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Berry SK, Takakura W, Patel D, Govalan R, Ghafari A, Kiefer E, Huang SC, Bresee C, Nuckols TK, Melmed GY. A randomized controlled trial of a proactive analgesic protocol demonstrates reduced opioid use among hospitalized adults with inflammatory bowel disease. Sci Rep 2023; 13:22396. [PMID: 38104145 PMCID: PMC10725490 DOI: 10.1038/s41598-023-48126-0] [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: 12/17/2022] [Accepted: 11/22/2023] [Indexed: 12/19/2023] Open
Abstract
Most hospitalized patients with inflammatory bowel disease (IBD) experience pain. Despite the known risks associated with opioids in IBD including risk for misuse, overdose, infection, readmission, and even death, opioid use is more prevalent in IBD than any other chronic gastrointestinal condition. Most hospitalized IBD patients receive opioids; however, opioids have not been shown to improve pain during hospitalization. We conducted a randomized controlled trial in hospitalized patients with IBD to evaluate the impact of a proactive opioid-sparing analgesic protocol. Wearable devices measured activity and sleep throughout their hospitalization. Chronic opioid users, post-operative, and pregnant patients were excluded. The primary endpoint was a change in pain scores from admission to discharge. Secondary endpoints included opioid use, functional activity, sleep duration and quality, and length of stay. Of 329 adults with IBD evaluated for eligibility, 33 were enrolled and randomized to the intervention or usual care. Both the intervention and control group demonstrated significant decreases in pain scores from admission to discharge (- 2.6 ± 2.6 vs. - 3.0 ± 3.2). Those randomized to the intervention tended to have lower pain scores than the control group regardless of hospital day (3.02 ± 0.90 vs. 4.29 ± 0.81, p = 0.059), used significantly fewer opioids (daily MME 11.8 ± 15.3 vs. 30.9 ± 42.2, p = 0.027), and had a significantly higher step count by Day 4 (2330 ± 1709 vs. 1050 ± 1214; p = 0.014). There were no differences in sleep duration, sleep quality, readmission, or length-of-stay between the two groups. A proactive analgesic protocol does not result in worsening pain but does significantly reduce opioid-use in hospitalized IBD patients.Clinical trial registration number: NCT03798405 (Registered 10/01/2019).
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Affiliation(s)
- Sameer K Berry
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, USA
| | - Will Takakura
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, USA
| | - Devin Patel
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, USA
| | | | - Afsoon Ghafari
- F. Widjaja Inflammatory Bowel Disease Institute, Karsh Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Elizabeth Kiefer
- Research Informatics and Scientific Computing Core, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Shao-Chi Huang
- Research Informatics and Scientific Computing Core, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Catherine Bresee
- Biostatistics and Bioinformatics Core, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Teryl K Nuckols
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, USA
| | - Gil Y Melmed
- F. Widjaja Inflammatory Bowel Disease Institute, Karsh Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
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A Mobile Phone App Improves Patient-Physician Communication and Reduces Emergency Department Visits After Colorectal Surgery. Dis Colon Rectum 2023; 66:130-137. [PMID: 34933314 DOI: 10.1097/dcr.0000000000002187] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Emergency visits after colorectal surgery are common and require significant health care resources. However, many visits may be avoidable with alternative access to care. Mobile health technologies can facilitate patient access to health care providers. OBJECTIVE We hypothesized that a mobile app for postdischarge monitoring with patient-provider communication ability would reduce emergency visits after elective abdominopelvic colorectal surgery. DESIGN This is a prospective cohort study with a regression analysis after coarsened exact matching. SETTING The study was conducted at a single colorectal referral center from May 2019 to September 2020. PATIENTS A total of 114 patients were recruited to the intervention and were matched to a retrospective cohort of 608 patients from the 24 months before the study. All patients were managed according to an enhanced recovery pathway. INTERVENTIONS A mobile phone app comprised of patient education material, daily questionnaires assessing postdischarge recovery, and patient-provider chat function was used. MAIN OUTCOME MEASURES The primary outcomes included potentially preventable 30-day emergency visits defined according to a validated algorithm. Secondary outcomes included length of stay, complications, total emergency department visits, readmissions, and app usability. RESULTS Coarsened-exact matching resulted in a matched sample of 94 prospective intervention patients and 256 retrospective control patients. The prospective group was associated with fewer preventable emergency department visits (incidence rate ratio 0.34; p = 0.043) and shorter length of stay (-1.62 days; p = 0.011). There were no differences in 30-day complications, total number of emergency visits, or readmissions. Patient-reported usability of the mobile app was high, with 88% of patients reporting that the app improved their ability to communicate with their surgeon. LIMITATIONS We did not account for patient activation or perform a cost-analysis. CONCLUSION Use of a mobile app was associated with fewer potentially preventable emergency visits and shorter length of stay after major elective colorectal surgery, which may be due to enhanced postdischarge monitoring and patient-provider communication. See Video Abstract at http://links.lww.com/DCR/B878 . APLICACIN DE TELFONO MVIL MEJORA LA COMUNICACIN ENTRE MDICO Y PACIENTE Y REDUCE LAS VISITAS AL DEPARTAMENTO DE EMERGENCIAS DESPUS DE CIRUGA COLORECTAL ANTECEDENTES:Las visitas de emergencia después de la cirugía colorrectal son frecuentes y requieren importantes recursos sanitarios. Sin embargo, muchas visitas pueden evitarse con un acceso alternativo a la atención. Las tecnologías de salud móviles pueden facilitar el acceso de los pacientes a los proveedores de atención médica.OBJETIVO:Se planteó la hipótesis de que una aplicación móvil para el seguimiento posterior al alta con capacidad de comunicación entre el paciente y el médico reduciría las visitas de emergencia después de cirugía colorrectal abdominopélvica electiva.DISEÑO:Este es un estudio de cohorte prospectivo con un análisis de regresión después de un emparejamiento exacto aproximado.ENTORNO CLINICO:El estudio se llevó a cabo en un solo centro de referencia colorrectal entre 05/2019 y 09/2020.PACIENTES:Se reclutó un total de 114 pacientes para la intervención y se emparejaron con una cohorte retrospectiva de 608 pacientes de los 24 meses anteriores al estudio. Todos los pacientes fueron tratados con protocolo de enhanced recovery .INTERVENCIONES:Se utilizó una aplicación para teléfono móvil compuesta de material educativo para el paciente, cuestionarios diarios que evalúan la recuperación posterior al alta y una función de chat entre el paciente y el médico.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios incluyeron visitas a la emergencia en 30 días potencialmente prevenibles, definidas según un algoritmo validado. Los resultados secundarios incluyeron la duración de la estancia, complicaciones, total de visitas al departamento de emergencias, reingresos y la usabilidad de la aplicación.RESULTADOS:El emparejamiento aproximado-exacto resultó en una muestra emparejada de 94 APP + y 256 APP-. APP + se asoció con menos visitas evitables al servicio de urgencias (IRR 0,34, p = 0,043) y una estancia más corta (-1,62 días, p = 0,011). No hubo diferencias en las complicaciones a los 30 días, número total de visitas de emergencia y reingresos. La usabilidad de la aplicación móvil informada por los pacientes fue alta, y el 88% de los pacientes informaron que la aplicación mejoró su capacidad para comunicarse con su cirujano.LIMITACIONES:No contabilizamos la activación del paciente ni realizamos un análisis de costos.CONCLUSIÓNES:El uso de una aplicación móvil se asoció con menos visitas a la emergencia potencialmente prevenibles y una estadía más corta después de una gran cirugía colorrectal electiva, lo que puede deberse a una mejor monitorización posterior al alta y a la comunicación entre el paciente y el médico. Consulte Video Resumen en http://links.lww.com/DCR/B878 . (Traducción-Dr. Francisco M. Abarca-Rendon ).
