Patient readmission and mortality after surgery for hepato-pancreato-biliary malignancies

Exocrine pancreatic insufficiency after partial pancreatectomy: impact on primary healthcare utilization and expenditures

INTRODUCTION

We sought to characterize the impact of exocrine pancreatic insufficiency (EPI) on primary healthcare utilization and expenditures following partial pancreatectomy (PP).

METHODS

Patients who underwent PP between 2004 and 2019 were identified using SEER-Medicare. Patients who developed EPI within 6 months following surgery were included in the EPI cohort and were followed for 1-year post-surgery. Differences in post-surgery PCP visit frequency and healthcare expenditures within 1-year were evaluated.

RESULTS

Among 1119 patients, median age was 74 years (IQR: 69-78), about one-half were female (52.5%), and the majority were White (85.2%). Following PP, 22.4% of patients developed EPI. Patients with EPI were more likely to be concomitantly diagnosed with diabetes following PP (EPI: 11.6% vs. no EPI: 3.7%; p < 0.001). On multivariable analyses, EPI was associated with increased PCP visits (Ref. No EPI; percent difference [%diff]: 29.62, 95%CI 15.15-45.90) and higher healthcare costs (Ref. No EPI; total postoperative expenditure: %diff 37.01, 95%CI 12.89-66.29; p < 0.01) within 1-year following PP.

CONCLUSION

Roughly 1 in 4 patients experienced EPI after PP. EPI was associated with increased PCP utilization and higher healthcare expenditures.

Single stage management of suspected gallbladder cancer guided by intraoperative frozen section analysis: a retrospective cohort study

BACKGROUND

The management of radiologically suspected gallbladder cancers (GBC) that lack definitive radiological features usually involves performing a first-stage routine laparoscopic cholecystectomy, followed by an open second-stage liver resection (segments IVB and V) and hilar lymphadenectomy (extended cholecystectomy) if subsequent formal histology confirms a malignancy. Performing a cholecystectomy with an intraoperative frozen section to guide the need for conversion to an extended cholecystectomy as a single-stage procedure has multiple benefits compared to a two-stage approach. However, the safety and efficacy of this approach have not yet been evaluated in a tertiary setting.

METHODS

A retrospective cohort study was performed using a database of all consecutive patients with suspected GBC who had been referred to our tertiary unit. Following routine cholecystectomy, depending on the operative findings, the gallbladder specimen was removed and sent for frozen-section analysis. If malignancy was confirmed, the depth of tumour invasion was evaluated, followed by simultaneous extended cholecystectomy, when appropriate. The sensitivity and specificity of frozen section analysis for the diagnosis of GBC were measured using formal histopathology as a reference standard.

RESULTS

A total of 37 consecutive cholecystectomies were performed. In nine cases, GBC was confirmed by intraoperative frozen section analysis, three of which had standard cholecystectomy only as their frozen section showed adenocarcinoma to be T1a or below ( n =2) or were undetermined ( n =1). In the remaining six cases, malignant invasion beyond the muscularis propria (T1b or above) was confirmed; thus, a synchronous extended cholecystectomy was performed. The sensitivity (95% CI: 66.4-100%) and specificity (95% CI: 87.7-100%) for identifying GBC using frozen section analysis were both 100%. The net cost of the single-stage pathway in comparison to the two-stage pathway resulted in overall savings of £3894.

CONCLUSION

Intraoperative frozen section analysis is a reliable tool for guiding the use of a safe, single-stage approach for the management of GBC in radiologically equivocal cases. In addition to its lower costs compared to a conventional two-stage procedure, intraoperative analysis also affords the benefit of a single hospital admission and single administration of general anaesthesia, thus greatly enhancing the patient's experience and relieving the burden on waiting lists.

Hospital readmissions after robotic hepatectomy for neoplastic disease: Analysis of risk factors, survival, and economical impact. A logistical regression and propensity score matched study

BACKGROUND

As the first comprehensive investigation into hospital readmissions following robotic hepatectomy for neoplastic disease, this study aims to fill a critical knowledge gap by evaluating risk factors associated with readmission and their impact on survival and the financial burden.

METHODS

The study analyzed a database of robotic hepatectomy patients, comparing readmitted and non-readmitted individuals post-operatively using 1:1 propensity score matching. Statistical methods included Chi-square, Mann-Whitney U, T-test, binomial logistic regression, and Kaplan-Meier analysis.

RESULTS

Among 244 patients, 44 were readmitted within 90 days. Risk factors included hypertension (p ​= ​0.01), increased Child-Pugh score (p ​< ​0.01), and R1 margin status (p ​= ​0.05). Neoadjuvant chemotherapy correlated with lower readmission risk (p ​= ​0.045). Readmissions didn't significantly impact five-year survival (p ​= ​0.42) but increased fixed indirect hospital costs (p ​< ​0.01).

CONCLUSIONS

Readmission post-robotic hepatectomy correlates with hypertension, higher Child-Pugh scores, and R1 margins. The use of neoadjuvant chemotherapy was associated with a lower admission rate due to less diffuse liver disease in these patients. While not affecting survival, readmissions elevate healthcare costs.

Conditional cumulative incidence of postoperative complications stratified by complexity classification for laparoscopic liver resection: Optimization of in-hospital observation

BACKGROUND

The optimal in-hospital observation periods associated with minimal risks of complications and unplanned readmission after laparoscopic liver resection are unknown. The purpose of this study was to assess changes in the risks of postoperative complications over time.

METHODS

Surgical complexity of laparoscopic liver resection was stratified into grades I (low complexity), II (intermediate), and III (high) using our 3-level complexity classification. The cumulative incidence rate and conditional probability of postoperative complication and risk factors for complication Clavien-Dindo grade ≥II (defined as treatment-requiring complications) were assessed.

RESULTS

The cumulative incidence of treatment-requiring complications was higher in patients undergoing grade III resection than in patients undergoing grade I resection (32.3% vs 10.4%, P < .001) and grade II resection (32.3% vs 20.7%, P = .019). The conditional probability of postoperative complication stratified by our complexity classification decreased over time and was <10% for patients undergoing grade I resection on postoperative day 1, grade II resection on postoperative day 4, and grade III resection on postoperative day 10.

CONCLUSION

The conditional cumulative incidence of treatment-requiring complications for patients undergoing laparoscopic liver resection is well stratified based on the 3-level complexity classification. Conditional complication risk analysis stratified by the 3 complexity grades may be useful for optimizing in-hospital observation after laparoscopic liver resection.

Readmission Within the First Day of Discharge Is Painful: Experience From an Australian General Surgical Service

Background Unplanned readmission to the hospital after discharge is a costly issue for healthcare systems and patients. It is a delicate balance between the resolution of the surgical problem and the length of hospital stay. Most studies have focused on readmissions within 28 or 30 days after discharge, despite data showing that many occur early in this period. This study examined the reasons for unplanned readmission within the first day after discharge.  Methods A retrospective cohort analysis of readmissions between 1st May 2016 and 1st May 2021 was undertaken by chart review. Readmissions on the "day of" and the "day after" discharge and their respective index admissions were identified via the hospital's patient administration database, webPAS (DXC Technology, USA). Results There were 126 readmissions (0.5%) across 25,119 admissions. Common reasons for readmission were pain (28%, n=35), readmission for the same diagnosis (21%, n=26), surgical site infection (SSI) (11%, n=14), bleeding (11%, n=14) and ileus (6%, n=7). Analysis of index admissions showed that 18/35 readmissions for pain had inadequate pain management based on pain scores, analgesic use and discharge medications and 7/14 readmissions for SSI did not have appropriate treatment of a recognised SSI or did not have antibiotic prophylaxis guidelines adhered to. Fourteen of 26 readmissions for the same diagnosis received just continuation of treatment initiated at index admission.  Conclusion Pain is the most common reason for readmission within the first day after discharge in surgical patients. Better pain management, following antibiotic prophylaxis guidelines, and involving patients in discharge planning could prevent many readmissions.

