Hospital readmission after a pancreaticoduodenectomy: an emerging quality metric?

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1 DOI: /j x HPB ORIGINAL ARTICLE Hospitl redmission fter pncreticoduodenectomy: n emerging qulity metric? Zchry J. Kstenberg, John M. Morton, Brendn C. Visser, Jeffrey A. Norton & George A. Poultsides Deprtment of Surgery, Stnford University Medicl Center, Stnford, CA, USA Abstrct Bckground: Hospitl redmission hs ttrcted ttention from policymkers s mesure of qulity nd trget for cost reduction. The im of the study ws to evlute the frequency nd ptterns of rehospitliztion fter pncreticoduodenectomy (PD). Methods: The records of ll ptients undergoing PD t n cdemic medicl centre for mlignnt or benign dignoses between Jnury 2006 nd September 2011 were retrospectively reviewed. The incidence, etiology nd predictors of subsequent redmission(s) were nlysed. Results: Of 257 consecutive ptients who underwent PD, 50 (19.7%) were redmitted within 30 dys from dischrge. Both the presence of ny post-opertive compliction (P = 0.049) nd dischrge to nursing/rehbilittion fcility or to home with helth cre services (P = 0.018) were ssocited with redmission. The most common resons for redmission were diet intolernce (36.0%), pncretic fistul/bscess (26.0%) nd superficil wound infection (8.0%). Nine (18.0%) redmissions hd lengths of sty of 2 dys or less nd in four of those (8.0%) dignostic evlution ws eventully negtive. Conclusion: Approximtely one-fifth of ptients require hospitl redmission within 30 dys of dischrge fter PD. A smll frction of these redmissions re short (2 dys or less) nd my be preventble or mngeble in the outptient setting. Received 18 My 2012; ccepted 10 August 2012 Correspondence George A. Poultsides, Division of Surgicl Oncology, Stnford University School of Medicine, 300 Psteur Drive, H3680D, Stnford, CA , USA. Tel: Fx: E-mil: gpoultsides@stnford.edu Introduction The Affordble Cre Act (ACA) of 2010 set the foundtion for number of new qulity mesures for the helth cre system. Beginning s erly s October of 2012, Medicre reimbursements will likely be decresed for 30-dy hospitl redmissions bove specified observed-to-expected rtio for cute myocrdil infrction (AMI), hert filure nd pneumoni. 1 It is nticipted tht the list of conditions to which these rules re pplied will expnd in the Sources of Funding: This project ws supported in prt by Grnt Number HS from AHRQ (ZJK) nd its contents re solely the responsibility of the uthors nd do not necessrily represent the officil views of the AHRQ. This mnuscript ws presented t the nnul AHPBA meeting, Mimi, 7 11 Mrch coming yers. Complex bdominl surgery is of prticulr interest for cost svings given high rtes of post-opertive morbidity nd redmission. Pncreticoduodenectomy (PD) hs been the focus of redmission studies given post-opertive morbidity rtes of 40 60% nd 30-dy redmission rtes rnging from 16 22% (Tble 1). 2 8 Redmission fter PD is commonly ssocited with number of procedure-specific complictions s well s with generl postopertive complictions nd disese progression. While the debte continues regrding whether ny of these redmissions re truly preventble, it is cler tht there is n ssocited economic burden. A recent study by Kent et l. found n pproximte increse in men overll medicl cost of $ per ptient redmitted fter PD ($41 000) reltive to their non-redmitted counterprts ($25 000). 2

