Early discharge and readmission after colorectal resection

Early Discharge after Uncomplicated Elective Colectomy and Risk of Postdischarge Complication

BACKGROUND

This was a retrospective cohort study of adult patients undergoing uncomplicated elective colectomy using the NSQIP database from January 2012 to December 2019. A colectomy is deemed uncomplicated if there are no complications reported during the hospitalization. The objective of this study was to examine the association between discharge timing and postdischarge complications in patients who undergo uncomplicated elective colectomy.

STUDY DESIGN

Patients were stratified into an early discharge group if their length of postoperative hospitalization was ≤3 days for laparoscopic or robotic approaches, or ≤5 days for the open approach, and otherwise into delayed discharge groups. The association between early discharge and any postdischarge complication was examined using unadjusted logistic regression after propensity score matching between early and delayed discharge groups.

RESULTS

Of the 113,940 patients included, 77,979, 15,877, and 20,084 patients underwent uncomplicated laparoscopic, robotic, and open colectomy, respectively. After propensity score matching, the odds of a postdischarge complication were lower for the early discharge group in laparoscopic (odds ratio 0.73, 95% CI 0.68 to 0.79) and robotic (odds ratio 0.63, 95% CI 0.52 to 0.76) approaches, and not different in the open approach (odds ratio 1.02, 95% CI 0.91 to 1.15). There were no clinically meaningful differences in the risk of return to the operating room for all surgical approaches.

CONCLUSIONS

Early discharge after uncomplicated colectomy appears to be safe and is associated with lower odds of postdischarge complications in minimally invasive approaches. Our findings suggest that surgical teams practice sound clinical judgments on selecting patients who benefit from early discharge.

Days at home alive after major surgery in patients with and without diabetes: an observational cohort study

OBJECTIVE

We hypothesized that days at home alive up to 30 days after surgery (DAH30), a novel patient-centered outcome metric, as well as long-term mortality, would be impaired in patients with type 1 or 2 diabetes mellitus (DM) undergoing major surgery.

METHODS

This cohort study investigated patients > 18 years with and without DM presenting for major non-cardiovascular, non-ambulatory surgical procedures at 23 hospitals in Sweden between 2007 and 2014. We identified 290,306 patients. Data were matched with various quality registers. The primary outcome was the composite score, DAH30. The secondary outcome was mortality from 31 to 365 days. Using multivariable logistic regression, significant independent risk factors influencing the primary and secondary outcomes were identified, and their adjusted odds ratios were calculated.

RESULTS

Patients with DM type 1 and 2 had significantly lower DAH30 as compared to non-diabetics. Patients with DM were older, had higher co-morbid burden, and needed more emergency surgery. After adjustment for illness severity and age, the odds of having a DAH30 less than 15, indicating death and/or complications, were significantly increased for both type 1 and type 2 diabetes. In the year after surgery, DM patients had a higher mortality as compared to those without diabetes.

CONCLUSIONS

The results of this large cohort study are likely broadly generalizable. To optimize patient and societal outcomes, specific perioperative care pathways for patients with diabetes should be evaluated.

Factors Associated with Early Discharge after Non-Emergent Right Colectomy for Colon Cancer: A NSQIP Analysis

The National Surgical Quality Improvement Project (NSQIP) dataset was used to identify perioperative variables associated with the length of stay (LOS) and early discharge among cancer patients undergoing colectomy. Patients who underwent non-emergent right colectomy for colon cancer from 2012 to 2019 were identified from the NSQIP and colectomy-targeted databases. Postoperative LOS was analyzed based on postoperative day (POD) of discharge, with patients grouped into Early Discharge (POD 0-2), Standard Discharge (POD 3-5), or Late Discharge (POD ≥ 6) cohorts. Multivariable ordinal logistic regression was performed to identify risk factors associated with early discharge. The NSQIP query yielded 26,072 patients: 3684 (14%) in the Early Discharge, 13,414 (52%) in the Standard Discharge, and 8974 (34%) in the Late Discharge cohorts. The median LOS was 4.0 days (IQR: 3.0-7.0). Thirty-day readmission rates were 7% for Early Discharge, 8% for Standard Discharge, and 12% for Late Discharge. On multivariable regression analysis, risk factors significantly associated with a shorter LOS included independent functional status, minimally invasive approach, and absence of ostomy or additional bowel resection (all p < 0.001). Perioperative variables can be used to develop a model to identify patients eligible for early discharge after right colectomy for colon cancer. Efforts to decrease the overall median length of stay should focus on optimization of modifiable risk factors.

Factors associated with prolonged postoperative length of hospital stay after laparoscopic colorectal cancer resection: a secondary analysis of a randomized controlled trial

BACKGROUND

The postoperative length of hospital stay (PLOS) is an important indicator of surgical quality. We identified perioperative factors that affect prolonged PLOS (PPLOS) after laparoscopic colorectal cancer resection, which is the preferred surgical approach for colorectal cancer, the third most common cancer.