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Cheung DC, Muaddi H, de Almeida JR, Finelli A, Karanicolas P. Cost-Effectiveness Analysis of Negative Pressure Wound Therapy to Prevent Surgical Site Infection After Elective Colorectal Surgery. Dis Colon Rectum 2022; 65:767-776. [PMID: 34840300 DOI: 10.1097/dcr.0000000000002154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgical site infection is common after colorectal surgery and is associated with increased costs. Prophylactic negative pressure wound therapy has previously been shown to reduce surgical site infection compared with conventional dressings. However, negative pressure wound therapy application is met with hesitancy because of its additional cost. OBJECTIVE This study aims to determine whether the application of prophylactic negative pressure wound therapy after elective colorectal surgery is cost-effective. DESIGN A cost-effectiveness analysis comparing prophylactic negative pressure wound therapy versus conventional dressing was completed using a Markov microsimulation model. A publicly funded single health care payer perspective was adopted across a lifetime horizon. SETTING This study was conducted using in-hospital elective colorectal surgery. PATIENTS The base case was an age-, sex-, and comorbidity-standardized patient undergoing open elective colorectal surgery. INTERVENTION Negative pressure wound therapy was applied postoperatively over closed incisions. MAIN OUTCOMES The primary outcomes of interest were the number of surgical site infections, total costs, and quality-adjusted life-years gained. Secondary outcomes included emergency department presentation, hospital readmission, nursing wound care utilization, fascial dehiscence, incisional hernia, and non-surgical site infection-related complications. RESULTS We found that prophylactic negative pressure wound therapy, standardized to 1000 patients, prevented 51 surgical site infections, 3 fascial dehiscences, 10 incisional hernias, 22 emergency department presentations, and 6 hospital readmissions. This resulted in a total cost saving of $17,066 and 92.2 quality-adjusted life-years gained ($17.07 and 0.09 quality-adjusted life-years gained on average per patient). When the patients' risk of surgical site infections was greater than 3.2%, negative pressure wound therapy was a cost-effective strategy at a willingness to pay of $50,000/quality-adjusted life-years. LIMITATIONS We did not model for societal perspective, emergent presentations of incarcerated hernias, or complications with hernia repair. The results of this model are reliant on the published negative pressure wound therapy efficacy and may change when additional data arise. CONCLUSION The use of negative pressure wound therapy is the dominant strategy with improved outcomes and reduced costs compared with conventional dressing in patients undergoing colorectal surgery, particularly in at-risk patients. See Video Abstract at http://links.lww.com/DCR/B782. ANLISIS DE RENTABILIDAD DE LA TERAPIA DE PRESIN NEGATIVA PARA PREVENIR INFECCIN DEL SITIO QUIRRGICO DESPUS DE CIRUGA COLORRECTAL ELECTIVA ANTECEDENTES:La infección del sitio quirúrgico es común después de la cirugía colorrectal y se asocia con un aumento de los costos. Anteriormente se demostró que la terapia profiláctica con presión negativa reduce la infección del sitio quirúrgico en comparación con los apósitos convencionales. Sin embargo, el uso de la terapia de presión negativa se encuentra en dudas debido a su costo adicional.OBJETIVO:Determinar si la aplicación de la terapia profiláctic con presión negativa después de la cirugía colorrectal electiva es rentable.DISEÑO:Se completó un análisis de costo-efectividad comparando la terapia profiláctica con presión negativa versus apósito convencional utilizando un modelo de microsimulación de Markov. Se adoptó una perspectiva de pagador único de asistencia sanitaria financiada con fondos públicos a lo largo de toda la vida.AJUSTE:Cirugía colorrectal electiva intrahospitalaria.PACIENTES:El caso base fue un paciente estandarizado por edad, sexo y comorbilidad sometido a cirugía colorrectal abierta electiva.INTERVENCIÓN:Aplicación postoperatoria de terapia de presión negativa sobre incisiones cerradas.RESULTADOS PRINCIPALES:Los resultados primarios de interés fueron el número de infecciones del sitio quirúrgico, los costos totales y los años de vida ganados ajustados por calidad. Los resultados secundarios incluyeron presentación en la sala de emergencias, reingreso al hospital, la utilización del cuidado de heridas por enfermería, dehiscencia fascial, hernia incisional y complicaciones relacionadas con infecciones del sitio no quirúrgico.RESULTADOS:Estandarizado para 1,000 pacientes, encontramos que la terapia profiláctica con presión negativa previno 51 infecciones del sitio quirúrgico, 3 dehiscencias fasciales, 10 hernias incisionales, 22 presentaciones en la sala de emergencias y 6 reingresos al hospital. Esto resultó en un ahorro total de costos de $ 17.066 y 92.2 años de vida ganados ajustados por calidad ($ 17.07 y 0.09 años de vida ganados ajustados por calidad en promedio por paciente). Cuando el riesgo de infección del sitio quirúrgico de los pacientes era superior al 3,2%, la terapia de presión negativa era una estrategia rentable con una disposición a pagar de 50.000 dólares por años de vida ajustados por calidad.LIMITACIONES:No modelamos para la perspectiva social, presentaciones emergentes de hernias encarceladas o complicaciones con la reparación de hernias. Los resultados de este modelo dependen de la eficacia publicada de la terapia de presión negativa y pueden cambiar cuando surjan más datos.CONCLUSIONES:El uso de la terapia de presión negativa es la estrategia dominante con mejores resultados y costos reducidos en comparación con el apósito convencional en pacientes sometidos a cirugía colorrectal, particularmente en pacientes de riesgo. Consulte Video Resumen en http://links.lww.com/DCR/B782. (Traducción- Dr. Francisco M. Abarca-Rendon).
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Affiliation(s)
- Douglas C Cheung
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Hala Muaddi
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - John R de Almeida
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Antonio Finelli
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, University Health Network, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada
| | - Paul Karanicolas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Ontario, Canada
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Abstract
BACKGROUND The emergency department plays a common and critical role in the treatment of postoperative patients. However, many quality improvement databases fail to record these interactions. As such, our understanding of the prevalence and etiology of postoperative emergency department visits in contemporary colorectal surgery is limited. Visits with potentially preventable etiologies represent a significant target for quality improvement, particularly in the current era of rapidly evolving postoperative and ambulatory care patterns. OBJECTIVE We aimed to characterize postoperative emergency department visits and identify factors associated with these visits for potential intervention. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted at an academic medical center. PATIENTS Consecutive patients undergoing colectomy or proctectomy within the division of colorectal surgery at an academic medical center between 2014 and 2018 were included. MAIN OUTCOME MEASURES Frequency and indication for emergency department visits, as well as clinical and sociodemographic factors associated with emergency department visits in the postoperative period, were included measures. RESULTS From the 1763 individual operations, there were 207 emergency department visits from 199 patients (11%) within 30 days of discharge. Two thirds of emergency department visits led to readmission. Median (interquartile range) time to presentation was 8 days (4-16 d). Median time in the emergency department was 7.8 hours (6.0-10.1 h). One third of visits were identified as potentially preventable, most commonly for pain (17%) and stoma complications (excluding dehydration; 13%). A primary language other than English was associated with any postoperative emergency department visit risk ratio of 2.7 (95% CI, 1.3-5.3), as well as a preventable visit risk ratio of 3.6 (95% CI, 1.7-8.0). LIMITATIONS This was a single-center study and a retrospective review. CONCLUSIONS One third of emergency department visits after colorectal surgery are potentially preventable. Special attention should be directed toward those patients who do not speak English as a primary language. See Video Abstract at http://links.lww.com/DCR/B648. SE PUEDEN EVITAR LAS VISITAS AL SERVICIO DE URGENCIA DESPUS DE UNA CIRUGA COLORECTAL ANTECEDENTES:Las unidades de emergencia tienen un rol fundamental en el periodo posterior a una cirugía. Sin embargo muchos de los registros en las bases de datos de estas secciones no son de buena calidad. Por esto analizar la prevalencia y etiología de las visitas postoperatorias en cirugía colorectal resulta ser bastante limitada. Para lograr una mejoría en la calidad es fundamental analizar las causas potencialmente evitables, especialmente al considerer la rapida evolucion de los parametros de medición actuales.OBJETIVO:Nuestro objetivo es caracterizar las visitas postoperatorias al servicio de urgencias e identificar los factores asociados potencialmente evitables.DISEÑO:Estudio de cohorte retrospectivo.AJUSTE:Centro médico académico, 2014-2018.PACIENTES:Pacientes consecutivos sometidos a colectomía o proctectomía dentro de la división de cirugía colorrectal en un centro médico académico entre 2014 y 2018.PRINCIPALES MEDIDAS DE RESULTADO:Frecuencia e indicación de las visitas al servicio de urgencias en el period postoperatorio: factores clínicos y sociodemográficos.RESULTADOS:De 1763 operaciones individuales, hubo 207 visitas al departamento de emergencias de 199 pacientes (11%) en los 30 días posteriores al alta. Dos tercios de las visitas al servicio de urgencias dieron lugar a readmisiones. La mediana [rango intercuartílico] de tiempo hasta la presentación fue de 8 [4-16] días. La mediana de tiempo en el servicio de urgencias fue de 7,8 [6-10,1] horas. Un tercio de las visitas se identificaron como potencialmente evitables, más comúnmente dolor (17%) y complicaciones del estoma (excluida la deshidratación) (13%). En los pacientes con poco manejo del inglés se asoció con una mayor frecuencia razón de visitas al departamento de emergencias posoperatorias [IC del 95%] 2,7 [1,3-5,3], así como opetancialmente evitables con un RR de 3,6 [1,7-8,0].LIMITACIONES:Estudio de un solo centro y revisión retrospectiva.CONCLUSIÓN:Al menos un tercio de las visitas al servicio de urgencias después de una cirugía colorrectal son potencialmente evitables. Se debe prestar especial atención a los pacientes que no hablan inglés como idioma materno. Consulte Video Resumen en http://links.lww.com/DCR/B648.
