. BIP could decrease intraoperative hemorrhage and postoperative complications compared to CLAMP.
CONCLUSION: Simple saline-coupled BIP should be considered a safe and reliable technique for liver resection to decrease intraoperative hemorrhage and postoperative complications.
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Ejaz A, Sachs T, He J, Spolverato G, Hirose K, Ahuja N, Wolfgang CL, Makary MA, Weiss M, Pawlik TM. A comparison of open and minimally invasive surgery for hepatic and pancreatic resections using the Nationwide Inpatient Sample. Surgery 2014; 156:538-47. [PMID: 25017135 DOI: 10.1016/j.surg.2014.03.046] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 03/07/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND The use of minimally invasive surgery (MIS) techniques for pancreatic and liver operations remains ill defined. We sought to compare inpatient outcomes among patients undergoing open versus MIS pancreas and liver operations using a nationally representative cohort. METHODS We queried the Nationwide Inpatient Sample database for all major pancreatic and hepatic resections performed between 2000 and 2011. Appropriate International Classification of Diseases, 9th Revision (ICD-9) coding modifiers for laparoscopy and robotic assist were used to categorize procedures as MIS. Demographics, comorbidities, and inpatient outcomes were compared between the open and MIS groups. RESULTS A total of 65,033 resections were identified (pancreas, n = 36,195 [55.7%]; liver, n = 28,035 [43.1%]; combined pancreas and liver, n = 803 [1.2%]). The overwhelming majority of operations were performed open (n = 62,192, 95.6%), whereas 4.4% (n = 2,841) were MIS. The overall use of MIS increased from 2.3% in 2000 to 7.5% in 2011. Compared with patients undergoing an open operation, MIS patients were older and had a greater incidence of multiple comorbid conditions. After operation, the incidence of complications for MIS (pancreas, 35.4%; liver, 29.5%) was lower than for open (pancreas, 41.6%; liver, 33%) procedures (all P < .05) resulting in a shorter median length of stay (8 vs 7 days; P = .001) as well as a lower in-hospital mortality (5.1% vs 2.8%; P = .001). CONCLUSION During the last decade, the number of MIS pancreatic and hepatic operations has increased, with nearly 1 in 13 HPB cases now being performed via an MIS approach. Despite MIS patients tending to have more preoperative medical comorbidities, postoperative morbidity, mortality, and duration of stay compared favorably with open surgery.
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Affiliation(s)
- Aslam Ejaz
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Teviah Sachs
- 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
| | - Gaya Spolverato
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kenzo Hirose
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nita Ahuja
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Martin A Makary
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew Weiss
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
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The timing of complications impacts risk of readmission after hepatopancreatobiliary surgery. Surgery 2014; 155:945-53. [DOI: 10.1016/j.surg.2013.12.034] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 12/30/2013] [Indexed: 11/24/2022]
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Randomized, controlled comparison of advanced hemostatic pads in hepatic surgical models. ISRN SURGERY 2014; 2014:930803. [PMID: 24729905 PMCID: PMC3960770 DOI: 10.1155/2014/930803] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 01/23/2014] [Indexed: 01/26/2023]
Abstract
Blood loss during hepatic surgery leads to poor patient outcomes. This study investigates the hemostatic efficacy of a novel sealing hemostatic pad (polyethylene glycol-coated collagen, PCC) and a fibrin sealant pad (fibrin-thrombin coated collagen, FTC) in a leporine hepatic segmentectomy and a porcine hepatic abrasion model. A segmentectomy was used to compare hemostatic success and hematoma incidence in 20 rabbits (10/group). Hepatic abrasions were used to compare hemostatic success up to 10 min after application in six pigs (42 lesions/group). In the segmentectomy model, PCC achieved 100% hemostatic success within 2 min (95% CI: 72.3% to 100%) and FTC achieved 80% hemostatic success within 3 min (49.0% to 94.3%). PCC had lower hematoma incidence at 15 min (0.0 versus 11.1%) and 24 h (20.0 versus 66.7%). In the abrasion model, PCC provided superior hemostatic success at 3 (odds ratio: 24.8, 95% CI: 8.86 to 69.2, P < 0.001), 5 (66.3, 28.5 to 153.9, P < 0.001), 7 (177.5, 64.4 to 489.1, P < 0.001), and 10 min (777.6, 148.2 to 4078, P < 0.001) leading to statistically significant less blood loss. The novel sealing hemostat provides faster and more sustained hemostasis than a fibrin sealant pad in a leporine hepatic segmentectomy and a porcine hepatic abrasion model of hepatic surgery.