METHODS

This study was a secondary analysis of a randomized trial (clinicaltrials.gov ID: NCT03160144) that included 280 patients who underwent laparoscopic colorectal cancer resection. The primary outcome was a PPLOS, defined as a PLOS that was longer than the median PLOS. Baseline, anesthetic, surgical, and postoperative management factors were included in the univariate and multivariate analyses to identify factors influencing PPLOS.

RESULTS

The median PLOS was 10 days, and 117 patients had a PPLOS. We identified six influencing factors for PPLOS: preoperative pulse oxygen saturation < 96% (odds ratio [OR], 3.09 [95% confidence interval (CI) 1.38-6.92]; P = 0.006), distant tumor metastasis (OR, 0.34 [95% CI 0.13-0.91]; P = 0.031), the Miles procedure or left hemicolectomy (OR, 4.51 [95% CI 1.67-12.18]; P = 0.003), perioperative surgical events (OR, 2.44 [95% CI 1.25-4.76]; P = 0.009), postoperative albumin infusion (OR, 2.19 [95% CI 1.14-4.19]; P = 0.018), and postoperative early ambulation (OR, 0.35 [95% CI 0.18-0.68]; P = 0.002). Further stratified analysis showed that postoperative albumin infusion might be a risk factor for PPLOS, even in patients with a preoperative albumin level < 40 g/L (OR, 2.29 [95% CI 0.98-5.34]; P = 0.056) or duration of surgery ≥ 3 h (OR, 2.52 [95% CI 1.08-5.87]; P = 0.032).

CONCLUSIONS

A low preoperative pulse oximetry reading, complex surgical procedures, perioperative surgical events, and postoperative albumin infusion may be risk factors for PPLOS after laparoscopic colorectal cancer resection, whereas distant tumor metastasis and postoperative early ambulation might be protective factors. The association between postoperative albumin infusion, a modifiable factor, and PLOS or clinical outcomes warrants further investigation.

Home to Stay: A randomized controlled trial protocol to assess use of a mobile app to reduce readmissions following colorectal surgery

AIM

Patients undergoing colorectal surgery face high rates of emergency room visits and readmission to hospital. These unplanned hospital visits lead to both increased patient anxiety and health care costs. The aim of this study is to evaluate the use of mobile application to support patients undergoing colorectal surgery following discharge from hospital.

METHOD

This study is a randomized controlled trial in which the control group will receive standard follow-up care following discharge after surgery and the intervention group will receive standard follow-up care in addition to the mobile application. The primary outcome is the proportion of patients with unplanned hospital visits within 30 days of discharge. The secondary outcomes are patient-reported outcomes on validated scales evaluating their quality of recovery following discharge. A sample size of 670 subjects is planned. For the primary outcome, the control and intervention groups will be compared using a generalized linear model to account for clustering of patients within centres. For the secondary outcomes, the overall scores on the Quality of Recovery 15 and Patient Activation Measure will be analysed using a linear regression model.

RESULTS

It is expected that the results of this study will show that the mobile app will lead to significant improvements in unplanned hospital visits as well as improved quality of recovery for patients.

CONCLUSION

If the trial is successful, the mobile app can be easily adopted more widely into clinical practice to support patients at home following surgery.

Early discharge after colorectal cancer resection: trends and impact on patient outcomes

BACKGROUND

Implementation of early discharge in colorectal surgery has been effective in improving patient satisfaction and reducing healthcare costs. Readmission rates following early discharge among colorectal cancer patients are believed to be low, however, remain understudied. The objectives of this study were: (i) to describe trends in early post-operative discharge and the associated hospitalization costs; (ii) to explore patient outcomes and resource utilization following early discharge; and (ii) to identify predictors of readmission following early discharge.

METHODS

This was a retrospective cohort study using the Nationwide Readmissions Database. Adult patients admitted with a primary colorectal neoplasm who underwent colectomy or proctectomy between 2010 and 2017 were identified using ICD-9/10 codes. The exposure of interest was early post-operative discharge defined as ≤ 3 days from surgery. Main outcome measures were 30-day readmissions, post-operative complication rates, LOS and cost.

RESULTS

In total, 342,242 patients were identified, and of those, 51,977 patients (15.2%) had early discharges. During the study period, the proportion of early discharges significantly increased (R2 = 0.94), from 9.9 to 23.4%, while readmission rates in this group remained unchanged (mean 7.3% ± 0.5). Complications that required bounceback readmission (within 7 days) after early discharge, rather than during index admission, were an independent predictor of longer overall LOS (ß = 0.044, p < 0.001) and higher hospitalization costs (ß = 0.031, p < 0.001). On multiple logistic regression, factors independently associated with bounceback readmission following early discharge were: male gender (OR = 1.47, 95%CI 1.33-1.63); open surgery (OR = 1.37, 95%CI 1.23-1.52); presence of stoma (OR = 1.51, 95%CI 1.22-1.87); transfer to facility or discharge with home health service (OR = 1.53, 95%CI 1.34-1.75); and Medicare/Medicaid insurance (OR = 1.34, 95%CI 1.14-1.57), among others.