Association of Sarcopenia and Low Nutritional Status with Unplanned Hospital Readmission after Radical Gastrectomy in Patients with Gastric Cancer: A Case-Control Study

Objective. Sarcopenia is one of the influencing factors of poor prognosis in patients with gastric cancer but the association with readmission are unknown. We aimed to explore factors associated with readmission after gastrectomy and to determine whether preoperative sarcopenia is a common outcome in readmitted patients. Methods. In this case-control study, patients who underwent gastric resection in the First Affiliated Hospital of Wenzhou Medical University between April 2016 and September 2017 were included. The reasons of readmission patients were described. The readmission patients and non-readmission patients were matched by propensity score matching (PSM). The univariate analysis was applied for the baseline characteristics, operative details, postoperative prognosis and discharge disposition, and multiple logistic regression analysis for the independent risk factors of readmission. Results. The unplanned readmission rate within 30 days of radical gastrectomy for gastric cancer was 6.5% (43/657). The average time interval from discharge to readmission was 13 days. Delayed gastric evacuation was the main cause of readmission (18.6%, 8/43). Body mass index (BMI), nutritional risk screening (NRS) 2002 score, history of abdominal surgery, sarcopenia, and preoperative albumin were included in the multivariate logistic regression analysis. NRS 2002 (OR = 3.43, 95% CI: 1.10–10.72, $P=0.034$ ) and sarcopenia (OR = 4.25, 95% CI: 1.13–16.02, $P=0.033$ ) were found to be independently associated with unplanned readmission within 30 days of radical gastrectomy for cancer. Other factors such as age, sex, BMI, American Society of Anesthesiologists grade, surgical method, operation and reconstruction type, TNM stage, surgical duration, previous abdominal surgery, and preoperative albumin and hemoglobin level were not associated with unplanned readmission after radical gastrectomy for cancer. Conclusions. Sarcopenia and low nutritional status are independently associated with unplanned readmission within 30 days of radical gastrectomy for cancer.

Understanding conditional cumulative incidence of complications following liver resection to optimize hospital stay

BACKGROUND

After liver resection, the in-hospital observation periods associated with minimal risks for complications and unplanned readmission remains unclear. This study aimed to assess changes in risks of complications over time.

METHODS

Surgical complexity of liver resection was stratified into grades I (low complexity), II (intermediate), and III (high). The cumulative incidence rate and risk factors for complication ≥ Clavien-Dindo grade II (defined as treatment-requiring complications) were assessed.

RESULTS

Of 581 patients, grade I, II, and III resections were performed in 81 (13.9%), 119 (20.5%), and 381 patients (65.6%). Complexity grades (I vs. III, hazard ratio [HR] 0.45, P = 0.007; II vs. III, HR 0.60, P = 0.011) and background liver status (HR 1.76, P = 0.004) were risk factors for treatment-requiring complications. The cumulative incidence rate of treatment-requiring complications was higher after grade III resection than grade I resection (38.1% vs. 16.1%, P < 0.001) or grade II resection (38.1% vs. 25.2%, P = 0.019). Without cirrhosis/chronic hepatitis, the cumulative incidence rate of treatment-requiring complications decreased to less than 10% on postoperative day (POD) 3 after grade I resection, POD 5 after grade II resection, and POD 10 after grade III resection.

CONCLUSION

Conditional complication risk analysis stratified by surgical complexity may be useful for optimizing in-hospital observation.

Pilot trial of remote monitoring to prevent malnutrition after hepatopancreatobiliary surgery

Background

Patients undergoing hepatopancreatobiliary (HPB) surgery, such patients with pancreatic, periampullary, and liver cancer, are at high risk for malnutrition. Malnutrition increases surgical complications and reduces overall survival. Despite its severity, there are limited interventions addressing malnutrition after HPB surgery. The aim of this pilot trial was to examine feasibility, acceptability, usability, and preliminary efficacy of a remote nutrition monitoring intervention after HPB surgery.

Methods

Participants received tailored nutritional counseling before and after surgery at 2 and 4 weeks after hospital discharge. Participants also recorded nutritional intake daily for 30 days, and these data were reviewed remotely by registered dietitians before nutritional counseling visits. Descriptive statistics were used to describe study outcomes.

Results

All 26 patients approached to participate consented to the trial before HPB surgery. Seven were excluded after consent for failing to meet eligibility criteria (e.g., did not receive surgery). Nineteen participants (52.6% female, median age = 65 years) remained eligible for remote monitoring post-surgery. Nineteen used the mobile app food diary, 79% of participants recorded food intake for greater than 80% of study days, 95% met with the dietitian for all visits, and 89% were highly satisfied with the intervention. Among participants with complete data, the average percent caloric goal obtained was 82.4% (IQR: 21.7).

Conclusions

This intervention was feasible and acceptable to patients undergoing HPB surgery. Preliminary efficacy data showed most participants were able to meet calorie intake goals. Future studies should examine intervention efficacy in a larger, randomized controlled trial.

Trial registration

Clinicaltrials.gov. Registered 16 September 2019, https://clinicaltrials.gov/ct2/show/NCT04091165.

Risk Factors for 30-Day Unplanned Readmission After Hepatectomy: Analysis of 438 Pediatric Patients from the ACS-NSQIP-P Database

BACKGROUND

Hepatic resections are uncommon in children. Most studies reporting complications of these procedures and risk factors associated with unplanned readmissions are limited to retrospective data from single centers. We investigated risk factors for 30-day unplanned readmission after hepatectomy in children using the American College of Surgeons National Surgical Quality Improvement-Pediatric database.

METHODS

The database was queried for patients aged 0-18 years who underwent hepatectomy for the treatment of liver lesions from 2012 to 2018. Chi-squared tests were performed to evaluate for potential risk factors for unplanned readmissions. A multivariate regression analysis was performed to identify independent predictors for unplanned 30-day readmissions.

RESULTS

Among 438 children undergoing hepatectomy, 64 (14.6%) had unplanned readmissions. The median age of the hepatectomy cohort was 1 year (0-17); 55.5% were male. Patients readmitted had significantly higher rates of esophageal/gastric/intestinal disease (26.56% vs. 14.97%; p=0.022), current cancer (85.94% vs. 75.67%; p=0.012), and enteral and parenteral nutritional support (31.25% vs. 17.65%; p=0.011). Readmitted patients had significantly higher rates of perioperative blood transfusion (67.19% vs. 52.41%; p=0.028), organ/space surgical site infection (10.94% vs. 1.07%; p<.001), sepsis (15.63% vs. 3.74%; p<.001), and total parenteral nutrition at discharge (9.09% vs. 2.66%; p=0.041). Organ/space surgical site infection was an independent risk factor for unplanned readmission (OR=9.598, CI [2.070-44.513], p=0.004) by multivariable analysis.

CONCLUSION

Unplanned readmissions after liver resection are frequent in pediatric patients. Organ/space surgical site infections may identify patients at increased risk for unplanned readmission. Strategies to reduce these complications may decrease morbidity and costs associated with unplanned readmissions.

Hepatopancreatobiliary readmission score out performs administrative LACE+ index as a predictive tool of readmission

BACKGROUND

This study aims to compare the LACE + readmission index to a novel hepatopancreatobiliary readmission risk score (HRRS) in predicting post-operative hepatopancreatobiliary (HPB) cancer patient readmissions.

METHODS

A retrospective review of 104 postoperative HPB cancer patients from January 2017 to July of 2019 was performed. Univariable and multivariable analyses were utilized.

RESULTS

The LACE + index did not predict 30-day (OR 1.01, 95% CI, 0.97-1.05, p = 0.81, c-statistic = 0.52) or 90-day (OR 1.02, 95% CI, 0.98-1.05, p = 0.43) readmission. Patients readmitted within 30 days had significantly increased HRRS scores compared to those who were not (0 vs 34, p < 0.001). A single unit increase in HRRS corresponded to a 6.5% increased risk of readmission; (OR 1.065, 95% CI, 1.038-1.094, p < 0.0001). HRRS independently predicted 30-day (OR 1.07, 95% CI, 1.04-1.11, p < 0.0001) and 90-day postoperative readmission (OR 1.05, 95% CI 1.03-1.08, p < 0.0001).

CONCLUSIONS

HRRS better predicts postoperative readmissions for HPB surgical patients compared to LACE+. Accurate assessment of postoperative readmission must include readmission scores focused on clinically relevant perioperative parameters.

The burden of readmission after discharge from necrotizing soft tissue infection

BACKGROUND

The need for extensive surgical debridement with necrotizing soft tissue infections (NSTIs) may put patients at high risk for unplanned readmission. However, there is a paucity of data on the burden of readmission in patients afflicted with NSTI. We hypothesized that unplanned readmission would significantly contribute to the burden of disease after discharge from initial hospitalization.

METHODS

The Nationwide Readmission Database was used to identify adults undergoing debridement for NSTI hospitalizations from 2010 to 2017. Risk factors for 90-day readmission were assessed by Cox proportional hazards regression.

RESULTS

There were a total of 82,738 NSTI admissions during the study period, of which 25,076 (30.3%) underwent 90-day readmissions. Median time to readmission was 25 days (interquartile range, 9-49 days). Fragmentation of care, longer length of index stay (>2 weeks), and Medicaid status were independent risk factors for readmission. Median cost of a readmission was US $10,543. Readmission added 174,640 hospital days to episodes of care over the study period, resulting in an estimated financial burden of US $1.4 billion.