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Ruel M, Ramirez Garcia M, Arbour C. Transition from hospital to home after elective colorectal surgery performed in an enhanced recovery program: An integrative review. Nurs Open 2021; 8:1550-1570. [PMID: 34102021 PMCID: PMC8186688 DOI: 10.1002/nop2.730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 09/29/2020] [Accepted: 10/27/2020] [Indexed: 12/14/2022] Open
Abstract
AIM This study aimed to investigate the transition from hospital to home after elective colorectal surgery performed in an Enhanced Recovery After Surgery (ERAS) programme. DESIGN An integrative review. METHODS A search of ten electronic databases was conducted. Data extraction and quality assessment were performed independently by two authors. Data analysis and synthesis were based on Meleis' Transitions Theory (2010). RESULTS Forty-two articles were included, and most (N = 27) were of good or very good quality. The researchers identified five categories to document the nature of transition postsurgery, three conditions affecting such transition, eleven indicators informing about the quality of the transition and several nursing interventions. Overall, this review revealed that the transition from hospital to home after ERAS colorectal surgery is complex. A holistic understanding of this phenomenon may help nurses to recognize what they need to do to optimize the in-home recovery of this clientele.
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Affiliation(s)
| | - Maria‐Pilar Ramirez Garcia
- Faculty of NursingUniversité de MontréalMontréalQCCanada
- Research CenterCentre Hospitalier de l’Université de MontréalMontréalQCCanada
| | - Caroline Arbour
- Faculty of NursingUniversité de MontréalMontréalQCCanada
- Research CenterHôpital du Sacré‐Cœur de MontréalCIUSSS du Nord‐de‐l’Île‐de‐MontréalMontréalQCCanada
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Turrentine FE, Smolkin ME, McMurry TL, Scott Jones R, Zaydfudim VM, Davis JP. Determining the Association Between Unplanned Reoperation and Readmission in Selected General Surgery Operations. J Surg Res 2021; 267:309-319. [PMID: 34175585 DOI: 10.1016/j.jss.2021.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/19/2021] [Accepted: 05/04/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Unplanned reoperations and unplanned readmissions can increase morbidity and mortality. Few studies however, have explored the association of reoperation and readmission among general surgery patients. Our aim was to examine this relationship in selected abdominal operations. METHODS Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data Files from 2014 to 2018 were utilized. Six groups of operations, defined by ACS NSQIP procedure codes for ventral hernia repair, colectomy, appendectomy, proctectomy, small bowel resection, and gastrectomy, were assessed. Patients discharged ≤ 14 days after operation were included in the study. This time period was selected to reduce ACS NSQIP 30 day post-surgery follow-up bias. Unplanned reoperations were defined as those occurring during the index hospitalization. The primary outcome was unplanned readmission that occurred ≤ 14 days from the date of discharge. Logistic regression models were used to examine variables associated with unplanned readmission for each procedure group. RESULTS A total of 787,118 patients were included: ventral hernia repair 35.2%, colectomy 30.6%, appendectomy 26.5%, proctectomy 3.7%, small bowel resection 3.2%, and gastrectomy 0.8%. Unplanned reoperation was independently associated with unplanned readmission for ventral hernia repair (OR 2.84, 95% CI 2.28-3.54, P < 0.001), colectomy (OR 1.58, CI 1.42- 1.76, P < 0.001), appendectomy (OR 2.91, CI 2.21-3.84, P < 0.001), and proctectomy (OR 1.41, CI 1.10-1.81, P = 0.006). Other clinically relevant covariates associated with readmission were partially dependent functional status before colectomy (OR 1.34, CI 1.23-1.46, P < 0.001), ventral hernia repair (OR 1.79, CI 1.54-2.09, P < 0.001), and small bowel resection (OR 1.44, CI 1.18-1.77, P < 0.001; and ASA 4/5 classification for colectomy (OR 2.71, CI 2.36-3.11, P < 0.001), proctectomy (OR 2.10, CI 1.48-2.97, P < 0.001), ventral hernia repair (OR 8.19, CI 6.78-9.88, P < 0.001), appendectomy (OR 2.80, CI 2.35-3.34, P < 0.001), and small bowel resection (OR 3.42, CI 2.20-5.32, P < 0.001). ASA 2, ASA 3 classification, age, and sex were also associated with unplanned readmission for most procedures. CONCLUSIONS Unplanned reoperations are associated with an increase in unplanned readmission after selected abdominal operations included in this study. This factor should be considered in discharge and follow-up planning to help reduce unplanned readmissions.
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Affiliation(s)
- Florence E Turrentine
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia
| | - Mark E Smolkin
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia; Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Timothy L McMurry
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia; Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - R Scott Jones
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia
| | - Victor M Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia
| | - John P Davis
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia.
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Van Butsele J, Bislenghi G, D'Hoore A, Wolthuis AM. Readmission after rectal resection in the ERAS-era: is a loop ileostomy the Achilles heel? BMC Surg 2021; 21:267. [PMID: 34044794 PMCID: PMC8161575 DOI: 10.1186/s12893-021-01242-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/10/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Rectal resection surgery is often followed by a loop ileostomy creation. Despite improvements in surgical technique and development of enhanced recovery after surgery (ERAS) protocols, the readmission-rate after rectal resection is still estimated to be around 30%. The purpose of this study was to identify risk factors for readmission after rectal resection surgery. This study also investigated whether elderly patients (≥ 65 years old) dispose of a distinct patient profile and associated risk factors for readmission. METHODS This is a retrospective study of prospectively collected data from patients who consecutively underwent rectal resection for cancer within an ERAS protocol between 2011 and 2016. The primary study endpoint was 90-day readmission. Patients with and without readmission within 90 days were compared. Additional subgroup analysis was performed in patients ≥ 65 years old. RESULTS A total of 344 patients were included, and 25% (n = 85) were readmitted. Main reasons for readmission were acute renal insufficiency (24%), small bowel obstruction (20%), anastomotic leakage (15%) and high output stoma (11%). In multivariate logistic regression, elevated initial creatinine level (cut-off values: 0.67-1.17 mg/dl) (OR 1.95, p = 0.041) and neoadjuvant radiotherapy (OR 2.63, p = 0.031) were significantly associated with readmission. For ileostomy related problems, elevated initial creatinine level (OR 2.76, p = 0.021) was identified to be significant. CONCLUSION Recovery after rectal resection within an ERAS protocol is hampered by the presence of a loop ileostomy. ERAS protocols should include stoma education and high output stoma prevention.
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Affiliation(s)
- Johanna Van Butsele
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium
| | - Gabriele Bislenghi
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium
| | - Albert M Wolthuis
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium.