CONCLUSION

Early post-operative discharge of colorectal cancer patients is increasing despite a lack of improvement in readmission rates and an overall increase in hospitalization costs. Premature discharge of select patients may result in readmissions due to critical complications related to surgery resulting in increased resource utilization.

Discharge timing: Does targeting an ideal length of stay for patients undergoing colectomy impact readmissions and costs of care?

INTRODUCTION

In colorectal surgery, enhanced recovery protocols reduce length-of-stay (LOS). Concerns remain about increased readmission rates. Using a predictive model targeting ideal LOS (iLOS), we evaluate the impact of discharge timing on readmission.

METHODS

The HCUP-SID and AHA databases combined patient and hospital-level data from four states. Colectomy patients were stratified and propensity-matched based. We predicted iLOS using multivariate linear regression, created a discharge timing variable and used multivariate logistic regression to analyze 30-day and 90-day readmissions.

RESULTS

Of 100,701 patients, 6903 (6.85%) were Lap-Left, 16,883 (16.77%) were Open-Left, 32,173 (31.95%) were Lap-Right, and 44,742 (44.43%) were Open-Right. Very early discharge (>4d before iLOS) and very late discharge (>4d after iLOS) were predictors of readmission in Lap- Left (p < 0.05) and Open-Right (p < 0.05). In Lap-Right, early discharge was a significant predictor of readmission (p < 0.01).

CONCLUSION

Targeting using iLOS may optimize discharge timing after colectomy and avoid unplanned readmissions.

Hospital Length of Stay Reduction Over Time and Patient Readmission for Severe Adverse Events Following Surgery

OBJECTIVE

The aim of the study was to investigate whether patients who undergo surgery in hospitals experiencing significant length of stay (LOS) reductions over time are exposed to a higher risk of severe adverse events in the postoperative period.

SUMMARY BACKGROUND DATA

Surgical care innovation has encouraged hospitals to shorten LOS under financial pressures with uncertain impact on patient outcomes.

METHODS

We selected all patients who underwent elective colectomy or urgent hip fracture repair in French hospitals between 2013 and 2016. For each procedure, hospitals were categorized into 3 groups according to variations in their median LOS as follows: major decrease, moderate decrease, and no decrease. These groups were matched using propensity scores based on patients' and hospitals' potential confounders. Potentially avoidable readmission for severe adverse events and death at 6 months were compared between groups using Cox regressions.

RESULTS

We considered 98,713 patients in 540 hospitals for colectomy and 206,812 patients in 414 hospitals for hip fracture repair before matching. After colectomy, patient outcomes were not negatively impacted when hospitals reduced their LOS [hazard ratio (95% confidence interval): 0.93 (0.78-1.10)]. After hip fracture repair, patients in hospitals with major decreases in LOS had a higher risk of severe adverse events [1.22 (1.11-1.34)] and death [1.17 (1.04-1.32)].

CONCLUSIONS

Patients who underwent surgical procedures in hospitals experiencing major decreases in LOS were demonstrated worse postoperative outcomes after urgent hip fracture repair and not after elective colectomy. Development of care bundles to enhance recovery after emergency surgeries may allow better control of LOS reduction and patient outcomes.

Thirty-Day Readmission After Elective Colorectal Surgery for Colon Cancer: A Single-Center Cohort Study

Purpose

There is a concern that enhanced recovery after surgery may affect other proposed quality measures, including the rate of readmission due to early discharge. We examine the 30-day readmission rate, risk factors associated with readmission after elective colorectal surgery for colon cancer, causes of readmission, disease-free survival (DFS), and overall survival (OS) in a single institution.

Methods

We retrospectively investigated 292 patients who underwent elective colorectal surgery for colon cancer between 2010 and 2015. Baseline data including age, sex, body mass index, American Society of Anesthesiologists physical status classification, preoperative comorbidities, previous operation history, TNM stage, surgical approach, operation time, gas passage time, and length of hospital stay were obtained. Univariate and multivariate logistic regression analyses were performed to identify risk factors associated with 30-day readmission.

Results

A total of 229 patients who underwent elective colorectal surgery were enrolled. Twenty-four patients were readmitted 30 days after discharge. The most common readmission diagnoses were wound bleeding or surgical site infection. Multivariate analysis indicated that patients who had preoperative hepatic disease were at the highest risk of readmission (odds ratio [OR], 8.98; 95% confidence interval [CI], 7.35–10.61). Survival outcomes were significantly better in the nonreadmitted group (OS, P=0.00; DFS, P=0.04).

Conclusion

This study identified that preoperative comorbidities including hepatic and pulmonary diseases were associated with higher readmission rates after elective colorectal surgery. Moreover, the most common cause of readmission in patients who underwent elective colorectal surgery was wound bleeding or surgical site infection.

