Readmission after emergency general surgery

Trends in Clinical Outcomes After Major Emergency Abdominal Surgery in Denmark, Data From 2002-2022

Importance

Major emergency abdominal surgery is associated with high morbidity and mortality. Understanding trends in outcomes over time can reveal critical practice-changing improvements, identify gaps in postoperative care, and establish a large-scale benchmark for future research.

Objective

To investigate trends in morbidity and mortality after major emergency abdominal surgery in Denmark.

Design, Setting, and Participants

This was a nationwide, population-based cohort study. Analyses were performed based on data from Danish nationwide administrative registries. Within the public health care system in Denmark, all adult patients undergoing major emergency abdominal surgery from 2002 to 2022 were included. Major emergency abdominal surgeries included laparotomy or laparoscopy due to intra-abdominal pathologies, including intestinal perforation, ischemia, bowel obstruction, abscess, or bleeding.

Exposure

Major emergency abdominal surgery.

Main Outcomes and Measures

The primary outcome was the trend in 30- and 90-day mortality after major emergency abdominal surgery over time.

Results

A total of 61 476 patients (mean [SD] age, 66.2 [16.3] years; 34 827 female [56.7%]) were included. The annual number of surgeries remained constant, with a mean (SD) of 3044 (165) surgeries per year. The 30- and 90-day mortality was reduced from 25% and 33%, respectively, to 13% and 18%, respectively (P < .001). Median (IQR) hospital length of stay was decreased from 10 (5-17) days to 6 (4-13) days (P < .001). The rate of 30-day postoperative complications (classified Clavien-Dindo ≥3a) was reduced from 49% to 44% (P <.001) and the 90-day rate was reduced from 53% to 48% (P <.001), however, with a tendency toward more patients undergoing earlier intervention. The 30- and 90-day readmission rate increased drastically from 9% and 13%, respectively, to 25% and 33%, respectively (P < .001).

Conclusions and Relevance

Results of this cohort study suggest notable reductions in mortality and hospital length of stay after major emergency abdominal surgery. A marked increased readmission rate and a persistently high rate of postoperative complications were found. These shifts underscore the need for enhanced postoperative monitoring and postdischarge follow-up.

Deaths After Readmissions are Mostly Attributable to Failure-to-Rescue in EGS Patients

INTRODUCTION

We have recently shown that readmission after EGS procedures carries a 4-fold higher mortality rate when compared to those not readmitted. Understanding factors associated with death after readmission is paramount to improving outcomes for EGS patients. We aimed to identify risk factors contributing to failure-to-rescue (FTR) during readmission after EGS. We hypothesized that most post-readmission deaths in EGS are attributable to FTR.

METHODS

A retrospective cohort study using the NSQIP database 2013-2019 was performed. Patients who underwent 1 of 9 urgent/emergent surgical procedures representing 80% of EGS burden of disease, who were readmitted within 30 days post-procedure were identified. The procedures were classified as low- and high-risk. Patient characteristics analyzed included age, sex, BMI, ASA score comorbidities, postoperative complications, frailty, and FTR. The population was assessed for risk factors associated with mortality and FTR by uni- and multivariate logistic regression.

RESULTS

Of 312,862 EGS cases, 16,306 required readmission. Of those, 10,748 (3.4%) developed a postoperative complication. Overall mortality after readmission was 2.4%, with 90.6% of deaths attributable to FTR. Frailty, high-risk procedures, pulmonary complications, AKI, sepsis, and the need for reoperation increased the risk of FTR.

DISCUSSION

Death after a complication is common in EGS readmissions. The impact of FTR could be minimized with the implementation of measures to allow early identification and intervention or prevention of infectious, respiratory, and renal complications.

Health-related quality of life is a predictor of readmission following emergency laparotomy

BACKGROUND

Health-related quality of life (HRQoL) is a multidimensional concept used to examine the impact of patient-perceived health status on quality of life. Patients' perception of illness affects outcomes in both medical and elective surgical patients; however, not much is known about how HRQoL effects outcomes in the emergency surgical setting. This study aimed to examine if patient-reported HRQoL was a predictor of unplanned readmission after emergency laparotomy.