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Grass F, Hübner M, Crippa J, Lovely JK, Huebner M, Larson DW. Temporal patterns of hospital readmissions according to disease category for patients after elective colorectal surgery. J Eval Clin Pract 2021; 27:218-222. [PMID: 32212421 DOI: 10.1111/jep.13387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 11/28/2022]
Abstract
RATIONALE The aim of this study was to identify temporal readmission patterns according to baseline disease categories to provide opportunities for targeted interventions. METHODS Retrospective analysis of consecutive adult (≥18 years) patients who underwent elective colorectal resections (2011-2017) at Mayo Clinic Rochester, MN. A prospective administrative database including patient demographics, procedure characteristics, discharge information and specifics on 30-day readmissions (to index facility) including timing and reasons was utilized. The ICD-9 codes were regrouped into the main pathologies Cancer, Crohn's disease (CD)/chronic ulcerative colitis (CUC), and diverticular disease. RESULTS In total, 521 (7.2%) out of 7245 patients undergoing inpatient colorectal surgery were readmitted. In all increments of time from discharge (0-2 days: 31.3% of all readmissions, 3-7 days: 32.4% of all readmissions, 8-14 days: 18% of all readmissions, and 15-30 days: 18.3% of all readmissions), reasons for readmission differed significantly (all P < 0.001). Across all disease categories, early readmissions (within 2 days of discharge) were most likely due to ileus/obstruction (53.4% of early readmissions), whereas with 42.5%, infection was the most common cause for late readmissions (>7 days). Patients with home discharge were more likely to be readmitted earlier within the 30-day observation period (P = 0.099), whereas patients with a longer length of index hospital stay (>7 days) were readmitted later (P = 0.080). CONCLUSIONS Reasons for readmission appear to be universal across different disease categories. Targeted educational and collaborative measures may help to mitigate the burden of hospital readmissions to index facilities.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Jacopo Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jenna K Lovely
- Hospital Pharmacy Services, Mayo Clinic, Rochester, Minnesota, USA
| | - Marianne Huebner
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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9
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Newton L, Dewi F, McNair A, Gane D, Rogers J, Dean H, Pullyblank A. The community burden of surgical site infection following elective colorectal resection. Colorectal Dis 2021; 23:724-731. [PMID: 33131179 DOI: 10.1111/codi.15420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/04/2020] [Accepted: 10/17/2020] [Indexed: 12/13/2022]
Abstract
AIM Surgical site infection (SSI) is common after colorectal surgery. Recent attempts to measure SSI have focused on inpatient SSI and readmissions. This study examined patient-reported SSI at 30 days over 8 years. METHODS The Health Protection Agency questionnaire was used to prospectively measure 30-day patient-reported SSI in patients undergoing elective colorectal operations between February 2011 and April 2019. Questionnaires were sent by post and followed up with a phone call. Data relating to hospital stay were prospectively recorded on an enhanced recovery database. RESULTS In all, 80.7% (1268) of 1559 patients responded to the questionnaire with an overall SSI rate of 15.9% (201/1268). The majority of patients who reported SSI presented in the community (66.7%) of whom 65% consulted their general practitioner and 35% saw a community nurse. Patient-reported SSI was validated by a health professional in over 90% of cases. Overall, only 1.5% of readmissions and 2% of ward attendances were due to an isolated wound problem. Patients who developed SSI during their index admission had a longer length of stay (11 days vs. 4 days) but there was no difference in delayed discharge or complications between patients with and without SSI, suggesting that a previously described association between SSI and increased length of stay may be due to observational bias. CONCLUSION Existing surveillance audits are suboptimal for monitoring SSIs following colorectal surgery as most SSIs present after discharge. There is a need for robust 30-day surveillance with a standardized methodology if comparisons are to be made between units.
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Affiliation(s)
- Lydia Newton
- Department of Colorectal Surgery, North Bristol NHS Trust, Bristol, UK
| | - Ffion Dewi
- Department of Colorectal Surgery, North Bristol NHS Trust, Bristol, UK
| | - Angus McNair
- National Institute for Health Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Dawn Gane
- Department of Colorectal Surgery, North Bristol NHS Trust, Bristol, UK
| | - Jodie Rogers
- Department of Colorectal Surgery, North Bristol NHS Trust, Bristol, UK
| | - Harry Dean
- Department of Colorectal Surgery, North Bristol NHS Trust, Bristol, UK
| | - Anne Pullyblank
- Department of Colorectal Surgery, North Bristol NHS Trust, Bristol, UK
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10
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Sampaio MAF, Sampaio SLP, Leal PDC, Moura ECR, Alvares LGGS, DE-Oliveira CMB, Torres OJM, Martins MDG. ACERTO PROJECT: IMPACT ON ASSISTANCE OF A PUBLIC EMERGENCY HOSPITAL. ACTA ACUST UNITED AC 2021; 33:e1544. [PMID: 33470374 PMCID: PMC7812687 DOI: 10.1590/0102-672020200003e1544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 04/13/2020] [Indexed: 02/06/2023]
Abstract
Background: In Brazil, the goal-based approach was named Project ACERTO and has obtained
good results when applied in elective surgeries with shorter hospitalization
time, earlier return to activities without increased morbidity and
mortality. Aim: To analyze the impact of ACERTO on emergency surgery care. Methods: An intervention study was performed at a trauma hospital. Were compared 452
patients undergoing emergency surgery and followed up by the general surgery
service from October to December 2018 (pre-ACERTO, n=243) and from March to
June 2019 (post-ACERTO, n=209). Dietary reintroduction, volume of infused
postoperative venous hydration, duration of use of catheters, probes and
drains, postoperative analgesia, prevention of postoperative vomiting, early
mobilization and physiotherapy were evaluated. Results: After the ACERTO implantation there was earlier reintroduction of the diet,
the earlier optimal caloric intake, earlier venous hydration withdrawal,
higher postoperative analgesia prescription, postoperative vomiting
prophylaxis and higher physiotherapy and mobilization prescription were
achieved early in all (p<0.01); in the multivariate analysis there was no
change in the complication rates observed before and after ACERTO (10.7% vs.
7.7% (p=0.268) and there was a decrease in the length of hospitalization
after ACERTO (8,5 vs. 6,1 dias (p=0.008). Conclusion: The implementation of the ACERTO project decreased the length of hospital
stay, improved medical care provided without increasing the rates of
complications evaluated.
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Affiliation(s)
| | | | - Plinio da Cunha Leal
- Postgraduate Program in Adult Health, Federal University of Maranhão, São Luís, MA, Brazil
| | - Ed Carlos Rey Moura
- Postgraduate Program in Adult Health, Federal University of Maranhão, São Luís, MA, Brazil
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11
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Dumitra T, Ganescu O, Hu R, Fiore JF, Kaneva P, Mayo N, Lee L, Liberman AS, Chaudhury P, Ferri L, Feldman LS. Association Between Patient Activation and Health Care Utilization After Thoracic and Abdominal Surgery. JAMA Surg 2021; 156:e205002. [PMID: 33146682 DOI: 10.1001/jamasurg.2020.5002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Increased patient activation (PA) (ie, knowledge, skills, motivation, confidence to participate in care) may result in improved outcomes, especially in surgical settings. Objective To estimate the extent to which PA is associated with 30-day postdischarge unplanned health care utilization after major thoracic or abdominal surgery. Design, Setting, and Participants This cohort study was performed at 2 centers of a tertiary care hospital network between October 2017 and January 2019. Adult patients undergoing thoracic or abdominal surgery were included. Of 880 patients assessed for eligibility, 692 were deemed eligible, of whom 34 declined to participate, 1 withdrew consent, and 4 were excluded after consent. Exposures Patient activation was measured immediately after surgery during the initial admission using the Patient Activation Measure (score range, 0-100). Patients were dichotomized into low and high PA groups using previously described thresholds (Patient Activation Measure score, ≤55.1). Main Outcomes and Measures The primary outcome was unplanned 30-day postdischarge health care utilization (composite including emergency department and outpatient clinic visits and/or hospital readmission). Secondary outcomes were length of stay, 30-day emergency department visits, 30-day readmissions, and postoperative complications. Results A total of 653 patients admitted for thoracic, general, colorectal, and gynecologic surgery were included in the study (mean [SD] age, 58 [15] years; 369 women [56%]; 366 [56%] had minimally invasive surgery; 52 [8%] had emergency surgery), of which 152 (23%) had a low level of PA. Baseline characteristics were similar between patients with low- and high-level PA. Low PA was associated with unplanned health care utilization (odds ratio [OR], 3.15; 95% CI, 2.05-4.86; P < .001), emergency department visits (OR, 1.64; 95% CI, 1.02-2.64; P = .04), complications (OR, 1.63; 95% CI, 1.11-2.41; P = .01), and length of stay (adjusted mean difference, 1.19 days; 95% CI, 0.06-2.33; P = .04). Low PA was not associated with a higher risk of readmission (adjusted OR, 1.04; 95% CI, 0.56-1.93; P = .90). Conclusions and Relevance In this study, low level of PA was associated with postdischarge unplanned health care use, hospital stay, and complications after major surgery. Identification of patients with low activation may allow the implementation of interventions to improve health care knowledge and support self-management postdischarge.