National Study of Immediate and Delayed Readmissions After Colostomy Creation

BACKGROUND

Readmissions after colorectal operations adversely impact patient recovery and are associated with about $300 million in additional health care expenditure in the United States alone. The present study aimed to characterize nonelective, short-term readmissions of colorectal surgery patients who underwent colostomy.

METHODS

The Nationwide Readmissions Database was used to identify patients who received a colostomy from 2010 to 2015. Patients were stratified by discharge-to-readmission interval: immediate (within 7 d) and delayed (7-30 d). Nonparametric trend analysis and multivariable regression were performed to identify predictors of immediate and delayed readmission.

RESULTS

Of an estimated 376,693 operations requiring colostomies during the study, in-hospital survival was 92.3%, with higher rates after elective compared with nonelective operations (96.5 versus 90.8%, P < 0.001). Overall, 15.3% patients undergoing elective and nonelective colostomy creation returned to the hospital within 30 d, with 41.6% of these readmissions occurring by the first week of discharge (immediate). Readmission rates and proportion of immediate and delayed groups did not significantly change over the 6-year study period. Nonhome discharge increased the odds of immediate (AOR 1.25, 95% CI 1.17-1.34) and delayed readmission (AOR 1.44, 95% CI 1.35-1.54). Annually, immediate and delayed rehospitalizations after colostomy creation were responsible for $64 and 82 million in excess costs, respectively.

CONCLUSIONS

Colostomy creation is associated with a steady and high rate of rehospitalization. Nonhome discharge, in addition to several patient comorbidities, is associated with higher odds of readmission. Programs aimed at reduction of immediate readmission are warranted.

Hospital Teaching Status Impacts Surgical Discharge Efficiency

OBJECTIVE

There is a paucity of data regarding the efficiency of care provided by teaching hospitals. Yet, instruction on transitions in care and an understanding of systems-based practice are key components of modern graduate medical education. We aimed to determine the relationship between hospital teaching status and the discharge efficiency from a surgical service.

SETTING

Patients who were cared for at teaching and nonteaching hospitals captured in the Healthcare Cost and Utilization Project National Inpatient Sample from 2012.

PARTICIPANTS

A total of 272,090 patients who underwent one of 44 predefined general surgery procedure types.

DESIGN

Patients were stratified based on treating hospital teaching status (TH vs. NTH). Procedure-specific early discharge (PSED) was defined for each operation type as a discharge that occurred within the lowest 25th percentile for overall length of stay. PSED was used as the discharge efficiency metric. To adjust for cofounders and hospital level clustering, multivariable mixed-effects logistic regression was used to examine the association between teaching status and PSED. Subgroup analysis was performed by operation type. Models were constructed with and without adjustment for inpatient complications.

RESULTS

There were 140,878 (51.8%) patients who received care at a TH. TH status was significantly associated with lower PSED (TH: 10.7% vs. NTH: 11.4%; p < 0.001) and longer length of stay (TH: 5.5 days vs. NTH: 4.5 days; p < 0.001). In the adjusted model of the overall cohort, patients treated at a TH were 8% less likely to receive a PSED compared to those treated at NTH (odds ratio 0.92, 95% confidence interval (0.88, 0.97); p < 0.002). Differences in the rates and odds of PSED were noted across the subgroups.

CONCLUSIONS

Teaching hospital status is associated with a reduced likelihood of PSED. The effect of TH on PSED varied by procedure subgroup. Examining the recovery pathways and discharge practices at NTH may allow for the identification of more efficient methods of care that can be applied to the broader healthcare system.

Early Discharge After Radical Nephrectomy: An Analysis of Complications and Readmissions

INTRODUCTION

Length of stay (LOS) is increasingly being viewed as a quality metric, and efforts to reduce LOS are present across most surgical subspecialties. However, data on whether reducing LOS is safe in patients who undergo radical nephrectomy (RN) are lacking. The purpose of this study was to assess whether early discharge after RN affects readmission rates and postdischarge complications using a national cohort of patients.

PATIENTS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent RN from 2012 to 2015. Procedures were stratified as minimally invasive or open. Early discharge was defined as less than or equal to the procedure-specific 25th percentile for LOS. Multivariable analysis was used to identify factors associated with readmission and postdischarge complications. A sensitivity analysis excluded patients with a LOS >75th percentile.

RESULTS

A total of 11,429 patients were included. The 25th percentile for LOS was 2 days in the minimally invasive group and 3 days in the open group. In multivariable analysis, early discharge did not increase the risk of postdischarge complications (odds ratio, 0.88; 95% confidence interval, 0.71-1.08; P = .214) and decreased the risk of readmission (odds ratio, 0.72; 95% confidence interval, 0.59-0.87; P = .001).

CONCLUSION

Early discharge after RN does not increase the risk of postdischarge complications or readmission. With the appropriate patient selection, decreasing LOS might lead to decreased surgical costs and improved patient flow. This work provides a foundation for future research that might optimize perioperative care pathways to decrease LOS.