METHODS

This study included 215 patients who underwent emergency laparotomy at the Copenhagen University Hospital, Herlev, between August 1, 2021, and July 31, 2022. Patient-reported HRQoL was assessed with the EuroQol group EQ5D index (EQ5D5L descriptive system and EQ-VAS). The population was followed from 0 to 180 days after discharge, and readmissions and days alive and out of hospital were registered. A Cox proportional hazard model was used to examine HRQoL and the risk of readmission within 30 and 180 days.

RESULTS

Within 30 days, 28.4% of patients were readmitted; within 180 days, the number accumulated to 45.1%. Low self-evaluated HRQoL predicted 180-day readmission and was significantly associated with fewer days out of hospital within both 90 and 180 days. Low HRQoL and discharge with rehabilitation were independent risk factors for short- (30-day) and long-term (180-day) emergency readmission.

CONCLUSION

Patient-perceived quality of life is an independent predictor of 180-day readmission, and the number of days out of hospital was correlated to self-reported HRQoL.

Short and long-term readmission after major emergency abdominal surgery: a prospective Danish study

PURPOSE

Major emergency abdominal surgery is associated with severe in-hospital complications and loss of performance. After discharge, a substantial fraction of patients are readmitted emergently; however, limited knowledge exists of the long-term consequences. The aim of this study was to examine the risks and causes of short-term (30-day) and long-term (180-day) readmission among patients undergoing major emergency abdominal surgery.

METHODS

This study included 504 patients who underwent major emergency abdominal surgery at the Zealand University Hospital between March 1, 2017, and February 28, 2019. The population was followed from 0 to 180 days after discharge, and detailed readmission information was registered. A Cox proportional hazards model was used to examine the independent risk factors for readmission within 30 and 180 days.

RESULTS

From 0 to 30 days after discharge, 161 (31.9%) patients were readmitted emergently, accumulating to 241 (47.8%) patients within 180 days after discharge. The main reasons for short-term readmission were related to the gastrointestinal tract and surgical wounds, whereas long-term readmissions were due to infections, cardiovascular complications, and abdominal pain. Stomal placement was an independent risk factor for short-term readmission, whereas an ASA score of 3 was a risk factor for both short-term and long-term readmission.

CONCLUSION

Close to 50% of all patients who underwent major emergency abdominal surgery had one or more emergency readmission within 180 days of discharge, and these data points towards the risk factors involved.

A Content Framework of a Novel Patient-Reported Outcome Measure for Detecting Early Adverse Events After Major Abdominal Surgery

BACKGROUND

Systematic health monitoring with patient-reported outcome instruments may predict post-discharge complications after major surgery. The objective of this study was to conceptualize a novel patient-reported outcome instrument for detecting early adverse events within two weeks of discharge after major emergency abdominal surgery and colorectal cancer surgery.

METHODS

This study was conducted in two phases. (1) An exhaustive health concept pool was generated using systematic content analysis of existing patient-reported outcome measures (N = 31) and semi-structured interviews of readmitted patients (N = 49) and health professionals (N = 10). Concepts were categorized into three major domains: 'Symptoms,' 'functional status,' and 'general health perception.' We calculated the frequency of each health concept as the proportion of patients, who experienced the respective concept prior to readmission. (2) Colorectal cancer surgeons (N = 13) and emergency general surgeons (N = 12) rated the relevance of each health concept (1 = irrelevant, 5 = very relevant) in the context of detecting post-discharge adverse events. We selected concepts with either a high mean relevance score (≥ 4) or a combination of moderate mean relevance score and high patient-reported frequency (≥ 3 and ≥ 20% or ≥ 2.5 and ≥ 50%, respectively).

RESULTS

Content analysis of existing items with additions from patients and experts resulted in 58 health concepts, of which the majority were distinct symptoms (N = 40). The selection procedure resulted in 29 patient-reported health concepts relevant for detecting adverse events after discharge.

CONCLUSION

The outlined framework provides content validity for future patient-reported outcome instruments detecting adverse events in the early post-discharge period after major emergency abdominal surgery and colorectal cancer surgery.