CONCLUSION

Unplanned readmission caused by NSTIs is common and costly. Interventions that target patients at risk for readmission may help decrease the burden of disease.

LEVEL OF EVIDENCE

Economic/Epidemiological, level IV.

Comparison of cerebral AVMs in patients undergoing surgical resection with and without prior endovascular embolization

AIM

Brain arteriovenous malformations (AVMs) are congenital anomalies that present as intracranial hemorrhage or epilepsy. AVMs often remain clinically silent for extended periods. Although AVM treatment methods are controversial, three treatment strategies are usually combined or applied alone: surgical removal, embolization and stereotactic radiosurgery. We compared clinical and radiological outcomes in intracranial AVM patients treated via surgical resection with and without prior embolization.

MATERIALS AND METHODS

Patients who did (30 patients) and did not (30 patients) undergo endovascular embolization before surgical resection at the İzmir Katip Çelebi University Atatürk Training and Research Hospital Neurosurgery Clinic from 2011 to 2019 were included in this retrospective, cohort study. Symptoms at diagnosis, comorbidities and clinical (AVM and Spetzler-Martin grade) and morphological characteristics were assessed.

RESULTS

A mean one-year follow-up assessed outcomes using the modified Rankin score, and imaging studies assessed AVM obliteration post-procedure. Mean operation times for surgical resection with and without embolization were 166.50 ± 32.02 and 204.47 ± 26.66 min, respectively. Mean patient hospitalization periods for surgical resection with and without embolization were 8.43 ± 3.60 and 12.00 ± 5.51 days, respectively.

CONCLUSION

Among patients who underwent surgical resection, significant operation time and hospitalization time differences were observed in favor of patients who underwent embolization, indicating that preoperative embolization is a safe and beneficial method for treating ruptured and non-ruptured AVMs.

Care Fragmentation and Mortality in Readmission after Surgery for Hepatopancreatobiliary and Gastric Cancer: A Patient-Level and Hospital-Level Analysis of the Healthcare Cost and Utilization Project Administrative Database

BACKGROUND

Hepatopancreatobiliary (HPB) and gastric oncologic operations are frequently performed at referral centers. Postoperatively, many patients experience care fragmentation, including readmission to "outside hospitals" (OSH), which is associated with increased mortality. Little is known about patient-level and hospital-level variables associated with this mortality difference.

STUDY DESIGN

Patients undergoing HPB or gastric oncologic surgery were identified from select states within the Healthcare Cost and Utilization Project database (2006-2014). Follow-up was 90 days after discharge. Analyses used Kruskal-Wallis test, Youden index, and multilevel modeling at the hospital level.

RESULTS

There were 7,536 patients readmitted within 90 days of HPB or gastric oncologic surgery to 636 hospitals; 28% of readmissions (n = 2,123) were to an OSH, where 90-day readmission mortality was significantly higher: 8.0% vs 5.4% (p < 0.01). Patients readmitted to an OSH lived farther from the index surgical hospital (median 24 miles vs 10 miles; p < 0.01) and were readmitted later (median 25 days after discharge vs 12; p < 0.01). These variables were not associated with readmission mortality. Surgical complications managed at an OSH were associated with greater readmission mortality: 8.4% vs 5.7% (p < 0.01). Hospitals with <100 annual HPB and gastric operations for benign or malignant indications had higher readmission mortality (6.4% vs 4.7%, p = 0.01), although this was not significant after risk-adjustment (p = 0.226).

CONCLUSIONS

For readmissions after HPB and gastric oncologic surgery, travel distance and timing are major determinants of care fragmentation. However, these variables are not associated with mortality, nor is annual hospital surgical volume after risk-adjustment. This information could be used to determine safe sites of care for readmissions after HPB and gastric surgery. Further analysis is needed to explore the relationship between complications, the site of care, and readmission mortality.

Effect of Enhanced Recovery After Surgery program on hospital stay and 90-day readmission after pancreaticoduodenectomy: a single, tertiary center experience in Korea

Purpose

Despite increasing number of reports on Enhanced Recovery After Surgery program (ERAS) and readmission after pancreaticoduodenectomy (PD) from Western countries, there are very few reports on this topic from Asian countries. This study aimed to evaluate the effects of ERAS on hospital stay and readmission and to identify reasons and risk factors for readmission after PD.

Methods

This retrospective cohort study included 670 patients who underwent open PD from January 2003 to December 2017. The patients were classified into ERAS (n = 352) and non-ERAS (n = 318) groups. Patients' characteristics, perioperative outcomes, and readmission rates were compared.

Results

There were no significant differences in the postoperative complication rates between the groups. The mean postoperative hospital stay was significantly shorter in the ERAS group (24.5 vs. 18.0 days, P < 0.001), but the 90-day readmission rate was similar in the 2 groups (9.1% vs. 8.5%, P = 0.785). Complications associated with pancreatic fistula (42.4%) were the most common cause for readmission. In the multivariate analysis, diabetes mellitus (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.05–3.24; P = 0.034), preoperative non-jaundice (OR, 0.45; 95% CI, 0.25–0.82; P = 0.009) and severe postoperative complications (OR, 4.12; 95% CI, 2.34–7.26; P < 0.001) were identified as risk factors for readmission.

Conclusion

The results confirmed that the ERAS program for PD was beneficial in reducing postoperative stay without increasing readmission risks. To decrease readmission rates, prudent discharge planning and medical support should be considered in patients who experience severe complications.

Early Fistulography Can Predict Whether Biochemical Leakage Develops to Clinically Relevant Postoperative Pancreatic Fistula

BACKGROUND

As complete prevention of postoperative pancreatic fistula (POPF) after pancreatic surgery remains difficult, many risk factors for clinically relevant POPF (CR-POPF) have been reported. However, their clinical impact could be limited because all previous reports included patients without biochemical leakage (BL) that rarely developed to CR-POPF. Therefore, a new strategy for identifying high-risk patients who develop delayed complications from patients with confirmed BL and for implementing interventions for such patients in the early postoperative period is required. This study aimed to examine the role of fistulography in predicting CR-POPF from confirmed BL.

METHODS

Consecutive patients diagnosed with BL on postoperative day 3 after pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) from January 2013 to June 2015 in our institution were included. Fistulography was performed 1 week after the operation, and the associations between findings on fistulography and delayed complications associated with POPF were evaluated.

RESULTS

Eighty-four (37%) of 227 patients who underwent PD and 45 (48%) of 94 patients who underwent DP were included and divided to two groups according to fistulographic findings (simple type, n = 107, 83%; cavity type, n = 22, 17%). The latter finding was associated with a greater morbidity rate (Clavien-Dindo grade ≥ 2: 36% vs 59%, p = 0.018) and a worse final POPF grade (B/C 64% vs 95%, p = 0.003). In the multivariate analysis, cavity type on fistulography was a significant predictive factor for grade B/C POPF.

CONCLUSIONS

Fistulography is a useful examination for identifying patients with a high risk of developing delayed complications associated with POPF.

Readmission After Surgical Resection and Transplantation for Hepatocellular Carcinoma: A Retrospective Cohort Study

BACKGROUND

Hepatocellular carcinoma (HCC) is a leading cause of cancer mortality worldwide. Liver resections and transplantations have increasingly become feasible options for potential cure. These complex surgeries are inherently associated with increased rates of readmission. In the meanwhile, hospital readmission rates are rapidly becoming an important quality of care metric. Therefore, it is very important to understand the effect of 30-day readmission on mortality and the factors associated with increased 30- and 90-day mortality rates.

METHODS

This is a retrospective cohort study utilizing data from the National Cancer Database. Patients included were 18 years or older who underwent liver resection or liver transplantation for HCC between 2003 and 2011. Our primary outcomes of interest were 30- and 90-day mortality rates. Our primary independent variable of interest was 30-day readmission.

RESULTS

16 658 patients underwent either a liver resection or transplantation for HCC between 2003 and 2011. For patients with liver transplantations, increased readmission rates were associated with lower risks of 30-day mortality (P = .012) but a trend toward higher 90-day mortality (P = .057). Patients who underwent liver resection for HCC also demonstrated increased readmission rates to be associated with lower risk of 30-day mortality (P = .014) but higher 90-day mortality (P ≤ .001).

CONCLUSION

This is the only study to utilize a national database to investigate the association between readmission rates and mortality rates of both liver transplantations and resections for patients with HCC. We demonstrate 30-day readmission to show no increase in 30-day mortality, but rather higher 90-day mortality.