Readmissions after colorectal surgery: not all are equal

PURPOSE

This study aims to assess factors associated with preventable readmissions after colorectal resection.

METHODS

All readmissions following colorectal resection from May 2013 to May 2016 at an academic medical center were reviewed. Readmissions that could be prevented were identified. Factors associated with preventable readmission were assessed using logistic regression.

RESULTS

Of 686 patients discharged during the study period, there were 75 patients (11%) with unplanned readmission. Twenty-nine readmissions (39%) were preventable-these readmissions were due to dehydration or acute kidney injury, pain, ostomy complications, and gastrointestinal bleeding. On regression analysis, the strongest preoperative risk factors associated with preventable readmission were urgent or emergent operation (OR 4.0, 95% CI 1.6-9.9), recent myocardial infarction (OR 2.9, 95% CI 1.0-9.0), total or subtotal colectomy (OR 2.8, 95% CI 1.1-7.3), and American Society of Anesthesiologist score ≥ 3 (OR 2.2, 95% CI 1.0-4.7). Intraoperative risk factors associated with preventable readmission included intraoperative stapler complication (OR 24.2, 95% CI 1.5-397). Postoperative risk factors associated with preventable readmission included postoperative arrhythmia (OR 5.6, 95% CI 2.0-16.1), and postoperative anemia (OR 2.6, 95% CI 1.2-5.7). On multivariable analysis while controlling for procedure type, urgent or emergent operation (OR 2.9, 95% CI 1.1-8.2), intraoperative stapler complication (OR 37.5, 95% CI 2.3-627.8), and postoperative arrhythmia (OR 4, 95% CI 1.3-12.8) remained statistically significant.

CONCLUSION

Approximately 40% of readmissions following colorectal surgery are potentially preventable. Since specific patients and factors that are associated with preventable readmission can be identified, resources should be targeted to factors associated with preventable readmissions.

The Impact of Discharge Timing on Readmission Following Hepatopancreatobiliary Surgery: a Nationwide Readmission Database Analysis

OBJECTIVE

Decreasing hospital length-of-stay (LOS) may be an effective strategy to reduce costs while also improving outcomes through earlier discharge to the non-hospital setting. The objective of the current study was to define the impact of discharge timing on readmission, mortality, and charges following hepatopancreatobiliary (HPB) surgery.

METHODS

The Nationwide Readmissions Database (NRD) was used to identify patients undergoing HPB procedures between 2010 and 2014. Length of stay (LOS) was categorized as early discharge (4-5 days), routine discharge (6-9 days), and late discharge (10-14 days). Univariable and multivariable analyses were utilized to identify factors associated with 90-day readmission.

RESULTS

A total of 28,114 patients underwent HPB procedures. Overall median LOS was 7 days (IQR 5-11); 10,438 (37.1%) patients had an early discharge, while 13,665 (48.6%) and 4011 (14.3%) patients had a routine or late discharge. The probability of early discharge increased over time (referent 2010: 2011-4% (OR 1.04, 95% CI 0.96-1.15) vs. 2012-10% (OR 1.10, 95% CI 1.01-1.20) vs. 2013-21% (OR 1.21, 95% CI 1.11-1.32) vs. 2014-32% (OR 1.32, 95% CI 1.21-1.44)) (p < 0.001). Early discharge was associated with insurance status, diagnosis (benign vs. malignant disease), general health, and overall hospital volume (all p < 0.05). Among patients who had an early discharge, 30- and 90-day readmission was 11.5 and 17.4%, respectively. In contrast, 30- and 90-day readmission was 16.9 and 24.7%, respectively, among patients who had a routine discharge group (p < 0.001). Among patients readmitted within 90 days, in-hospital mortality was similar among patients who had early (n = 43, 2.4%) versus routine discharge (n = 65, 1.9%). Median charges were lower among patients who had an early versus routine versus late discharge ($54,476 [IQR 40,053-79,100] vs. $75,192 [IQR 53,296-113,123] vs. $115,061 [IQR 79,162-171,077], respectively) (p < 0.001).

CONCLUSIONS

Early discharge after HPB surgery was not associated with increased 30- or 90-day readmission. Overall 90-day in-hospital mortality following a readmission was comparable among patients with an early, routine, and late discharge, while median charges were lower in the early discharge group.