A comprehensive analysis of 30-day readmissions after emergency general surgery procedures: Are risk factors modifiable?

BACKGROUND

Modifiable risk factors associated with procedure-related 30-day readmission after emergency general surgery (EGS) have not been comprehensively studied. We set out to determine risk factors associated with EGS procedure-related 30-day unplanned readmissions.

METHODS

A retrospective cohort study was conducted using the National Surgical Quality Improvement Project database (2013-2019). It included nine surgical procedures encompassing 80% of the burden of EGS diseases, performed on an urgent/emergent basis. The procedures were classified as low risk (open and laparoscopic appendectomy and laparoscopic cholecystectomy) and high risk (open cholecystectomy, laparoscopic and open colectomy, lysis of adhesions, perforated ulcer repair, small bowel resection, and exploratory laparotomy). Data on patient characteristics, admission status, procedure risk, hospital length of stay, and discharge disposition were analyzed by multivariate logistic regression.

RESULTS

A total of 312,862 patients were included (16,306 procedure-related 30-day readmissions [5.2%]). Thirty-day readmission patients were older, had higher American Association of Anesthesiology scores, were more often underweighted or markedly obese, and were more frequently presented with sepsis. Risk factors associated with EGS procedure-related 30-day unplanned readmissions included age older than 40 years (adjusted odds ratio [AOR], 1.15), American Association of Anesthesiology ≥3 (AOR, 1.41), sepsis present at the time of surgery (AOR, 1.84), body mass index <18 kg/m 2 (AOR, 1.16), body mass index ≥40 kg/m 2 (AOR, 1.12), high-risk procedures (AOR, 1.51), LOS ≥4 d (AOR, 2.04), and discharge except to home (AOR, 1.33). Thirty-day readmissions following low-risk procedures occurred at a median of 5 days (interquartile range, 2-11 days) and 6 days (interquartile range, 3-11 days) after high-risk procedures. Surgical site infections, postoperative sepsis, wound disruption, and thromboembolic events were more prevalent in the 30-day readmission group. Mortality rate was fourfold higher in the 30-day readmission group (2.4% vs. 0.6%).

CONCLUSION

We identified several unmodifiable patients and EGS disease-related factors associated with 30-day unplanned readmissions. Readmissions could be potentially reduced by the implementation of a postdischarge surveillance systems between hospitals and postdischarge destination facilities, leveraging telehealth and outpatient care.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Outcomes after emergency general surgery and trauma care in incarcerated individuals: an EAST multi-center study

BACKGROUND

The US incarcerates more individuals than any other country. Prisoners are the only population guaranteed health care by the US constitution, but little is known about their surgical needs. This multicenter study aimed to describe the acute care surgery (ACS) needs of incarcerated individuals.

METHODS

Twelve centers prospectively identified incarcerated patients evaluated in their emergency department (ED) by the ACS service. Centers collected diagnosis, treatment, and complications from chart review. Patients were classified as either emergency general surgery (EGS) patients or trauma patients and their characteristics and outcomes were investigated. Poisson regression accounting for clustering by center was used to calculate the relative risk (RR) of readmission, re-presentation within 90 days, and failure to follow up as an outpatient within 90 days for each cohort.

RESULTS

Over 12 months, ACS services evaluated 943 patients, 726 (80.3%) from jail, 156 (17.3%) from prison, and 22 (2.4%) from other facilities. Most were men (89.7%) with a median age of 35 years (IQR 27,47). Trauma patients comprised 54.4% (n = 513) of the cohort. Admission rates were similar for trauma (61.5%) and EGS patients (60.2%). Head injuries and facial fractures were the most common injuries, while infections were the most common EGS diagnosis. Self-harm resulted in 102 trauma evaluations (19.9%). Self-inflicted injuries were associated with increased risk of readmission (RR 4.3, 95%CI: 3.02-6.13) and reevaluation within 90 days (RR 4.96, 95%CI 3.07-8.01).

CONCLUSIONS

Incarcerated patients who present with a range of trauma and EGS conditions frequently require admission, and follow-up after hospitalization was low at the treating center. Poor follow-up coupled with high rates of assault, self-harm, mental health, and substance use disorders highlight the vulnerability of this population. Hospital and correctional facility interventions are needed to decrease self-inflicted injuries and assaults while incarcerated.