Endoscopic management versus transanal surgery for early primary or early locally recurrent rectal neoplasms-a systematic review and meta-analysis

BACKGROUND

Both endoscopic techniques and transanal surgery are viable options that allow organ preservation for early rectal neoplasms. Whilst endoscopic approaches are less invasive and carry less morbidity, it is unclear whether they are as oncologically effective.

AIM

To compare endoscopic techniques with transanal surgery in the management of early rectal neoplasms.

METHODS

A systematic literature search was performed for randomised and observational studies comparing these techniques. The pre-specified main outcomes measured were en bloc and R0 resection rates and recurrence. Pair-wise meta-analysis was performed.

RESULTS

This review included 1044 patients. Transanal surgery had increased R0 resection rates (odds ratio (OR) 2.66; 95% CI 1.64; 4.31; p < 0.001) versus endoscopic management. The latter was associated with higher rates of incomplete resection (OR 2.25; 95% CI 1.14, 4.46; p = 0.02) and further intervention (OR 1.78; 95% CI 1.09, 2.88; p = 0.02). There was no difference in the rates of late recurrence (OR 1.01; 95% CI 0.53, 1.91; p = 0.99) or further major surgery (OR 0.87; 95% CI 0.39, 1.94; p = 0.73) between the groups. Endoscopic treatment was associated with a shorter operating time (weighted mean difference (WMD) - 12.08; 95% CI - 18.97, - 5.19; p < 0.001) and LOS (WMD - 1.94; 95% CI - 2.43, - 1.44; p < 0.001), as well as lower rates of urinary retention post-operatively (OR 0.12; 95% CI 0.02, 0.63; p = 0.01).

CONCLUSION

Endoscopic techniques should be favoured in the setting of benign early rectal neoplasms given their decreased morbidity and increased cost-effectiveness. However, where malignancy is suspected transanal surgery should be the preferred option given the superior R0 resection rate.

Long-term outcomes after resection of alcohol-related versus hepatitis-related hepatocellular carcinoma: A SEER-Medicare database analysis

BACKGROUND

The objective of this study was to define the relative impact of alcohol and/or hepatitis-related HCC etiology on the outcomes of patients who underwent resection or transplantation for HCC.

METHODS

The SEER-Medicare database was used to identify patients with HCC between 2004 and 2015. Patients with history of alcohol abuse or hepatitis were identified. Overall survival (OS) and cancer-specific survival (CSS) were calculated using the Kaplan-Meier method and multivariable Cox regression analysis.

RESULTS

Among 1140 patients, 11.9% (n = 136) of patients had alcohol-related HCC, 30.0% (n = 342) hepatitis-related HCC, and 58.1% (n = 662) had other cause-related HCC. On multivariable analysis, patients with alcohol-related HCC (HR:1.06, 95%CI:0.82-1.35) or hepatitis-related HCC (HR:1.05, 95%CI:0.88-1.26) had similar hazards of death compared with patients who had non-alcohol/non-hepatitis-related HCC. Patients who had tumor size ≤5 cm had lower hazards of death (HR:0.81, 95%CI:0.68-0.97), while individuals who underwent liver resection (vs. transplantation) had almost a two-fold higher hazards of death (HR:1.99, 95%CI:1.47-2.69).

CONCLUSION

Tumor specific factors (i.e. tumor size and stage) and operative approach (i.e. resection vs. transplantation) -rather than HCC etiology- dictated both OS and CSS.

Factors affecting readmission rates after pancreatectomy

BACKGROUND

Pancreatectomy is a complex operation with a historic readmission rate of approximately 20%. Hospital readmissions lead to increased patient and health system costs, morbidity, and mortality making them a topic of great interest. The objective of this study was to identify factors associated with readmission after pancreatectomy in order to target areas for improvement.

METHODS

Pancreatectomy procedures for malignancy in adults from 2005 to 2011 were identified in the California State Inpatient Database. Descriptive analysis was conducted to evaluate the association between baseline variables and readmission status. Logistic regression models were developed to determine whether the bivariate associations identified persisted after adjusting for patient characteristics.

RESULTS

Of the 4262 patients who underwent a pancreatectomy, 843 (19.8%) were readmitted within 30 days. Readmission rates by year did not vary over the study period. Results from multivariable analysis showed that males, Hispanics, Medicare recipients, patients with an initial length of stay >11 days, patients who were discharged to a skilled nursing facility, and those with chronic anemia were more likely to be readmitted compared to those without these characteristics. The majority of readmissions occurred within 15 days after discharge.

CONCLUSIONS

Readmissions after pancreatectomy are multifactorial. Preoperative optimization, minimizing postoperative complications, and assuring patients have been evaluated by a multidisciplinary team may reduce the readmission rate.

Personalized community-based prehabilitation for a high-risk surgical patient opting for pylorus-preserving pancreaticoduodenectomy: a case report

Introduction: Prehabilitation aims for an optimal physical functioning level before, during, and after hospitalization for major surgery. The purpose of this case report was to illustrate the care pathway of a high-risk patient who opted for pylorus-preserving pancreaticoduodenectomy, including preparation for this procedure by participating in a community-based exercise prehabilitation program. The report describes patient examination, evaluation in decision-making for surgery, the prehabilitation program, and outcomes within the context of the Hypothesis-Oriented Algorithm for Clinicians II.Case Description: The patient was a 75-year-old woman with a history of several comorbidities and a polypoid mass in the descending segment of the duodenum. Based on the preoperative assessment, the level of physical functioning was expected to be insufficient to cope adequately with the stress of hospitalization and surgery.Intervention: A 4-week prehabilitation program, including aerobic, resistance, and functional task training in a community-based physical therapy practice.Outcomes: Prehabilitation had a beneficial impact on improving functional mobility preoperatively (timed up-and-go test score improved from 19.4 to 10.0 s, five times sit-to-stand test score improved from 30.1 to 10.1 s, and two-minute walk test distance improved from 55.0 to 107.0 m). Surgery and postoperative recovery proceeded without complications. She achieved independent physical functioning on postoperative day 6 and was discharged home on postoperative day 12.Conclusion: Preoperative risk-assessment can support clinical decision-making in a high-risk patient opting for major abdominal surgery. Furthermore, a remarkable improvement in physical functioning can be achieved by community-based prehabilitation in a high-risk surgical patient.

Skilled nursing facility (SNF) utilization and impact of SNF star-quality ratings on outcomes following hepatectomy among Medicare beneficiaries

BACKGROUND

An increasing number of patients require admission to a skilled nursing facility (SNF) following surgery. However, the impact of SNF quality on post-operative outcomes is unknown.

METHODS

The Medicare Standard Analytic Files and Nursing Home Compare Dataset were used to define SNF utilization and determine the influence of SNF star quality ratings on outcomes following hepatectomy.

RESULTS

Among 7256 Medicare beneficiaries, 918 (12.7%) required. Compared to patients discharged home, individuals discharged to SNF were older (median age: 75 [IQR 71-80] vs. 71 [IQR 68-76] years), and had a higher incidence of complications such as pulmonary failure, pneumonia, and acute renal failure during index hospitalization (all p < 0.05). Patients sent to a SNF were more likely to be readmitted within 30-days (30.1% vs. 13.4%, p < 0.001). The incidence of new complications within 30- and 90-days of discharge was similar regardless of star quality ratings (all p > 0.05). On multivariable analysis, Charlson comorbidity score ≥3 was the factor most strongly associated with 30-day readmission (OR 1.32-15.29, p = 0.016).

CONCLUSION

While post-discharge outcomes were similar across SNF quality ratings, roughly one in three Medicare patients discharged to a SNF were readmitted within 30-days.

Variation in Preoperative and Postoperative Physical Therapist Management of Patients Opting for Elective Abdominal Surgery

BACKGROUND

Evidence about the role of physical therapy in perioperative care pathways to improve postoperative outcomes is growing. However, it is unclear whether research findings have been translated into daily practice.

OBJECTIVE

The objectives of this study were to describe the current content and between-hospital variability of perioperative physical therapist management for patients undergoing colorectal, hepatic, or pancreatic resection in the Netherlands and to compare currently recommended state-of-the-art physical therapy with self-reported daily clinical physical therapist management.

DESIGN

This was a cross-sectional survey study.

METHODS

Hospital physical therapists were asked to complete an online survey about pre- and postoperative physical therapy at their hospital. To explore the variability of perioperative physical therapist management between hospitals, frequency variables were clustered to determine the level of uniformity. Latent class analysis was performed to identify clusters of hospitals with certain homogeneous characteristics on a 19-item dichotomous scale.