One-year Unplanned Readmission After Colorectal Cancer Surgery in Western China

Purpose: Readmissions are common after colorectal cancer surgery. There are limited data related one-year unplanned readmission after colorectal cancer surgery. The aim of this study was to ascertain the incidence rate of unplanned readmission in Western China, identify causes and risk factors of one-year unplanned readmission (UR) in patients who underwent enhanced recovery pathways for colorectal cancer (CRC) surgery. Materials and Methods: A retrospective study using a CRC surgery database of patients treated in West China Hospital was performed. Patients who underwent enhanced recovery pathways for colorectal cancer surgery between January 2013 and May 2016 were investigated. The postoperative follow-up data were all routinely recorded for up to one year or more, the one-year unplanned readmission rate after initial discharge and major reasons for UR were recorded. Multivariate logistic regression analyses was used to identify risk factors of UR. Results: A total of 446 patients were included, with 18.6% of patients readmitted. In a multivariable analysis, preoperative comorbidity was associated with the largest risk of readmission (odds ratio, 2.91[95% CI, 1.32- 6.99]). The main reason of readmission within 30 days after discharge was wound bleeding or infection. While intestinal obstruction was the major cause for readmission after 3 months of discharge. Conclusions: One-year unplanned readmission occurs frequently after CRC in Western China and is strongly associated with preoperative comorbidity. Attention should be paid to wound healing at the early stage of discharge, and bowel obstruction 3 months after discharge.

Enhanced Recovery After Surgery (ERAS®) in Individuals with Diabetes: A Systematic Review

BACKGROUND

Prevalence of diabetes in surgical patients is 10-40%. It is well recognized that they have higher rates of complications, and longer stays in hospital compared to patients without diabetes. Enhanced recovery after surgery (ERAS) is an evidence-based multimodal surgical care pathway that improves postoperative complications and length of stay in patients without diabetes. This review evaluates the evidence on whether individuals with diabetes would benefit from ERAS implementation.

METHODS

MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE searched with no language restrictions applied. Conference proceedings and bibliographies were reviewed. Experts in the field were contacted, and www.clinicaltrials.gov searched for ongoing trials.

SELECTION CRITERIA

Randomized controlled trials (RCT) looking at individuals with diabetes undergoing surgery randomized to ERAS^® or conventional care. Non-randomized controlled trials, controlled before-after studies, interrupted time series, and cohort studies with concurrent controls were also considered. Two authors independently screened studies.

RESULTS

The electronic search yielded 437 references. After removing duplicates, 376 were screened for eligibility. Conference proceedings and bibliographies identified additional references. Searching www.clinicaltrials.gov yielded 59 references. Contacting experts in the field identified no further studies. Fourteen full articles were assessed and subsequently excluded for the following reasons: used an intervention other than ERAS^®, did not include patients with diabetes, or used an uncontrolled observational design.

CONCLUSIONS

To date, the effects of ERAS^® on patients with diabetes have not been rigorously evaluated. This review highlights the lack of evidence in this area and provides guidance on design for future studies.

Emergency Room Visits and Readmissions Following Implementation of an Enhanced Recovery After Surgery (iERAS) Program

BACKGROUND

Enhanced Recovery After Surgery (ERAS) guidelines have been widely promoted and supported largely due to several studies showing decreased post-operative complications and length of stay. The objective of this study was to review the emergency room (ER) visits and readmission rates and reasons for both in patients who were part of the Implementation of an Enhanced Recovery After Surgery (iERAS) program for colorectal surgery.

METHODS

All patients having elective colorectal surgery at 15 academic hospitals were enrolled in the iERAS program. All patients were prospectively followed until 30 days post-discharge. Data were analyzed using descriptive statistics and multivariable analysis.

RESULTS

A total of 2876 patients (48% female; mean 60 years old) were enrolled. Cancer was the most frequent indication (68.2%) for surgery. Overall, the median length of stay (LOS) was 5 days. Post-discharge, 359 (11.6%) of patients had a visit to the ER not requiring admission. The most common reasons for visiting the ER were surgical site infections (SSI) (34.5%), other wound complications (10.0%), and urinary tract infections (UTI) (8.6%). In addition, a smaller proportion of patients, 260 (8.2%) required readmission. The most common reasons for readmission were ileus and nausea/vomiting (26.1%), intra-abdominal abscess (23.9%), and SSI (11.5%). Patient and disease factors associated with ER visits, on multivariable analysis, included extremes of BMI (RR 1.02, 95%CI 1.01-1.04, p = 0.002), rectal surgery versus colon surgery (RR 1.34, 95%CI 1.14-1.58, p < 0.001), and open operative approach (RR 1.63, 95%CI 1.28-2.09, p < 0.001). Independent factors associated with hospital readmissions included rectal surgery (RR 1.89, 95%CI 1.34-2.77, p < 0.001), formation of a stoma (RR 1.34, 95%CI 1.04-1.74, p = 0.026), and reoperation during first admission (RR 4.60, 95%CI 3.50-6.05, p < 0.001). Length of stay of 5 days or less was not associated with ER visits or readmission (RR 0.99, 95%CI 0.72-1.35 and RR 0.91, 95%CI 0.71-1.18, respectively).

CONCLUSION

Following colorectal surgery using an ERAS pathway, shortened length of stay is not associated with an increased return to the ER or hospital readmission. The majority of return visits to the hospital are ER visits not requiring readmission and the predominant reason for return are surgical site infections and wound complications.