LEVEL OF EVIDENCE

Prognostic and Epidemiological, III.

The hidden burden of unplanned readmission after emergency general surgery

BACKGROUND

There are no national studies of nonelective readmissions after emergency general surgery (EGS) diagnoses that track nonindex hospital readmission. We sought to determine the rate of overall and nonindex hospital readmissions at 30 and 90 days after discharge for EGS diagnoses, hypothesizing a significant portion would be to nonindex hospitals.

METHODS

The 2013 to 2014 Nationwide Readmissions Database was queried for all patients 16 years or older admitted with an EGS primary diagnosis and survived index hospitalization. Multivariable logistic regression identified risk factors for nonelective 30- and 90-day readmission to index and nonindex hospitals.

RESULTS

Of 4,171,983 patients, 13% experienced unplanned readmission at 30 days. Of these, 21% were admitted to a nonindex hospital. By 90 days, 22% experienced an unplanned readmission, of which 23% were to a nonindex hospital. The most common reason for readmission was infection. Publicly insured or uninsured patients accounted for 67% of admissions and 77% of readmissions. Readmission predictors at 30 days included leaving against medical advice (odds ratio [OR], 2.51 [2.47-2.56]), increased length of stay (4-7 days: OR, 1.42 [1.41-1.43]; >7 days: OR, 2.04 [2.02-2.06]), Charlson Comorbidity Index ≥2 (OR, 1.72 [1.71-1.73]), public insurance (Medicare: OR, 1.45 [1.44-1.46]; Medicaid: OR, 1.38 [1.37-1.40]), EGS patients who fell into the "Other" surgical category (OR, 1.42 [1.38-1.48]), and nonroutine discharge. Risk factors for readmission remained consistent at 90 days.

CONCLUSION

Given that nonindex hospital EGS readmission accounts for nearly a quarter of readmissions and often related to important benchmarks such as infection, current EGS quality metrics are inaccurate. This has implications for policy, benchmarking, and readmission reduction programs.

LEVEL OF EVIDENCE

Epidemiological study, level III.

Unplanned readmission after emergency laparotomy: A post hoc analysis of an EAST multicenter study

BACKGROUND

Hospital readmission is an important quality-of-care indicator. We sought to examine the rates and predictors of unplanned readmission for the high-risk non-trauma emergency laparotomy patient.

METHODS

This is a post hoc analysis of a multicenter prospective observational study. Between April 2018 and June 2019, a total of 19 centers enrolled all adult patients undergoing emergency laparotomies and systematically collected preoperative, operative, and 30-day postoperative variables. For the purpose of this study, we defined unplanned readmission as a readmission occurring within 30 days from discharge and one that was immediately preceded by an emergency department visit. Patients were excluded if they died during the index admission, were discharged to hospice, or were transferred to other hospitals. Predictors of unplanned readmission were evaluated using a multivariable logistic regression model, adjusting for patient demographics, comorbidities, laboratory variables, and preoperative acuity of disease variables.

RESULTS

A total of 1,347 patients were included, of which 234 (17.4%) had an unplanned readmission. The median patient age was 60 y, 49.4% were male, and 71.4% were white. The most common diagnoses were hollow viscus perforation (28.1%) and small bowel obstruction (24.5%). Predictors of unplanned readmission included patient factors (eg, disseminated cancer [odds ratio: 2.22, confidence interval: 1.35-3.64, P = .002], weight loss >10% in the past 6 months [odds ratio: 1.65, confidence interval: 1.07-2.54, P = .023], dyspnea at baseline [odds ratio: 1.62, confidence interval: 1.06-2.48, P = .026], wound complications [odds ratio: 2.23, confidence interval: 1.55-3.19, P < .001], and discharge to nursing homes [odds ratio: 1.68, confidence interval: 1.02-2.80, P = .044]).

CONCLUSION

Unplanned readmission after emergency laparotomies are common, especially for patients with wound complications or requiring nursing homes. These system factors are potential quality improvement targets to reduce readmissions.