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Affiliation(s)
- Teodora Dumitra
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Olivia Ganescu
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Richard Hu
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Pepa Kaneva
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Nancy Mayo
- Division of Clinical Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - A Sender Liberman
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Prosanto Chaudhury
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Lorenzo Ferri
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
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12
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Abstract
BACKGROUND Thirty-day readmissions, emergency department visits, and observation stays are common after colorectal surgery (9%-25%, 8%-12%, and 3%-5%), yet it is unknown to what extent planned postdischarge care can decrease the frequency of emergency department visits. OBJECTIVE This study's aim was to determine whether early follow-up with the surgical team reduces 30-day emergency department visits. DESIGN This retrospective cohort study used a central data repository of clinical and administrative data for 2013 through 2018. SETTING This study was conducted in a large statewide health care system (10 affiliated hospitals, >300 practices). PATIENTS All adult patients undergoing colorectal surgery were included unless they had a length of stay <1 day or died during the index hospitalization. INTERVENTION Early (<10 days after discharge) versus late (≥10 days) follow-up at the outpatient surgery clinic, or no outpatient surgery clinic follow-up, was assessed. MAIN OUTCOME MEASURES The primary outcome measured was the time to 30-day postdischarge emergency department visit. RESULTS Our cohort included 3442 patients undergoing colorectal surgery; 38% of patients had an early clinic visit. Overall, 11% had an emergency department encounter between 11 and 30 days after discharge. Those with early follow-up had decreased emergency department encounters (adjusted HR 0.13; 95% CI, 0.08-0.22). An early clinic visit within 10 days, compared to 14 days, prevented an additional 142 emergency department encounters. Nationwide, this could potentially prevent 8433 unplanned visits each year with an estimated cost savings of $49 million annually. LIMITATIONS We used retrospective data and were unable to assess for health care utilization outside our health system. CONCLUSIONS Early follow-up within 10 days of adult colorectal surgery is associated with decreased subsequent emergency department encounters. See Video Abstract at http://links.lww.com/DCR/B330. EL SEGUIMIENTO TEMPRANO DESPUÉS DE LA CIRUGÍA COLORRECTAL REDUCE LAS VISITAS AL SERVICIO DE URGENCIAS POSTERIOR AL ALTA: Los readmisión a los treinta días, las visitas al servicio de urgencias y las estancias de observación son comunes después de la cirugía colorrectal, 9-25%, 8-12% y 3-5%, respectivamente. Sin embargo, se desconoce en qué medida la atención planificada posterior al alta puede disminuir la frecuencia de las visitas al servicio de urgencias.Determinar si el seguimiento temprano con el equipo quirúrgico reduce las visitas a 30 días al servicio de urgencias.Este estudio de cohorte retrospectivo utilizó un depósito central de datos clínicos y administrativos para 2013-2018.Gran sistema de salud estatal (10 hospitales afiliados,> 300 consultorios).Se incluyeron todos los pacientes adultos de cirugía colorrectal a menos que tuvieran una estadía <1 día o murieran durante el índice de hospitalización.Temprano (<10 días después del alta) versus tardío (≥10 días) o sin seguimiento en la clínica de cirugía ambulatoria.Tiempo para la visita al servicio de urgencias a 30 días después del alta.Nuestra cohorte incluyó 3.442 pacientes de cirugía colorrectal; El 38% de los pacientes tuvieron una visita temprana a clínica. En total, el 11% tuvo un encuentro con el servicio de urgencias entre 11 y 30 días después de ser dado de alta. Aquellos con seguimiento temprano disminuyeron las visitas al servicio de urgencias (HR 0,13; IC del 95%: 0,08 a 0,22). Además, una visita temprana a la clínica en un plazo de 10 días, en comparación con 14 días, evitó 142 encuentros adicionales en el servicio de urgencias. A nivel nacional, esto podría prevenir 8.433 visitas no planificadas cada año con un ahorro estimado de $ 49 millones anuales.Utilizamos datos retrospectivos y no pudimos evaluar la utilización de la atención médica fuera de nuestro sistema de salud.El seguimiento temprano dentro de los 10 días de la cirugía colorrectal en adultos se asocia con una disminución de los encuentros posteriores en el servicio de urgencias. Consulte Video Resumen en http://links.lww.com/DCR/B330. (Traducción-Dr. Gonzalo Hagerman).
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13
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Abstract
BACKGROUND Hospital readmission rate is an important quality metric and has been recognized as a key measure of hospital value-based purchasing programs. OBJECTIVE This study aimed to assess the risk factors for hospital readmission with a focus on potentially preventable early readmissions within 48 hours of discharge. DESIGN This is a retrospective cohort study. SETTINGS This study was conducted at a tertiary academic facility with a standardized enhanced recovery pathway. PATIENTS Consecutive patients undergoing elective major colorectal resections between 2011 and 2016 were included. MAIN OUTCOME MEASURES Univariable and multivariable risk factors for overall and early (<48 hours) readmissions were identified. Specific surgical and medical reasons for readmission were compared between early and late readmissions. RESULTS In total, 526 of 4204 patients (12.5%) were readmitted within 30 days of discharge. Independent risk factors were ASA score (≥3; OR, 1.5; 95% CI, 1.1-2), excess perioperative weight gain (OR, 1.7; 95% CI, 1.3-2.3), ileostomy (OR, 1.4; 95% CI, 1-2), and transfusion (OR, 2; 95% CI, 1.4-3), or reoperation (OR, 11.4; 95% CI, 7.4-17.5) during the index stay. No potentially preventable risk factor for early readmission (128 patients, 24.3% of all readmissions, 3% of total cohort) was identified, and index hospital stay of ≤3 days was not associated with increased readmission (OR, 0.9; 95% CI, 0.7-1.2). Although ileus and small-bowel obstruction (early: 43.8% vs late: 15.5%, p < 0.001) were leading causes for early readmissions, deep infections (3.9% vs 16.3%, p < 0.001) and acute kidney injury (0% vs 5%, p = 0.006) were mainly observed during readmissions after 48 hours. LIMITATIONS Risk of underreporting due to loss of follow-up and the potential co-occurrence of complications were limitations of this study. CONCLUSIONS Early hospital readmission was mainly due to ileus or bowel obstruction, whereas late readmissions were related to deep infections and acute kidney injury. A suspicious attitude toward potential ileus-related symptoms before discharge and dedicated education for ostomy patients are important. A short index hospital stay was not associated with increased readmission rates. See Video Abstract at http://links.lww.com/DCR/B237. REINGRESOS DENTRO DE LAS 48 HORAS POSTERIORES AL ALTA: RAZONES, FACTORES DE RIESGO Y POSIBLES MEJORAS: La tasa de reingreso hospitalario es una métrica de calidad importante y ha sido reconocida como una medida clave de los programas hospitalarios de compras basadas en el valor.Evaluar los factores de riesgo para el reingreso hospitalario con énfasis en reingresos tempranos potencialmente prevenibles dentro de las 48 horas posteriores al alta.Estudio de cohorte retrospectivo.Institución académica terciaria con programa de recuperación mejorada estandarizado.Pacientes consecutivos sometidos a resecciones colorrectales mayores electivas entre 2011 y 2016.Se identificaron factores de riesgo uni y multivariables para reingresos totales y tempranos (<48 horas). Se compararon razones médicas y quirúrgicas específicas para el reingreso entre reingresos tempranos y tardíos.En total, 526/4204 pacientes (12,5%) fueron readmitidos dentro de los 30 días posteriores al alta. Los factores de riesgo independientes fueron puntuación ASA (≥3, OR 1.5; IC 95% 1.1-2), aumento de peso perioperatorio excesivo (OR 1.7; IC 95% 1.3-2.3), ileostomía (OR 1.4, IC 95%: 1-2) y transfusión (OR 2, IC 95% 1.4-3) o reoperación (OR 11.4; IC 95% 7.4-17.5) durante la estadía índice. No se identificó ningún factor de riesgo potencialmente prevenible para el reingreso temprano (128 pacientes, 24.3% de todos los reingresos, 3% de la cohorte total), y la estadía hospitalaria índice de ≤ 3 días no se asoció con un aumento en el reingreso (OR 0.9; IC 95% 0.7-1.2) Mientras que el íleo / obstrucción del intestino delgado (temprano: 43.8% vs. tardío: 15.5%, p < 0.001) fueron las principales causas de reingresos tempranos, infecciones profundas (3.9% vs 16.3%, p < 0.001) y lesión renal aguda (0 vs 5%, p = 0.006) se observaron principalmente durante los reingresos después de 48 horas.Riesgo de subregistro debido a la pérdida en el seguimiento, posible co-ocurrencia de complicaciones.El reingreso hospitalario temprano se debió principalmente a íleo u obstrucción intestinal, mientras que los reingresos tardíos se relacionaron con infecciones profundas y lesión renal aguda. Es importante tener una actitud suspicaz hacia los posibles síntomas relacionados con el íleo antes del alta y una educación específica para los pacientes con ostomía. La estadía hospitalaria índice corta no se asoció con mayores tasas de reingreso. Consulte Video Resumen en http://links.lww.com/DCR/B237.