Early discharge in Mild Acute Pancreatitis. Is it possible? Observational prospective study in a tertiary-level hospital

BACKGROUND AND AIMS

In acute pancreatitis (AP), first 24 h are crucial as this is the period in which the greatest amount of patients presents an organ failure. This suggests patients with Mild AP (MAP) could be early identified and discharged. This is an observational prospective trial with the aim to demonstrate the safety of early discharge in Mild Acute Pancreatitis (MAP).

METHODS

Observational prospective study in a third level single centre. Consecutive patients with AP from March 2012 to March 2014 were collected.

INCLUSION CRITERIA

MAP, tolerance to oral intake, control of pain, C Reactive Protein <150 mg/dL and blood ureic nitrogen < 5 mg/dL in two samples.

EXCLUSION CRITERIA

pregnant, lack of family support, active comorbidities, temperature and serum bilirubin elevation. Patients with MAP, who met the inclusion criteria, were discharged within the first 48 h. Readmissions within first week and first 30 days were recorded. Adverse effects related to readmissions were also collected.

RESULTS

Three hundred and seventeen episodes were collected of whom 250 patients were diagnosed with MAP. From these, 105 were early discharged. Early discharged patients presented a 30-day readmission rate of 15.2% (16 patients out of 105) corresponding to the readmission rates in Acute Pancreatitis published to date. Any patient presented adverse effects related to readmissions.

CONCLUSION

Early discharge in accurately selected patients with MAP is feasible, safe and efficient and leads to a decrease in median stay with the ensuing savings per process and with no increase in readmissions or inmorbi-mortality.

Reducing Length of Hospital Stay Does Not Increase Readmission Rates in Early-Stage Gastric, Colon, and Lung Cancer Surgical Cases in Japanese Acute Care Hospitals

Background

The Japanese government has worked to reduce the length of hospital stay by introducing a per-diem hospital payment system that financially incentivizes the timely discharge of patients. However, there are concerns that excessively reducing length of stay may reduce healthcare quality, such as increasing readmission rates. The objective of this study was to investigate the temporal changes in length of stay and readmission rates as quality indicators in Japanese acute care hospitals.

Methods

We used an administrative claims database under the Diagnosis Procedure Combination Per-Diem Payment System for Japanese hospitals. Using this database, we selected hospitals that provided data continuously from July 2010 to March 2014 to enable analyses of temporal changes in length of stay and readmission rates. We selected stage I (T1N0M0) gastric, colon, and lung cancer surgical patients who had been discharged alive from the index hospitalization. The outcome measures were length of stay during the index hospitalization and unplanned emergency readmissions within 30 days after discharge.

Results

From among 804 hospitals, we analyzed 42,585, 15,467, and 40,156 surgical patients for gastric, colon, and lung cancer, respectively. Length of stay was reduced by approximately 0.5 days per year. In contrast, readmission rates were generally stable at approximately 2% or had decreased slightly over the 4-year period.

Conclusions

In early-stage gastric, colon, and lung cancer surgical patients in Japan, reductions in length of stay did not result in increased readmission rates.

Length of hospital stay after craniotomy for tumor: a National Surgical Quality Improvement Program analysis

OBJECT

Although the length of hospital stay is often used as a measure of quality of care, data evaluating the predictors of extended hospital stay after craniotomy for tumor are limited. The goals of this study were to use multivariate regression to examine which preoperative characteristics and postoperative complications predict a prolonged hospital stay and to assess the impact of length of stay on unplanned hospital readmission.

METHODS

Data were extracted from the National Surgical Quality Improvement Program (NSQIP) database from 2007 to 2013. Patients who underwent craniotomy for resection of a brain tumor were included. Stratification was based on length of hospital stay, which was dichotomized by the upper quartile of the interquartile range (IQR) for the entire population. Covariates included patient age, sex, race, tumor histology, comorbidities, American Society of Anesthesiologists (ASA) class, functional status, preoperative laboratory values, preoperative neurological deficits, operative time, and postoperative complications. Multivariate logistic regression with forward prediction was used to evaluate independent predictors of extended hospitalization. Thereafter, hierarchical multivariate logistic regression assessed the impact of length of stay on unplanned readmission.

RESULTS

The study included 11,510 patients. The median hospital stay was 4 days (IQR 3-8 days), and 27.7% (n = 3185) had a hospital stay of at least 8 days. Independent predictors of extended hospital stay included age greater than 70 years (OR 1.53, 95% CI 1.28%-1.83%, p < 0.001); African American (OR 1.75, 95% CI 1.44%-2.14%, p < 0.001) and Hispanic (OR 1.68, 95% CI 1.36%-2.08%) race or ethnicity; ASA class 3 (OR 1.52, 95% CI 1.34%-1.73%) or 4-5 (OR 2.18, 95% CI 1.82%-2.62%) designation; partially (OR 1.94, 95% CI 1.61%-2.35%) or totally dependent (OR 3.30, 95% CI 1.95%-5.55%) functional status; insulin-dependent diabetes mellitus (OR 1.46, 95% CI 1.16%-1.84%); hematological comorbidities (OR 1.68, 95% CI 1.25%-2.24%); and preoperative hypoalbuminemia (OR 1.78, 95% CI 1.51%-2.09%, all p ≤ 0.009). Several postoperative complications were additional independent predictors of prolonged hospitalization including pulmonary emboli (OR 13.75, 95% CI 4.73%-39.99%), pneumonia (OR 5.40, 95% CI 2.89%-10.07%), and urinary tract infections (OR 11.87, 95% CI 7.09%-19.87%, all p < 0.001). The C-statistic of the model based on preoperative characteristics was 0.79, which increased to 0.83 after the addition of postoperative complications. A length of stay after craniotomy for tumor score was created based on preoperative factors significant in regression models, with a moderate correlation with length of stay (p = 0.43, p < 0.001). Extended hospital stay was not associated with differential odds of an unplanned hospital readmission (OR 0.97, 95% CI 0.89%-1.06%, p = 0.55).