RESULTS

Of 82 eligible Dutch hospitals, 65 filled out the survey (79.3%). Preoperative physical therapy was performed in 34 hospitals (54.0%; 2/65 responding hospitals were excluded from the data analysis). Postoperative physical therapy was performed in all responding hospitals, focusing mainly on regaining independent physical functioning. Latent class analysis identified a 3-class model. Hospitals in classes I and II were more likely to provide preoperative physical therapist interventions than hospitals in class III.

LIMITATIONS

The use of self-reported answers can lead to bias.

CONCLUSIONS

There was a wide degree of variability between hospitals regarding pre- and postoperative clinical physical therapist practice for patients opting for major abdominal surgery. Three different classes of daily practice were identified. Further translation of key research findings into clinical physical therapist practice is advised, especially for hospitals in which the physical therapist is not involved preoperatively. Moreover, improving uniformity by developing up-to-date clinical guidelines is recommended.

Assessment of the Value of Comorbidity Indices for Risk Adjustment in Colorectal Surgery Patients

BACKGROUND AND PURPOSE

Comorbidity indices (CIs) are widely used in retrospective studies. We investigated the value of commonly used CIs in risk adjustment for postoperative complications after colorectal surgery.

METHODS

Patients undergoing colectomy without stoma for colonic neoplasia at a single institution from 2009 to 2014 were included. Four CIs were calculated or obtained for each patient, using administrative data: Charlson-Deyo (CCI-D), Charlson-Romano (CCI-R), Elixhauser Comorbidity Score, and American Society of Anesthesiologists classification. Outcomes of interest in the 90-day postoperative period were any surgical complication, surgical site infection (SSI), Clavien-Dindo (CD) grade 3 or higher complication, anastomotic leak or abscess, and nonroutine discharge. Base models were created for each outcome based on significant bivariate associations. Logistic regression models were constructed for each outcome using base models alone, and each index as an additional covariate. Models were also compared using the DeLong and Clarke-Pearson method for receiver operating characteristic (ROC) curves, with the CCI-D as the reference.

RESULTS

Overall, 1813 patients were included. Postoperative complications were reported in 756 (42%) patients. Only 9% of patients had a CD grade 3 or higher complication, and 22.8% of patients developed an SSI. Multivariable modeling showed equivalent performance of the base model and the base model augmented by the CIs for all outcomes. The ROC curves for the four indices were also similar.

CONCLUSIONS

The inclusion of CIs added little to the base models, and all CIs performed similarly well. Our study suggests that CIs do not adequately risk-adjust for complications after colorectal surgery.

Time to Readmission and Mortality Among Patients Undergoing Liver and Pancreatic Surgery

BACKGROUND

The impact of time to readmission (TTR) on post-discharge mortality has not been well examined. We sought to define the impact of TTR on postoperative mortality after liver or pancreas surgery.

METHODS

A retrospective cohort analysis of liver and pancreas surgical patients was conducted using 2013-2015 Medicare Provider Analysis and Review database. Patients were subdivided into TTR groups: 1-5 days, 6-15, 15-30, 31-60, 61-90, and no readmission. The association of index complication, readmission causes, TTR, and mortality was assessed.

RESULTS

Among 18,177 patients, a total of 4485 (24.7%) patients were readmitted within 90 days of discharge. Major causes for readmission differed across TTR groups. Patients readmitted within 1-15 days were more likely to be readmitted for postoperative infection compared with patients who had a late readmission (1-5 days: 63.1% vs. 6-15 days: 65.0% vs. 61-90 days: 39.3%; P < 0.001). In contrast, causes of late readmissions were more likely related to gastrointestinal complications (1-5 days: 28.9% vs. 61-90 days: 39.7%; P < 0.001). Compared with no readmission, 180-day mortality was highest among patients readmitted within 16-30 days (aOR 3.60; 95% CI 2.94-4.41). Among patients with index complications, patients who were readmitted within 1-5 days had a higher risk-adjusted 180-day mortality than late readmission (1-5 days: 37.3% vs. 61-90 days: 27.1%) (P < 0.001).

CONCLUSIONS

Among patients who were readmitted, the incidence of mortality increased with TTR up to 60 days after discharge yet decreased thereafter. The relation of TTR and mortality was particularly pronounced among those patients who had an index complication. Future efforts should consider TTR when identifying specific approaches to decrease readmission.

Effect of critical care complications on perioperative mortality and hospital length of stay after hepatectomy: A multicenter analysis of 21,443 patients

OBJECTIVE

To determine predictors of critical care complications (CCC) in patients undergoing hepatectomy.

METHODS

All hepatectomy patients in NSQIP from 2012 to 2016 were analyzed. CCC included prolonged ventilation (>48 h), sepsis/septic shock, renal failure/insufficiency, cardiac arrest/AMI and pulmonary embolism.

RESULTS

A total of 21,443 patients underwent hepatectomy during the study period. Overall rate of CCC was 11%, with the most common being sepsis/septic shock (6.1%) and respiratory failure (4.9%). On multivariate analysis the preoperative risk factors associated with CCC included ASA Class IV-V (OR:2.04, p < 0.0001), diabetes (OR = 1.28, p = 0.0001), pre-operative ventilator use (OR: 17.75, p = 0.0003); COPD (OR: 1.65, p < 0.0001); pre-operative weight loss >10% (OR: 1.35, p = 0.0026); pre-operative sepsis (OR: 2.14, p < 0.0001). Propensity score matched analysis demonstrated a significant increased risk of mortality in patients with CCC (OR: 26.75, p < 0.0001) and a prolonged LOS of 10.5 days above the mean (β Estimate: 10.51, p < 0.0001).

CONCLUSIONS

ASA class, diabetes, COPD, pre-operative weight loss >10% and pre-operative sepsis are the strongest predictors of CCC after hepatectomy. The presence of CCC significantly increased the risk of peri-operative mortality 26-fold.

Nationwide outcomes and costs of laparoscopic and robotic vs. open hepatectomy

The safety of hepatectomy continues to improve and it holds a key role in the management of benign and malignant hepatic lesions. Laparoscopic and robotic approaches to hepatectomy are increasingly utilized. The purpose of this study was to compare outcomes and costs of laparoscopic and robotic vs. open approaches to hepatectomy and to determine the national nonelective postoperative readmission rate, including readmission to other hospitals. The Nationwide Readmission Database from 2013 to 2014 was queried for all patients undergoing hepatectomy. Patients undergoing laparoscopic and robotic hepatectomies were compared to patients undergoing open hepatectomy. Multivariate logistic regression was implemented to determine the odds ratios (OR) for non-elective readmission within 45 days. There were 10,870 patients who underwent hepatectomy from 2013 to 2014 and 724 (6.7%) were approached with laparoscopic or robotic technique. The robotic cohort had lower mean cost of the index admission ($24,983 ± $18,329 vs. open $32,391 ± $31,983, p < 0.001, 95% CI - 18,292 to 534), shorter LOS (4.5 ± 3.8 vs. lap 6.8 ± 6.0 vs. open 7.6 ± 7.7 days, p < 0.01), and were less likely to be readmitted within 45 days (7.9% vs. 13.0% lap vs. 13.8% open, p = 0.05). The robotic cohort was slightly younger (mean age 57.5 ± 13.5 vs. lap 60.1 ± 13.8 vs. open 58.9 ± 13.7, p < 0.05), and no significant differences were seen by Charlson Comorbidity Index. Anastomosis of hepatic duct to GI tract carried higher odds of mortality (OR 2.87, p < 0.01) and higher odds of readmission (OR 1.40, p < 0.01). LOS above 7 days increased odds of readmission (OR 2.24, p < 0.01). Nearly one-fifth of patients readmitted after hepatectomy present to a different hospital. Robotic hepatectomy was associated with favorable cost and readmission outcomes compared to laparoscopic and open hepatectomy patients, despite similar patient comorbid burdens and patient's age. Length of stay over 7 days and anastomosis of hepatic duct to GI tract are strong risk factors for readmission and mortality.

Specific Medicare Severity-Diagnosis Related Group Codes Increase the Predictability of 30-Day Unplanned Hospital Readmission After Pancreaticoduodenectomy

BACKGROUND

The Medicare Severity-Diagnosis Related Group coding system (MS-DRG) is routinely used by hospitals for reimbursement purposes following pancreatic surgery. We aimed to determine whether specific pancreatectomy MS-DRG codes, when combined with distinct clinicopathologic and perioperative characteristics, increased the accuracy of predicting 30-day readmission after pancreaticoduodenectomy (PD).

METHODS

Demographic, clinicopathologic, and perioperative factors were compared between readmitted and non-readmitted patients at Brigham and Women's Hospital following PD. Different pancreatectomy DRG codes, currently used for reimbursement purposes [407: without complication/co-morbidity (CC), 406: with CC, and 405: with major CC] were combined with clinical factors to assess their predictability of readmission. Univariate and multivariable analyses were performed to evaluate outcomes.