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14
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Shogan BD, Chen J, Duchalais E, Collins D, Chang M, Krull K, Krezalek MA, Larson DW, Walther-Antonio MR, Chia N, Nelson H. Alterations of the Rectal Microbiome Are Associated with the Development of Postoperative Ileus in Patients Undergoing Colorectal Surgery. J Gastrointest Surg 2020; 24:1663-1672. [PMID: 32323252 DOI: 10.1007/s11605-020-04593-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/02/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The most common complications after colorectal surgery, postoperative ileus, surgical site infections, and anastomotic leaks continue to occur despite advances in surgical technique and enhanced recovery pathways. Preclinical studies have documented that intestinal bacteria play a role in the development of these complication, yet human data is lacking. Here we hypothesized that patients that develop ileus, surgical site infection, and/or anastomotic leak following colorectal surgery harbor a specific preoperative gut microbiome. METHODS We performed a prospective cohort study on 101 patients undergoing colon or rectal resection at the Mayo Clinic. Rectal samples were collected preoperatively and on the ward on postoperative day two. The bacterial community from each sample was characterized by 16S rRNA and associated with the development of complications. RESULTS The rectal microbiome collected from patients in the operating room (p = .003) and on postoperative day two (p = .001) was significantly difference in patients whom later developed postoperative ileus compared with patients that had a normal return of bowel function. Patients whom developed ileus showed increased abundance of Bacteroides spp., Parabacteroides spp., and Ruminococcus spp., bacteria that are associated with promoting intestinal inflammation. There were no differences in the microbiome in patients that developed surgical site infections or anastomotic leaks. CONCLUSIONS In this pilot study, patients that develop postoperative ileus harbor a specific gut microbiome during the perioperative period. These findings demonstrate that the preoperative bacterial composition may predispose patients to the development of ileus and that perioperative manipulation of the gut bacteria may provide a novel method to promote normal return of bowel function.
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Affiliation(s)
- Benjamin D Shogan
- Division of Colon and Rectal Surgery, University of Chicago, Room J557F, MC 5095, 5841 S. Maryland Ave, Chicago, IL, 60637, USA.
| | - Jun Chen
- Division of Biomedical Statistics, Mayo Clinic, Rochester, MN, USA
| | - Emilie Duchalais
- Department of Digestive and Endocrine Surgery, CHU de Nantes, Nantes, France
| | | | - Melissa Chang
- Department of Surgery, St. Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Kimberly Krull
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Monika A Krezalek
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Nicholas Chia
- Division of Biomedical Statistics, Mayo Clinic, Rochester, MN, USA
| | - Heidi Nelson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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15
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Lumpkin ST, Mihas P, Baldwin X, Adams U, Carey T, Stitzenberg K. Surgical patient values frame and modify the impact of risk factors for non-routine postdischarge care: A mixed-methods study. Am J Surg 2020; 221:195-203. [PMID: 32723490 DOI: 10.1016/j.amjsurg.2020.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/08/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Adult colorectal surgery patients continue to have high rates of readmissions, despite known risk factors for non-routine postdischarge care (emergency department (ED) visit or rehospitalization) and countless interventions to address these. It is unclear how the difficult-to-quantify patient perspective frames and modifies the impact of these quantifiable risk factors. STUDY DESIGN We identified consecutive adult inpatient colorectal surgery patients from 2017 to 2018. This mixed methods study merged data from electronic health records and in-depth patient interviews. RESULTS We enrolled 258 participants, surveyed 167, and interviewed 18. Depressive symptoms represent one of many risk factors confirmed to increase non-routine healthcare utilization (RR 1.85, 95% CI 1.02-3.37), though the patient perspective explained why these symptoms seemed to greatly impact some patients more than others. Additionally, consistent with patient report, patients with non-routine postdischarge care (26%) were less likely to report communication with their surgical team (80% vs 97%, p < 0.001). CONCLUSION Patient perspectives add depth and understanding of the impact of risk factors on non-routine post-discharge care. This expanded knowledge explains why one patient is more likely to visit an ED close to home whereas another patient might prefer to visit their surgeon's clinic directly. Effective strategies to reduce unplanned postdischarge care should be tailored.
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Affiliation(s)
- Stephanie T Lumpkin
- General Surgery Resident PGY-6, University of North Carolina at Chapel Hill, Department of Surgery, 4050 Burnett Womack Building, Chapel Hill, NC, 27599, USA.
| | - Paul Mihas
- The Odum Institute, University of North Carolina at Chapel Hill, USA
| | - Xavier Baldwin
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Ursula Adams
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Timothy Carey
- Department of Medicine, University of North Carolina at Chapel Hill, USA
| | - Karyn Stitzenberg
- Division of Surgical Oncology, University of North Carolina at Chapel Hill, USA
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16
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Romanova AL, Carter-Brooks C, Ruppert KM, Zyczynski HM. 30-Day unanticipated healthcare encounters after prolapse surgery: impact of same day discharge. Am J Obstet Gynecol 2020; 222:482.e1-482.e8. [PMID: 31733206 DOI: 10.1016/j.ajog.2019.11.1249] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 10/16/2019] [Accepted: 11/04/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Same-day discharge is becoming increasingly common in gynecologic surgery; however, data are limited for frequency, setting, and severity of unanticipated healthcare visits for women who are discharged on the day of surgery after major prolapse repair. OBJECTIVE The purpose of this study was to evaluate whether discharge on the day of surgery is associated with increased 30-day unanticipated healthcare encounters after major pelvic organ prolapse surgery compared with discharge on or after postoperative day 1. STUDY DESIGN This is a retrospective analysis of women who underwent pelvic organ prolapse surgery by 8 female pelvic medicine and reconstructive surgery surgeons from January 2016 to October 2017. Unanticipated healthcare encounter was a composite variable of any visit to the office, emergency department, or hospital readmission. Number of visits, visit diagnoses, and complication severity (Clavien-Dindo classification) were compared by day of discharge with the use of χ2 tests. Multivariable analyses were performed. RESULTS Of 405 women, 258 (63.7%) were discharged on the day of surgery, and 147 (36.3%) were discharged on postoperative day 1 or later. Mean age was 66±11 years, body mass index was 27.9±4.8 kg/m2. Most had stage III prolapse (n=273; 67.4%). Procedures included laparoscopic or robotic sacrocolpopexy, (n=163; 40.2%), vaginal apical suspensions (n=115; 28.4%), obliterative (n=105; 25.9%), and concomitant hysterectomy (n=229; 56.5%). There was no increase in the number of women with at least 1 unanticipated healthcare encounter within 30 days of surgery, based on discharge on the day of surgery compared with postoperative day 1 (24.0% vs 26.5%; P=.572). The majority of visits occurred in the office (17.8% vs 19.0%; P=.760). There was no increase in 30-day readmissions (3.5% vs 4.8%; P=.527). The most common visit diagnosis was pain and accounted for 31.5% of all visits, followed by urologic and gastrointestinal symptoms. Diagnoses and complication severity did not vary by day of discharge, except that women who were discharged on the day of surgery were more likely to have a superficial wound separation (11.3% vs 0%; P=.011) and less likely to experience grade II complications (7.4% vs 15.6%, P=.009). Few women had >1 unscheduled visit, and rates were similar between the 2 groups (6.2% vs 6.8%; P=.810). On multivariable regression, younger women (adjusted odds ratio, 1.03; 95% confidence interval, 1.001-1.05), those with lower body mass index (adjusted odds ratio, 1.07; 95% confidence interval, 1.13-1.01), and higher initial postanesthesia recovery unit pain scores (adjusted odds ratio, 1.11; 95% confidence interval, 1.02-1.21) were more likely to have an unanticipated healthcare encounter. Pain complaints were evaluated most often in the office compared with the emergency department (41.1% vs 13.0%); medical complications such as cardiac (15.6% vs 0%) and respiratory (6.5% vs 0%) were more likely to be evaluated in the emergency department. Higher grade complications (II/III) were more likely to visit the emergence department (78.2% vs 27.1%; P<.0001). CONCLUSION Same-day discharge after prolapse surgery did not result in an increase in 30-day unanticipated healthcare encounters.
