Risk Factors Associated With Readmission After Pancreatectomy: A Single-Institution Retrospective Cohort Study

Discharge C-reactive protein predicts 90-day readmission after pancreatoduodenectomy: a conditional inference tree analysis

BACKGROUND

The aim of this study was to assess the predictive value of discharge C-reactive protein (CRP) and white blood cell (WBC) levels for 90-day readmission after pancreatoduodenectomy (PD).

METHODS

A two-centre, retrospective study was performed between 2008 and 2022. Receiver operating characteristic (ROC) curve analysis was used to determine the predictive value of CRP level and WBC count at discharge. A conditional inference tree (CTREE) was constructed to identify combined risks within subgroups using variables associated with readmission.

RESULTS

Of 438 patients, 54 (12%) were readmitted. The median WBC count at discharge was comparable between the readmitted and not readmitted groups (9.1 vs. 8.5 G/l). The CRP levels at discharge were predictive of 90-day readmission, with an area under the ROC curve (AUC) of 0.63 (95% CI: 0.55-0.63). A CRP concentration below 105 mg/l ruled out 90-day readmission, with a negative predictive value (NPV) of 90% (95% CI: 81%-95%). CTREE confirmed the diagnostic value of CRP at discharge (AUC = 0.68, 95% CI 0.60-0.68). CTREE additionally identified previous wound infection as a second risk factor for readmission in patients with CRP levels less than 101 mg/l (P = 0.003).

CONCLUSION

CRP levels below 105 mg/l at discharge allow for a safe discharge with a low 90-day readmission rate. Wound infection, but not WBC count, was a positive predictor of 90-day readmission with moderate accuracy, suggesting the need for predischarge imaging for undetected complications in this patient cohort.

TRIAL REGISTRATION

Our retrospective analysis did not require registration with a publicly accessible registry.

Classification of Post-pancreatectomy Readmissions and Opportunities for Targeted Mitigation Strategies

OBJECTIVE

Within a learning health system paradigm, this study sought to evaluate reasons for readmission to identify opportunities for improvement.

BACKGROUND

Post-pancreatectomy readmission rates have remained constant despite improved index hospitalization metrics.

METHODS

We performed a single-institution case-control study of consecutive patients with pancreatectomy (October 2016 to April 2022). Complications were prospectively graded in biweekly faculty and advanced practice provider meetings. We analyzed risk factors during index hospitalization and categorized indications for 90-day readmissions.

RESULTS

A total of 835 patients, median age 65 years and 51% (427/835) males, underwent 64% (534/835) pancreatoduodenectomies, 34% (280/835) distal pancreatectomies, and 3% (21/835) other resections. Twenty-four percent (204/835) of patients were readmitted. The primary indication for readmission was technical in 51% (105/204), infectious in 17% (35/204), and medical/metabolic in 31% (64/204) of patients. Procedures were required in 77% (81/105) and 60% (21/35) of technical and infectious readmissions, respectively, while 66% (42/64) of medical/metabolic readmissions were managed noninvasively. During the index hospitalization, benign pathology [odds ratio (OR): 1.8, P =0.049], biochemical pancreatic leak (OR: 2.3, P =0.001), bile/gastric/chyle leak (OR: 6.4, P =0.001), organ-space infection (OR: 3.4, P =0.007), undrained fluid on imaging (OR: 2.4, P =0.045), and increasing white blood cell count (OR: 1.7, P =0.045) were independently associated with odds of readmission.

CONCLUSIONS

Most readmissions following pancreatectomy were technical in origin. Patients with complications during the index hospitalization, increasing white blood cell count, or undrained fluid before discharge were at the highest risk for readmission. Predischarge risk stratification of readmission risk factors and augmentation of in-clinic resources may be strategies to reduce readmission rates.