RESULTS

Among 354 patients who underwent PD between 2010 and 2017, 69 (19%) were readmitted. The incidence of readmission was 13, 32, and 55% for patients with assigned DRG codes 407, 406, and 405, respectively (P = 0.0395). Readmitted patients were more likely to have had T4 disease (P = 0.0007), a vascular resection (P = 0.0078), and longer operative times (P = 0.012). On multivariable analysis, combining DRG 407 with relevant clinicopathologic factors was unable to predict readmission. In contrast, DRG 406 code among patients with N positive disease (P = 0.0263) and LOS > 10 days (P = 0.0505) was associated with readmission. DRG 405, preoperative obstructive jaundice (OR: 7.5, CI: 1.5-36, P = 0.0130), vascular resection (OR: 7.7, CI: 1.1-51, P = 0.0336), N positive stage of disease (OR: 0.2, CI: 0-0.9, P = 0.0447), and operative time > 410 min (OR: 5.9, CI: 1-32, P = 0.0399) were each strongly associated with 30-day readmission after PD [likelihood ratio (LR) < 0.0001].

CONCLUSIONS

Distinct pancreatectomy MS-DRG classification codes (405), combined with relevant clinicopathologic and perioperative characteristics, strongly predicted 30-day readmission after PD. DRG classification algorithms can be implemented to more accurately identify patients at a higher risk of readmission.

Surrogate indicators of quality are associated with survival following surgical treatment for hepatocellular carcinoma

INTRODUCTION

Quality/core measures have been collected for over 10 years. Studies have demonstrated hospital performance is related to postoperative outcomes. We hypothesize that hospital quality measures are associated with long-term survival following surgical resection for hepatocellular carcinoma (HCC).

METHODS

The National Cancer Data Base was queried for all HCC cases. Individual hospitals were deidentified. Quality markers were defined as hospital-specific median length of stay (LOS), 30-day mortality rate and readmit rate. A Cox regression stratified by stage estimated survival. To minimize confounding, a landmark analysis was estimated for patients that survived greater than 30 days.

RESULTS

A total of 16 202 HCC patients underwent surgical resection and 996 (6.1%) died within 30 days following surgery. Calculated by unique hospital, median 30-day death rate was 4.6% (interquartile range [IQR]: 1.2% to 7.6%). Thirty-day readmit rate was 2.6% (IQR: 0% to 5.9%) and median LOS was 8.0 days (IQR: 6.5 to 9.2). In the multivariate Cox regression, 30-day death rate (hazard ratio [HR], 1.89; 95% confidence interval [CI]: 1.32 to 2.71) and longer LOS (HR, 1.02; 95% CI: 1.01 to 1.02) were associated with worse survival. Higher 30-day readmission rate was associated with improved survival (HR, 0.61; 95% CI, 0.38 to 0.97).

CONCLUSIONS

Hospital-level surrogate markers of surgical quality appear to be significantly associated with HCC survival following resection. Patients treated in higher 30-day mortality centers, experienced worse outcomes. Individual hospitals should critically review disease-specific outcomes following resection to identify areas for improvement.

Assessment of length of stay in a general surgical unit using a zero-inflated generalized Poisson regression

Background: The effective use of limited health care resources is of prime importance. Assessing the length of stay (LOS) is especially important in organizing hospital services and health system. This study was conducted to identify predictors of LOS among patients who were admitted to a general surgical unit.

Methods: In this cross-sectional study, the sample included all patients who were admitted to the general surgical unit of Shariati hospital in 2013 (n= 334). To determine the factors affecting LOS, Zero-inflated Poisson (ZIP), zero-inflated negative binomial (ZINB), and zero-inflated generalized Poisson (ZIGP) regression models were fitted using R software, and then the best model was selected.

Results: Among all 334 patients, the mean (±SD) age of the patients was 45.2 (±16.47) years and 220 (65.9%) of them were male. The results revealed that based on ZIGP model, type of surgery (appendicitis, abdomen and its contents, hemorrhoids, lung, and skin), type of insurance, comorbid diseases (hypertension, heart disease, and hyperlipidemia), place of residence (local and non-local), age, and number of tests had significant effects on the LOS of GS patients.

Conclusion: According to the Akaike information criterion (AIC) in each fitted model, it was found that ZIGP regression model is more appropriate than ZIP and ZINB regression models in assessing LOS in GS patients, especially due to the presence of excess zeros and overdispersion in count data.

Predictors of 30-day readmission following pancreatic surgery: A retrospective review

BACKGROUND

Pancreatectomies have been identified as procedures with an increased risk of readmission. In surgical patients, readmissions within 30 days of discharge are usually procedure-related. We sought to determine predictors of 30-day readmission following pancreatic resections in a large healthcare system.

METHODS

We retrospectively collected information from the records of 383 patients who underwent pancreatic resections from 2004-2013. To find the predictors of readmission in the 30 days after discharge, we performed a univariate screen of possible variables using the Fisher's exact test for categorical variables and the Mann-Whitney U test for continuous variables. Multivariate analysis was used to determine the independent factors.

RESULTS

Fifty-eight (15.1%) patients were readmitted within 30 days of discharge. Of the patients readmitted, the most common diagnoses at readmission were sepsis (17.2%), and dehydration (8.6%). Multivariate logistic regression found that the development of intra-abdominal fluid collections (OR = 5.32, P < 0.0001), new thromboembolic events (OR = 4.08, P = 0.016), and pre-operative BMI (OR = 1.06, P = 0.040) were independent risk factors of readmission within 30 days of discharge.

CONCLUSION

Our data demonstrate that factors predictive of 30-day readmission are a combination of patient characteristics and the development of post-operative complications. Targeted interventions may be used to reduce the risk of readmission.

The impact of a malignant diagnosis on the pattern and outcome of readmission after liver and pancreatic surgery: An analysis of the nationwide readmissions database

BACKGROUND AND OBJECTIVES

Reducing readmissions is an important quality improvement metric. We sought to investigate patterns of 90-day readmission after hepato-pancreatic (HP) procedures.

METHODS

The Nationwide Readmissions Database (NRD) was used to identify patients undergoing HP procedures between 2010 and 2014. Patients were stratified according to benign versus malignant HP diagnoses and as index (same hospital as operation) versus non-index (different hospital) readmissions.

RESULTS

Among the 41 059 patients who underwent HP procedures, 26 563 (65%) underwent a liver resection while 14 496 (35%) pancreatic resection. Among all patients, 11 902 (29%) had a benign diagnosis versus 29 157 (71%) who had a cancer diagnosis. Overall 90-day readmission was 22% (n = 8 998) with a slight increase in readmissions among patients with a malignant (n = 6 655;23%) versus benign (n = 2 343;20%) diagnosis (P < 0.001). Readmission to an index hospital was more common (n = 7 316 81%) versus a non-index hospital (n = 1 682 19%). Non-index hospital readmissions were more frequent among patients with malignant HP diagnoses (OR, 1.41;P  = 0.001).

CONCLUSIONS

Up to one in four patients were readmitted after HP surgery. Late readmission was more common among patients with a cancer-diagnosis. While most readmissions occurred at the index hospital, 19% of all readmissions occurred at a non-index hospital and were more frequent among patients with malignant diagnoses.

Readmission Patterns After GI Cancer Hospitalizations: The Medical Versus Surgical Patient

PURPOSE

Readmission within 30 days has been used as a metric for quality of care received at hospitals for certain diagnoses. In the era of accountability, value-based care, and increasing cancer costs, policymakers are looking into cancer readmissions as well. It is important to describe the readmission profile of patients with cancer in the most clinically relevant approach to inform policy and health care delivery that can positively impact patient outcomes.

PATIENTS AND METHODS

We conducted a retrospective cohort study using linked Texas Cancer Registry and Medicare claims data. We included elderly Texas residents diagnosed with GI cancer and identified risk factors for unplanned readmission using generalized estimating equations, comparing medical with surgical cancer-related hospitalizations.

RESULTS

We analyzed 69,693 hospitalizations from 31,736 patients. The unplanned readmission rate was higher after medical hospitalizations than after surgical hospitalizations (21.6% v 13.4%, respectively). Shared risk factors for readmission after medical and surgical hospitalizations included advanced disease stage, high comorbidity index, and emergency room visit and radiation therapy within 30 days before index hospitalization. Several other associated factors and reasons for readmission were noted to be unique to medical or surgical hospitalizations alone.

CONCLUSION

Unplanned readmissions among elderly patients with GI cancer are more common after medical hospitalizations compared with surgical hospitalizations. There are shared risk factors and unique risk factors for these hospitalizations that can inform policy, health care delivery, and interventions to reduce readmissions. Other findings underscore the importance of care coordination and comorbidity management in this patient population.