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Affiliation(s)
- Anna L Romanova
- Department of Obstetrics, Gynecology and Reproductive Sciences of the University of Pittsburgh, Division of Urogynecology and Pelvic Reconstructive Surgery, Magee-Womens Hospital of the University of Pittsburgh Medical Center.
| | - Charelle Carter-Brooks
- Department of Obstetrics, Gynecology and Reproductive Sciences of the University of Pittsburgh, Division of Urogynecology and Pelvic Reconstructive Surgery, Magee-Womens Hospital of the University of Pittsburgh Medical Center
| | | | - Halina M Zyczynski
- Department of Obstetrics, Gynecology and Reproductive Sciences of the University of Pittsburgh, Division of Urogynecology and Pelvic Reconstructive Surgery, Magee-Womens Hospital of the University of Pittsburgh Medical Center
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Trends in emergency department utilization following common operations in New York State, 2005-2014. Surg Endosc 2019; 34:1994-1999. [PMID: 31300908 DOI: 10.1007/s00464-019-06975-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 07/09/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND ED overutilization is a leading cause of increased healthcare costs and a key target for healthcare reform. ED utilization patterns following common operative procedures are unknown. METHODS Using the SPARCS New York (NY) statewide longitudinal administrative database, a longitudinal analysis on 746,633 patients who underwent cholecystectomy (n = 355,368), appendectomy (n = 142,797) or inguinal hernia repair (n = 248,468) from 2005 to 2014 was performed. ED revisits were identified via unique patient identifiers which allow for patient tracking across hospitals in NY State. RESULTS In total, 59,255 (7.9%) patients presented to the ED within 30-days of their operation of which 21,638 (36.5%) were admitted. The aggregated rate of ED utilization and admission from the ED were as follows: cholecystectomy (9.5%, 40%), appendectomy (9.1%, 33.1%), and inguinal hernia repair (5.1%, 26.2%), respectively. A longitudinal analysis demonstrated a relative slowing of the rate of increase in hospital readmissions for cholecystectomy and inguinal hernia repair but no change in the number of ED revisits for inguinal hernia repair. CONCLUSIONS Nearly 1 in 10 patients undergoing cholecystectomy and appendectomy, and 1 in 20 patients undergoing inguinal hernia repair will present to the ED following surgery. The majority of ED visits do not result in admission, calling their necessity into question. These data suggest possible overutilization of the ED following common operations and support the consideration of ED utilization as a quality indicator.
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Liccardo F, Baird DLH, Pellino G, Rasheed S, Kontovounisios C, Tekkis PP. Predictors of short-term readmission after beyond total mesorectal excision for primary locally advanced and recurrent rectal cancer. Updates Surg 2019; 71:477-484. [PMID: 31250396 PMCID: PMC6686032 DOI: 10.1007/s13304-019-00669-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/22/2019] [Indexed: 11/24/2022]
Abstract
Unplanned readmissions heavily affect the cost of health care and are used as an indicator of performance. No clear data are available regarding beyond-total mesorectal excision (bTME) procedure. Aim of the study is to identify patient-related and surgery-related factors influencing the 30-day readmissions after bTME. Retrospective data were collected from 220 patients who underwent bTME procedures at single centre between 2006 and 2016. Patient-related and operative factors were assessed, including body mass index (BMI), age, gender, American Society of Anaesthesiologists’ (ASA) score, preoperative stage, neo-adjuvant therapy, primary tumour vs recurrence, the extent of surgery. The readmission rate was 8.18%. No statistically significant association was found with BMI, ASA score, length of stay and stay in the intensive care unit, primary vs recurrent tumour or blood transfusions. Not quite statistically significant was the association with pelvic side wall dissection (OR 3.32, p = 0.054). Statistically significant factors included preoperative stage > IIIb (OR: 4.77, p = 0.002), neo-adjuvant therapy (OR: 0.13, p = 0.0006), age over 65 years (OR: 5.96, p = 0.0005), any re-intervention during the first admission (OR: 7.4, p = 0.0001), and any post-operative complication (OR: 9.01, p = 0.004). The readmission rate after beyond-TME procedure is influenced by patient-related factors as well as post-operative morbidity.
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Affiliation(s)
- Filomena Liccardo
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Daniel L H Baird
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH, UK
| | - Gianluca Pellino
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Advanced Medical and Surgical Sciences, Universitá della Campania "Luigi Vanvitelli, Naples, Italy
| | - Shahnawaz Rasheed
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK. .,Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH, UK. .,Department of Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK.
| | - Paris P Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH, UK.,Department of Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK
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Hewitt J, Carter B, McCarthy K, Pearce L, Law J, Wilson FV, Tay HS, McCormack C, Stechman MJ, Moug SJ, Myint PK. Frailty predicts mortality in all emergency surgical admissions regardless of age. An observational study. Age Ageing 2019; 48:388-394. [PMID: 30778528 DOI: 10.1093/ageing/afy217] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 10/09/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND frail patients in any age group are more likely to die than those that are not frail. We aimed to evaluate the impact of frailty on clinical mortality, readmission rate and length of stay for emergency surgical patients of all ages. METHODS a multi-centre prospective cohort study was conducted on adult admissions to acute surgical units. Every patient presenting as a surgical emergency to secondary care, regardless of whether they ultimately underwent a surgical procedure was included. The study was carried out during 2015 and 2016.Frailty was defined using the 7-point Clinical Frailty Scale. The primary outcome was mortality at Day 90. Secondary outcomes included: mortality at Day 30, length of stay and readmission within a Day 30 period. RESULTS the cohort included 2,279 patients (median age 54 years [IQR 36-72]; 56% female). Frailty was documented in patients of all ages: 1% in the under 40's to 45% of those aged 80+. We found that each incremental step of worsening frailty was associated with an 80% increase in mortality at Day 90 (OR 1.80, 95% CI: 1.61-2.01) supporting a linear dose-response relationship. In addition, the most frail patients were increasingly likely to stay in hospital longer, be readmitted within 30 days, and die within 30 days. CONCLUSIONS worsening frailty at any age is associated with significantly poorer patient outcomes, including mortality in unselected acute surgical admissions. Assessment of frailty should be integrated into emergency surgical practice to allow prognostication and implementation of strategies to improve outcomes.
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Affiliation(s)
- J Hewitt
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - B Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - K McCarthy
- Department of General Surgery, North Bristol NHS Trust, Bristol, UK
| | - L Pearce
- Department of General Surgery, Manchester Royal Infirmary, Manchester, UK
| | - J Law
- Department of General Surgery, Blackpool Victoria Infirmary, Blackpool, UK
| | - F V Wilson
- Department of Geriatric Medicine, Sunderland Royal Hospital, Sunderland, UK
| | - H S Tay
- Department of Geriatric Medicine Aberdeen Royal Infirmary, Aberdeen, UK
| | - C McCormack
- Department of Geriatric Medicine Aberdeen Royal Infirmary, Aberdeen, UK
| | - M J Stechman
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - S J Moug
- Department of General Surgery, Royal Alexandra Hospital, Paisley, Greater Glasgow, UK
| | - P K Myint
- Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Research, University of Aberdeen, Aberdeen, UK
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Sizonenko NA, Surov DA, Solov'ev IA, Demko AE, Osipov AV, Gabrielyan MA, Pavlovsky AL. [Evolution of enhanced recovery after surgery: from the beginning of the study of stress to the introduction in emergency surgery]. Khirurgiia (Mosk) 2018:71-79. [PMID: 30531760 DOI: 10.17116/hirurgia201811171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Effectiveness of enhanced recovery program is being earnestly confirmed in various surgical areas. Certain aspects of fast track rehabilitation are analyzed in the article.