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49
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Kohlnhofer BM, Tevis SE, Weber SM, Kennedy GD. Multiple complications and short length of stay are associated with postoperative readmissions. Am J Surg 2014; 207:449-56. [PMID: 24524860 DOI: 10.1016/j.amjsurg.2013.10.022] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 09/20/2013] [Accepted: 10/03/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND The aim of this study was to characterize patients readmitted following inpatient general surgery procedures. We hypothesized that a decreased length of stay would increase risk for readmission. METHODS We utilized our institutional National Surgical Quality Improvement Project database from 2006 to 2011. The main outcome of interest was 30-day readmission. Univariate and logistic regression analyses identified risk factors for readmission. RESULTS We identified 3,556 patients, with 322 (9%) readmitted within 30 days after discharge. Multivariable analysis demonstrated age, dyspnea, and American Society of Anesthesiologists class to be independent risk factors for readmission. In addition, patients who suffered multiple complications had a decreased risk for readmission as length of stay increased. Patients with <2 postoperative complications had an increased risk for readmission as length of stay increased. CONCLUSIONS Contributors to postoperative readmissions are multifactorial. Perioperative factors predict risk for readmission and may help determine a target length of stay. Prevention of postoperative complications may reduce readmission rates.
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Affiliation(s)
| | - Sarah E Tevis
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin, Madison, WI, USA
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Risk factors associated with 30-day postoperative readmissions in major gastrointestinal resections. J Gastrointest Surg 2014; 18:35-43; discussion 43-4. [PMID: 24065366 DOI: 10.1007/s11605-013-2354-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 09/04/2013] [Indexed: 01/31/2023]
Abstract
PURPOSE Preventable readmissions represent a major burden on the health care system and risk stratification of patients can help direct costly resources. This study examines patient characteristics, surgical factors, and postoperative complications associated with 30-day postoperative readmissions in gastrointestinal (GI) resections. METHODS Inpatients undergoing major GI surgery were selected from the 2011 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Resections were classified into foregut, small bowel, colorectal, liver, and pancreatic using Current Procedural Terminology (CPT) codes. Postoperative complications were divided into pre- and post-discharge groups using time to complication and discharge. Univariate analysis compared patient and surgical characteristics and pre-discharge complications with 30-day unplanned readmission rates. Factors with a p value <0.1 were included in multivariate logistic regression. A p value <0.05 was considered statistically significant. RESULTS For 42,609 patients undergoing GI resection, the overall 30-day unplanned readmission rate was 12.3 % ranging from 11.8 % for colorectal resections to 16.3 % for pancreatic resections. Major predictors of 30-day readmissions included pre-discharge major complications (odds ratio [OR] = 1.28, 95 % confidence interval [CI] 1.18-1.39, p < 0.0001), chronic steroid use (OR = 1.67, 95 % CI 1.50-1.86, p < 0.0001), operative time ≥4 h (OR = 1.45, 95 % CI 1.35-1.56, p < 0.0001) and discharge to a facility other than home (OR = 1.37, 95 % CI 1.23-1.50, p < 0.0001). CONCLUSIONS Unplanned 30-day readmissions represent a major clinical and financial concern, but some may be foreseeable and potentially modifiable. This model provides insight into factors that could inform resource utilization and postoperative care to help prevent readmissions in select GI surgical patients.
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