Factors associated with prolonged length of stay for elective hepatobiliary and neurosurgery patients: a retrospective medical record review

BACKGROUND

Patients with prolonged length of hospital stay (LOS) not only increase their risks of nosocomial infections but also deny other patients access to inpatient care. Hepatobiliary (HPB) malignancies have some of highest incidences in East and Southeast Asia and the management of patients undergoing HPB surgeries have yet to be standardized. With improved neurosurgery techniques for intracranial aneurysms and tumors, neurosurgeries (NS) can be expected to increase. Elective surgeries account for far more operations than emergencies surgeries. Thus, with potentially increased numbers of elective HPB and NS, this study seeks to explore perioperative factors associated with prolonged LOS for these patients to improve safety and quality of practice.

METHODS

A retrospective cross-sectional medical record review study from January 2014 to January 2015 was conducted at a 1250-bed tertiary academic hospital in Singapore. All elective HPB and NS patients over 18 years old were included in the study except day and emergency surgeries, resulting in 150 and 166 patients respectively. Prolonged LOS was defined as above median LOS based on the complexity of the surgical procedure. The predictor variables were preoperative, intraoperative, and postoperative factors. Student's t-test and stepwise logistic regression analyses were conducted to determine which factors were associated with prolonged LOS.

RESULTS

Factors associated with prolonged LOS for the HPB sample were age and admission after 5 pm but for the NS sample, they were functional status, referral to occupational therapy, and the number of hospital-acquired infections.

CONCLUSION

Our findings indicate that preoperative factors had the greatest association with prolonged LOS for HPB and NS elective surgeries even after adjusting for surgical complexity, suggesting that patient safety and quality of care may be improved with better pre-surgery patient preparation and admission practices.

The Impact of Surgeon Volume on Outcomes After Pancreaticoduodenectomy: a Meta-analysis

BACKGROUND

Despite significant improvement in operative mortality rates following pancreaticoduodenectomy (PD), morbidity remains high. Outcomes following PD may be improved in high-volume centers and with high-volume surgeons. We sought to evaluate the association between surgeon experience and postoperative outcomes after PD.

METHODS

An online database search of MEDLINE and EMBASE was performed; key bibliographies were reviewed. Studies comparing operative outcomes of high-volume surgeon (HVS) and low-volume surgeon (LVS) performing PD were included. Odds ratios with the corresponding 95% confidence intervals (CI) by random fixed effects models of pooled data were calculated. Definition of HVS varied among the studies, ranging from 6 to >20 PD/year. The primary endpoint was 30-day mortality, and secondary outcomes were complication rates, length of stay (LOS), hospital costs, and readmission rates. Study quality was assessed using STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) criteria.

RESULTS

Search strategy yielded 360 publications. Eleven studies met the inclusion criteria comprising 36,449 patients. Among these patients, 12,512 (34.3%) PDs were performed by HVS and 23,937 (65.7%) by LVS. Meta-analysis of included studies showed that HVS had significantly lower mortality rates than LVS (2.4 vs. 6.7%, OR 2.88; 95% CI 2.51-3.27, p < 0.001). They also had significantly lower overall complication rates (36.3 vs. 50.3%, OR 1.71; 95% CI 1.62-1.81, p < 0.001), hospital costs (range $10,818-141,322 vs. $12,114-198,678, OR 0.13; 95% CI 0.07-0.19, p < 0.001), and LOS (range 11-35 vs. 14-38 days, OR 2.86; 95% CI 2.03-3.68, p < 0.001).

CONCLUSIONS

HVS performing PD have significantly better outcomes than LVS in terms of decreased mortality, morbidity, LOS, and hospital costs. Efforts toward increased regionalization of care should be discussed. Consensus regarding definition of HVS needs to be undertaken.

Preoperative Renal Insufficiency: Underreporting and Association With Readmission and Major Postoperative Morbidity in an Academic Medical Center

BACKGROUND

Making a formal diagnosis of chronic kidney disease (CKD) in the preoperative setting may be challenging because of lack of longitudinal data. We explored the predictive value of a single reduced preoperative estimated glomerular filtration rate (eGFR) value on adverse patient outcomes in the first 30 days after elective surgery. We compared the rate of major postoperative adverse events, including 30-day readmission rate, hospital length of stay, infection, acute kidney injury (AKI), and myocardial infarction across patients with declining preoperative eGFR values. We hypothesized that there is an association between decreasing preoperative eGFR values and major postoperative morbidity including readmission within 30 days of discharge and that the reasons for unplanned readmissions may be associated with poor preoperative renal function.

METHODS

This was a retrospective analysis of the electronic health record of 39 989 adult patients who underwent elective surgery between June 2011 and July 2013 at our institution. Patients with reduced eGFR (<60 mL/min/1.73 m) were identified and categorized by the stages of CKD that correlated with the preoperative eGFR value. Odds of readmission to our hospital within 30 days, as well as new diagnosis of AKI, myocardial infarction, and infection, were determined with multivariate logistic regression. The subset of patients who were readmitted within 30 days also were subdivided further into patients who had an eGFR <60 mL/min/1.73 m and those with an eGFR ≥60 mL/min/1.73 m, as well as whether the readmission was planned or unplanned.

RESULTS

Of the 4053 patients with eGFR <60 mL/min/1.73 m, 3290 (81.2%) did not carry a preoperative diagnosis of CKD. Adjusted odds ratios of being readmitted were 1.48 (99% confidence interval [CI], 1.18-1.87; P < .001) for eGFR 30 to 44 mL/min/1.73 m to 2.06 (99% CI, 1.32-3.23; P < .001) for eGFR <15 mL/min/1.73 m compared with patients with a preoperative eGFR value ≥60 mL/min/1.73 m. Patients with a lower eGFR also demonstrated increasing odds of AKI from 2.78 (99% CI, 1.86-4.17; P < .001) for eGFR 45 to 59 mL/min/1.73 m to 3.81 (99% CI, 1.68-8.16; P < .001) for eGFR <15 mL/min/1.73 m.

CONCLUSIONS

This study highlights that preoperative renal insufficiency may be underreported and appears to be significantly associated with postoperative complications. It extends the association between a single low preoperative eGFR and postoperative morbidity to a broader range of surgical populations than previously described. Our results suggest that preoperative calculation of eGFR may be a relatively low-cost, readily available tool to identify patients who are at an increased risk of readmission within 30 days of surgery and postoperative morbidity in patients presenting for elective surgery.

Costs and Consequences of Early Hospital Discharge After Major Inpatient Surgery in Older Adults

Importance

As prospective payment transitions to bundled reimbursement, many US hospitals are implementing protocols to shorten hospitalization after major surgery. These efforts could have unintended consequences and increase overall surgical episode spending if they induce more frequent postdischarge care use or readmissions.

Objective

To evaluate the association between early postoperative discharge practices and overall surgical episode spending and expenditures for postdischarge care use and readmissions.

Design, Setting, and Participants

This investigation was a cross-sectional cohort study of Medicare beneficiaries undergoing colectomy (189 229 patients at 1876 hospitals), coronary artery bypass grafting (CABG) (218 940 patients at 1056 hospitals), or total hip replacement (THR) (231 774 patients at 1831 hospitals) between January 1, 2009, and June 30, 2012. The dates of the analysis were September 1, 2015, to May 31, 2016. Associations between surgical episode payments and hospitals' length of stay (LOS) mode were evaluated among a risk and postoperative complication-matched cohort of patients without major postoperative complications. To further control for potential differences between hospitals, a within-hospital comparison was also performed evaluating the change in hospitals' mean surgical episode payments according to their change in LOS mode during the study period.

Exposure

Undergoing surgery in a hospital with short vs long postoperative hospitalization practices, characterized according to LOS mode, a measure least sensitive to postoperative outliers.

Main Outcomes and Measures

Risk-adjusted, price-standardized, 90-day overall surgical episode payments and their components, including index, outlier, readmission, physician services, and postdischarge care.

Results

A total of 639 943 Medicare beneficiaries were included in the study. Total surgical episode payments for risk and postoperative complication-matched patients were significantly lower among hospitals with lowest vs highest LOS mode ($26 482 vs $29 250 for colectomy, $44 777 vs $47 675 for CABG, and $24 553 vs $27 927 for THR; P < .001 for all). Shortest LOS hospitals did not exhibit a compensatory increase in payments for postdischarge care use ($4011 vs $5083 for colectomy, P < .001; $6015 vs $6355 for CABG, P = .14; and $7132 vs $9552 for THR, P < .001) or readmissions ($2606 vs $2887 for colectomy, P = .16; $3175 vs $3064 for CABG, P = .67; and $1373 vs $1514 for THR, P = .93). Hospitals that exhibited the greatest decreases in LOS mode had the highest reductions in surgical episode payments during the study period.