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Affiliation(s)
- N A Sizonenko
- S.M. Kirov Military Medical Academy Ministry of Defense of the Russia
| | - D A Surov
- S.M. Kirov Military Medical Academy Ministry of Defense of the Russia
| | - I A Solov'ev
- S.M. Kirov Military Medical Academy Ministry of Defense of the Russia
| | - A E Demko
- Saint-Petersburg I.I. Dzhanelidze research institute of emergency medicine, St. Petersburg, Russia
| | - A V Osipov
- S.M. Kirov Military Medical Academy Ministry of Defense of the Russia; Saint-Petersburg I.I. Dzhanelidze research institute of emergency medicine, St. Petersburg, Russia
| | - M A Gabrielyan
- S.M. Kirov Military Medical Academy Ministry of Defense of the Russia
| | - A L Pavlovsky
- S.M. Kirov Military Medical Academy Ministry of Defense of the Russia
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21
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An enhanced recovery program in colorectal surgery is associated with decreased organ level rates of complications: a difference-in-differences analysis. Surg Endosc 2018; 33:2222-2230. [PMID: 30334161 DOI: 10.1007/s00464-018-6508-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 10/11/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Perioperative care has lacked coordination and standardization. Enhanced recovery programs (ERPs) have been shown to decrease aggregate complications across surgical specialties. We hypothesize that the sustained implementation of an ERP will be associated with a decrease in a broad range of complications at the organ system level. STUDY DESIGN Adult patients undergoing elective colorectal procedures between 1/2011 and 10/2016 were included. Patients were stratified based on exposure to a sustained ERP (7/2014-10/2016) after an 18-month wash-in period in a pre-post analysis. The primary outcome was 30-day complication rate by organ category as collected by National Surgical Quality Improvement Program (NSQIP) abstractors. Demographic and other patient level data were collected. Complication rates were compared using multivariable regression employing a differences-in-differences (DiD) approach using the national NSQIP PUF file to account for secular trends. RESULTS A total of 1182 patients were included in this study, with 47% treated in an ERP. The two groups were similar in age, gender, race, BMI, comorbidity index, and procedure type. In a multivariable DiD analysis, significant reductions were seen in surgical site infection (OR 0.30; 95% CI 0.20-0.43), postoperative pulmonary complications (OR 0.46; 95% CI 0.24-0.90), transfusion (OR 0.27; 95% CI 0.15-0.51), urinary tract infections (OR 0.34; 95% CI 0.18-0.66), sepsis (OR 0.35; 95% CI 0.20-0.61), and cardiac complications (OR 0.10; 95% CI 0.01-0.84). A reduction in return to the operating room and 30-day readmission was also observed. Median length of stay (LOS) decreased from 5.2 to 3.5 days (p < 0.001). No significant changes occurred for acute kidney injury and hematologic complications. CONCLUSION An ERP was associated with reduced complication rates across a wide range of organ categories and > 1.5-day reduction in LOS in a colorectal surgery population.
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Wierdak M, Pisarska M, Kuśnierz-Cabala B, Witowski J, Major P, Ceranowicz P, Budzyński A, Pędziwiatr M. Serum Amyloid A as an Early Marker of Infectious Complications after Laparoscopic Surgery for Colorectal Cancer. Surg Infect (Larchmt) 2018; 19:622-628. [DOI: 10.1089/sur.2018.105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Mateusz Wierdak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Magdalena Pisarska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Beata Kuśnierz-Cabala
- Department of Diagnostics, Chair of Clinical Biochemistry, Jagiellonian University Medical College, Kraków, Poland
| | - Jan Witowski
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Piotr Ceranowicz
- Department of Physiology, Jagiellonian University Medical College, Kraków, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
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Jing X, Zhang B, Xing S, Tian L, Wang X, Zhou M, Li J. Cost-benefit analysis of enhanced recovery after hepatectomy in Chinese Han population. Medicine (Baltimore) 2018; 97:e11957. [PMID: 30142819 PMCID: PMC6113004 DOI: 10.1097/md.0000000000011957] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs have been proved effective for enhancing the clinical healing rate and reducing hospitalization cost in most countries of the world. It's a multi-model approach that designed to optimize perioperative pathway, attenuate the surgical stress response, and decrease postoperative complications. OBJECTIVE The economic benefit from the application of ERAS to colorectal surgery has been demonstrated in China. However, such economic benefit of ERAS programs for hepatectomy hasn't been clarified yet. This study was carried out to explore the clinical efficacy and cost effectiveness of ERAS in Chinese Han population after hepatectomy. METHODS ERAS program was implemented in our department for hepatectomy in December 2016. In total, 79 consecutive patients after hepatectomy were chosen as ERAS group (ERAS protocol) in coming half year while 121 consecutive patients after hepatectomy were chosen as Pre-ERAS group (traditional protocol) in past half year. The operation time, intraoperative blood loss, length of hospital stay (LOS), complication, readmission, and hospitalization cost of 2 groups were compared. RESULTS The LOS of ERAS group was 5.81 ± 1.79 days, significantly shorter than that of Pre-ERAS group (8.06 ± 3.40 d) (P = .000). The operation time was 168.03 ± 46.20 minutes for ERAS group and 175.41 ± 64.64 minutes for Pre-ERAS group respectively (P = .417). The intraoperative blood loss was 166.58 ± 194.13 mL (ERAS group) and 205.45 ± 279.63 mL (Pre-ERAS group) (P = .293). It should be noted that the hospitalization cost of ERAS group was 51556.18 ± 8926.05 Yuan (7835.05 ± 1355.45 US dollars), significantly less than that of Pre-ERAS group 60554.66 ± 15615.31 Yuan (9202.56 ± 2371.24 US dollars) (P = .000). The application of ERAS effectively saved 8998.48 Yuan (1367.51 US dollars) for each patient. CONCLUSIONS ERAS implementation for hepatectomy surgery is safe and feasible for Chinese Han population. It eventually enhanced the clinical healing rate. The benefits from such programs include a reduction of the LOS, complication, and readmission rates. So each patient has access to better medical service. It effectively relieved the financial burden of patients. The benefits from such programs include a reduction of the hospitalization cost, especially in medication cost. So each patient can afford the diseases.
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Abstract
This article begins by introducing the historical background surrounding the volume-outcomes relationship literature, particularly in complex cancer surgery. The state of evidence surrounding mortality, as well as other outcomes, in relation to both hospital and surgeon procedure volume is synthesized. Where it is understood, the level of adoption of regionalization of various complex surgeries in the United States is also presented. Various controversies are weighed and discussed. Finally, various models of regionalization and proposed alternatives to regionalization from the peer-reviewed literature are presented.
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Affiliation(s)
- Stephanie Lumpkin
- Department of Surgery, University of North Carolina, Chapel Hill, NC 27514, USA
| | - Karyn Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, NC 27514, USA.
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Denbo JW, Bruno M, Dewhurst W, Kim MP, Tzeng CW, Aloia TA, Soliz J, Speer BB, Lee JE, Katz MHG. Risk-stratified clinical pathways decrease the duration of hospitalization and costs of perioperative care after pancreatectomy. Surgery 2018; 164:424-431. [PMID: 29807648 DOI: 10.1016/j.surg.2018.04.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/21/2018] [Accepted: 04/09/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is associated with adverse events, increased duration of stay and hospital costs. We developed perioperative care pathways stratified by postoperative pancreatic fistula risk with the aims of minimizing variations in care, improving quality, and decreasing costs. STUDY DESIGN Three unique risk-stratified pancreatectomy clinical pathways-low-risk pancreatoduodenectomy, high-risk pancreatoduodenectomy, and distal pancreatectomy were developed and implemented. Consecutive patients treated after implementation of the risk-stratified pancreatectomy clinical pathways were compared with patients treated immediately prior. Duration of stay, rates of perioperative adverse effects, discharge disposition, and hospital readmission, as well as the associated costs of care, were evaluated. RESULTS The median hospital stay after pancreatectomy decreased from 10 to 6 days after implementation of the risk-stratified pancreatectomy clinical pathways (P < .001), and the median cost of index hospitalization decreased by 22%. Decreased changes in median hospital stay and costs of hospitalization were observed in association with low-risk pancreatoduodenectomy (P < .05) and distal pancreatectomy (P < .05), but not high-risk pancreatoduodenectomy. The rates of 90-day adverse events, grade B/C postoperative pancreatic fistula, discharge to a facility other than home, or readmission did not change after implementation. CONCLUSION Implementation of risk-stratified pancreatectomy clinical pathways decreased median stay and cost of index hospitalization after pancreatectomy without unfavorably affecting rates of perioperative adverse events or readmission, or discharge disposition. Outcomes were most favorably improved for low-risk pancreatoduodenectomy and distal pancreatectomy. Additional work is necessary to decrease the rate of postoperative pancreatic fistula, minimize variability, and improve outcomes after high-risk pancreatoduodenectomy.
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Affiliation(s)
- Jason W Denbo
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX; Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Morgan Bruno
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Whitney Dewhurst
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael P Kim
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ching-Wei Tzeng
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas A Aloia
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jose Soliz
- Department of Anesthesia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Barbara Bryce Speer
- Department of Anesthesia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey E Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthew H G Katz
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX.
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