CONCLUSIONS

In this NSQIP analysis that evaluated patients who underwent craniotomy for tumor, much of the variance in hospital stay was attributable to baseline patient characteristics, suggesting length of stay may be an imperfect proxy for quality. Additionally, longer hospitalizations were not found to be associated with differential rates of unplanned readmission.

Readmission After Resections of the Colon and Rectum: Predictors of a Costly and Common Outcome

BACKGROUND

Readmission rates are a measure of surgical quality and an object of clinical and regulatory scrutiny. Despite increasing efforts to improve quality and contain cost, 6% to 25% of patients are readmitted after colorectal surgery.

OBJECTIVE

The aim of this study is to define the predictors and costs of readmission following colorectal surgery.

DESIGN

This is a retrospective cohort study of patients undergoing elective and nonelective colectomy and/or proctectomy in the Healthcare Cost and Utilization Project Florida State Inpatient Database 2007 to 2011. Readmission is defined as inpatient admission within 30 days of discharge. Univariate analyses were performed of sex, age, Elixhauser score, race, insurance type, procedure, indication, readmission diagnosis, cost, and length of stay. Multivariate analysis was performed by logistic regression. Sensitivity analysis of nonemergent admissions was conducted.

SETTINGS

This study was conducted in Florida acute-care hospitals.

PATIENTS

Patients undergoing colectomy and proctectomy from 2007 to 2011 were included.

INTERVENTION(S)

There were no interventions.

MAIN OUTCOME MEASURE(S)

The primary outcomes measured were readmission and the cost of readmission.

RESULTS

A total of 93,913 patients underwent colectomy; 14.7% were readmitted within 30 days. From 2007 to 2011, readmission rates remained stable (14.6%-14.2%, trend p = 0.1585). After multivariate adjustment, patient factors associated with readmission included nonwhite race, age <65, and a diagnosis code other than neoplasm or diverticular disease (p < 0.0001). Patients with Medicare or Medicaid were more likely to be readmitted than those with private insurance (p < 0.0001). Patients with longer index admissions, those with stomas, and those undergoing all procedures other than sigmoid or transverse colectomy were more likely to be readmitted (p < 0.0001). High-volume hospitals had higher rates of readmission (p < 0.0001). The most common reason for readmission was infection (32.9%). Median cost of readmission care was $7030 (intraquartile range, $4220-$13,247). Fistulas caused the most costly readmissions ($15,174; intraquartile range, $6725-$26,660).

LIMITATIONS

Administrative data and retrospective design were limitations of this study.

CONCLUSIONS

Readmissions rates after colorectal surgery remain common and costly. Nonprivate insurance, IBD, and high hospital volume are significantly associated with readmission.

Factors predicting 30-day readmission after laparoscopic colorectal cancer surgery within an enhanced recovery programme

AIM

Hospital readmission within 30 days of surgery has become a marker of poor quality patient care. This study aimed to investigate factors predictive of 30-day readmission after laparoscopic colorectal cancer surgery within an enhanced recovery after surgery (ERAS) programme.

METHOD

Consecutive patients undergoing laparoscopic surgery for colorectal cancer within an ERAS programme between 2002 and 2009 were included. Data were collected relating to patient demographics, neoadjuvant chemoradiotherapy, ERAS compliance, and operative and postoperative outcomes. A logistic regression model was used to identify factors associated with readmissions after adjusting for the potential effect of covariables simultaneously.

RESULTS

In all, 268 cancer patients underwent laparoscopic colorectal surgery (108 rectal resections), of whom 34 (12.7%) were readmitted due most commonly to bowel obstruction (29%) and surgical site infection (18%). The use of neoadjuvant therapy (odds ratio 4.49, 95% CI 1.41-14.35; P = 0.011) and ERAS compliance above 93% (odds ratio 0.38, 95% CI 0.18-0.84; P = 0.016) were independent predictors of readmission.

CONCLUSION

Poor ERAS compliance and preoperative chemoradiotherapy were significant predictors of readmission following laparoscopic colorectal cancer surgery. Further research is required to expand the scope of ERAS beyond hospital discharge.