Conclusions and Relevance

Early routine postoperative discharge after major inpatient surgery is associated with lower total surgical episode payments. There is no evidence that savings from shorter postsurgical hospitalization are offset by higher postdischarge care spending. Therefore, accelerated postoperative care protocols appear well aligned with the goals of bundled payment initiatives for surgical episodes.

Is enhanced recovery enough for reducing 30-d readmissions after surgery?

BACKGROUND

Few enhanced recovery pathways (ERPs) include processes related to the hospital to home transfer. Little has been reported regarding readmissions in enhanced recovery programs. This study evaluates readmissions and identifies areas to optimize ERPs to prevent readmissions.

METHODS

We conducted an observational, retrospective study at a single tertiary care center. Patients in an ERP for colorectal surgery were compared with a similar cohort who underwent surgery before protocol implementation. We evaluated 30-d readmission, compliance to enhanced recovery protocol, and diagnoses and patient care experiences related to transition of care.

RESULTS

Readmission rates (17.6% versus 19.4%; P = 0.55) were similar. There was significant reduction in index hospitalization length of stay (5.3 versus 7.0 d; P < 0.001) and postoperative surgical site infection (7.3% versus 16.6%; P = 0.01). Although enhanced recovery was associated with reduced readmissions for surgical site infections (31% versus 50.7%, P = 0.02), there was a trend toward increased readmissions for small bowel obstruction-ileus (31% versus 19.1%, P = 0.13). ERPs did not impact perceptions of care transitions; however, those who were readmitted rated their transition lower than those that were not.

CONCLUSIONS

Although ERPs did not reduce readmissions, the program was associated with reduced length of stay and surgical site infections. ERPs did not influence perceptions of the transition to home. Transition process measures aimed at reducing readmission and improving patient outcomes, including use of transition guides, remote vital sign and symptom monitoring, and early clinical follow-up have not traditionally been part of ERP protocols but should be considered.

Pediatric surgical readmissions: Are they truly preventable?

BACKGROUND/PURPOSE

Reimbursement penalties for excess hospital readmissions have begun for the pediatric population. Therefore, research determining incidence and predictors is critical.

METHODS

A retrospective review of University HealthSystem Consortium database (N=258 hospitals; 2,723,621 patients) for pediatric patients (age 0-17years) hospitalized from 9/2011 to 3/2015 was performed. Outcome measures were 7-, 14-, and 30-day readmission rates. Hospital and patient characteristics were evaluated to identify predictors of readmission.

RESULTS

Readmission rates at 7, 14, and 30days were 2.1%, 3.1%, and 4.4%. For pediatric surgery patients (N=260,042), neither index hospitalization length of stay (LOS) nor presence of a complication predicted higher readmissions. Appendectomy was the most common procedure leading to readmission. Evaluating institutional data (N=5785), patients admitted for spine surgery, neurosurgery, transplant, or surgical oncology had higher readmission rates. Readmission diagnoses were most commonly infectious (37.2%) or for nausea/vomiting/dehydration (51.1%). Patients with chronic medical conditions comprised 55.8% of patients readmitted within 7days. 92.0% of patients requiring multiple rehospitalizations had comorbidities.

CONCLUSIONS

Readmission rates for pediatric patients are significantly lower than adults. Risk factors for adult readmissions do not predict pediatric readmissions. Readmission may be a misnomer for the pediatric surgical population, as most are related to chronic medical conditions and other nonmodifiable risk factors.

LEVEL OF EVIDENCE

Level IV.

Clinical predictors and outcome implications of early readmission in lung transplant recipients

BACKGROUND

The purpose of this study was to identify risk factors and outcome implications for 30-day hospital readmission in lung transplant recipients.

METHODS

We conducted a retrospective cohort study of lung transplant cases from a single, high-volume lung transplant program between January 2000 and March 2012. Demographic and health data were reviewed for all patients. Risk factors for 30-day readmission (defined as readmission within 30 days of discharge from index lung transplant hospitalization) were modeled using logistic regression, with selection of parameters by backward elimination.

RESULTS

The sample comprised 795 patients after excluding scheduled readmissions and in-hospital deaths. Overall 30-day readmission rate was 45.4% (n = 361). Readmission rates were similar across different diagnosis categories and procedure types. By univariate analysis, post-operative complications that predisposed to 30-day readmission included pneumonia, any infection, and atrial fibrillation (all p < 0.05). In the final multivariate model, occurrence of any post-transplant complication was the most significant risk factor for 30-day readmission (odds ratio = 1.764; 95% confidence interval, 1.259-2.470). Even for patients with no documented perioperative complication, readmission rates were still >35%. Kaplan-Meier analysis and multi-variate regression modeling to assess readmission as a predictor of long-term outcomes showed that 30-day readmission was not a significant predictor of worse survival in lung recipients.

CONCLUSIONS

Occurrence of at least 1 post-transplant complication increases risk for 30-day readmission in lung transplant recipients. In this patient population, 30-day readmission does not predispose to adverse long-term survival. Quality indicators other than 30-day readmission may be needed to assess hospitals that perform lung transplantation.

Discharge with Pancreatic Fistula after Pancreaticoduodenectomy Independently Predicts Hospital Readmission

Readmission rates after pancreaticoduodenectomy (PD) are among the highest of any surgical procedure. The purpose of this study was to identify those factors present at discharge that may predict readmission after PD. All patients undergoing PD between 2010 and 2015 at a very high (>35 PD/year) volume center were entered into a prospective database. Twenty factors present at discharge from index admission identified on univariate analysis were subjected to multivariate analysis to identify those independently predictive of 30-day hospital readmission. A total of 220 patients underwent PD during the study period, 88 per cent of which had cancer. Mean age was 64.4 ± 11.7 years with slight male preponderance (54.5%) and significant African American representation (33.2%). Surgical complications occurred in 67.3 per cent of patients the most common of which included infectious/leak (30%), gastrointestinal (29%), cardiorespiratory (13%), other (13%), minor complications (7%), multi system failure (5%), and new onset diabetes (3%). The 30-day readmission rate was 27.3 per cent and was due to infection (89%), failure to thrive (32%), nausea/vomiting (15%), or other (15%). On multivariate analysis, presence of pancreatic leak/fistula at discharge was the only significant predictor of readmission, present in 62.5 per cent of all readmitted patients ( P = 0.001). Comorbidities, length of stay, insurance status, obesity, smoking, and discharge to a care venue other than home did not predict readmission. Patients manifesting pancreatic fistula after PD are at high risk for hospital readmission. Enhanced scrutiny regarding suitability for discharge should be exercised in these patients and measures taken to minimize readmission whenever possible.

A matched-cohort analysis of 192 pancreatic anaplastic carcinomas and 960 pancreatic adenocarcinomas: A 13-year North American experience using the National Cancer Data Base (NCDB)

BACKGROUND

Anaplastic pancreatic carcinoma (APC) is a rare and poorly characterized disease. We sought to compare the clinical characteristics and outcomes of APC to pancreatic adenocarcinoma (PDAC).

METHODS

The American National Cancer Data Base was queried for patients with resected APC and PDAC using histologic and operative codes. APC cases were matched 1:5 with PDACs based on age, sex, pathologic tumor stage, operative margin status, lymph node positivity ratio, and use of adjuvant chemotherapy.

RESULTS

After 1:5 matching, 192 APCs and 960 PDACs were analyzed. When comparing APC vs PDAC the median tumor size was 45 mm (interquartile range, 33-60) vs 30 mm (interquartile range, 23-40; P < .001), and metastatic nodal disease was present in 40.6% and 38.0% of the cases (P = .25), respectively. APC cases were distributed equally between the head and the body/tail region of the pancreas (50%), while PDAC cases were located mainly in the head of the pancreas (75%; P < .001). Although the resected APC group had a lesser survival during the first year after the diagnosis (51% vs 69%; P = .029), the overall survival was similar in the 2 groups, with 21.6% vs 17.4% alive at 5 years, respectively for APC and PDAC (P = .32). Subgroup analysis of patients with APC with (n = 18) versus those without (n = 80) osteoclastlike giant cells showed a greater 5-year survival (50% versus 15%, P < .001).

CONCLUSION

Patients with resected APC tend to present with large tumors equally distributed between the head and body/tail of the pancreas. While APC is thought to have a more aggressive biology, our matched analysis showed similar overall survival compared with PDAC. The presence of osteoclastlike giant cells portends a significantly better prognosis compared with other histologic features of APCs.