2 HPB 143 Tble 1 Previous studies on incidence nd predictors of redmission fter mjor pncretic surgery Author Yer Study period Grewl et l Singleinstitution Kent et l Singleinstitution Type PD (n) Redmission with 30 dys from dischrge Predictors of redmission % LOS, chronic pncretitis, trnsfusion % Smll duct (<3 mm), ny/mjor complictions, clinicl or ltent pncretic fistul, DGE, SSI Reddy et l SEER % LOS > 10 dys, distl pncretectomy Yermilov et l OSHPD % LOS, ge >73 yrs, T-stge, comorbidity Not predictors of redmission Commorbidities, complictions, biliry stent, BMI, pylorus preservtion, vsculr reconstruction Age, gender, BMI, ASA, POSSUM, mlignncy, blood loss, trnsfusion Demogrphics, complictions Gender, rce, nodl sttus Within dys fter surgery. ASA, Americn Society of Anesthesiologists Physicl Sttus clssifiction system; BMI, body mss index; DGE, delyed gstric emptying; EBL, estimted blood loss; LOS, length of sty; OSHPD, Office of Sttewide Helth Plnning nd Development dtbse; PD, pncreticoduodenectomy; POSSUM, Physiologicl nd Opertive Severity Score for the enumertion of Mortlity nd Morbidity predictor of risk; SEER, Surveillnce Epidemiology nd End Results dtbse; SSI, surgicl site infection. With emerging politicl mesures imed t limiting the cost nd improving the qulity of the helth cre services provided in the United Sttes, it will become incresingly importnt for prctitioners to sty engged, long with pyers nd hospitl dministrtors, in defining expected disese- nd procedure-specific outcomes. While decresing redmission rtes will benefit ptients s well s the helth cre system, it is prudent to prevent the necessry redmission from being perceived s filed dischrge, but rther s n erly rescue. 9 The current study imed to further define the incidence, etiology nd chrcteristics of redmissions fter PD by evluting contemporry cohort of ptients t high-volume pncretic surgery centre. Methods After obtining institutionl review bord pprovl, the medicl records of ll ptients undergoing PD between Jnury 2006 nd September 2011 t our tertiry referrl cdemic medicl centre were retrospectively reviewed. Dt were collected from the index hospitliztion s well s ll subsequent redmissions within 12 months of the index dischrge. The time to redmission ws defined using the dy of index dischrge s the dy of reference. Redmissions to outside hospitls were not cptured. Individul ptient dt collection included bsic demogrphics, pre-opertive fctors [dibetes mellitus (DM), coronry rtery disese (CAD), hypertension (HTN), nd tobcco use], intropertive fctors (estimted blood loss, mjor vsculr reconstruction nd pylorus preservtion), postopertive outcomes nd hospitl length of sty (LOS). Post-opertive outcomes were identified by review of dischrge Interntionl Clssifiction of Diseses, 9th Revision (ICD-9) codes nd by individul review of the medicl record. Ptients were considered to hve pncretic fistul if they met minimum of the criteri required for the dignosis of grde A fistul s defined by the Interntionl Study Group of Pncretic Fistul (>3 norml serum mylse with no clinicl mnifesttion). 10 It should be noted, however, tht drin fluid mylse ws not routinely checked thus preventing the identifiction of some non-cliniclly relevnt pncretic fistule. Similrly, the dignosis of delyed gstric emptying (DGE) ws pplied to ny ptient who met t lest the minimum criteri required for the dignosis of grde A DGE s defined by the Interntionl Study Group of Pncretic Surgery (one of the following: nsogstric tube required for more thn 3 dys, NGT reinserted fter postopertive dy three or inbility to tolerte solid orl intke by post-opertive dy seven). 11 A surgicl site infection (SSI) ws defined ccording to the commonly ccepted Center of Disese Control (CDC) clssifiction scheme. 12 The post-opertive cre of the ptients included in this study ws left to the discretion of the ttending surgeon in conjunction with the house stff. No fst-trck progrmmes or post-opertive pthwys were instituted during the study period. Redmission dignoses were identified by ICD-9 codes nd were confirmed by review of the ssocited dmission note, dily progress notes nd dischrge summry. For the purpose of nlysis, dignoses were grouped into the following ctegories: procedure-relted complictions, generl post-opertive complictions, redmission for dignostic workup nd others. The procedure-relted ctegory included pncretic fistul, bdominl bscess/phlegmon, hemorrhge, cholngitis nd per os (PO) intolernce. The generl post-opertive ctegory included SSI, urinry trct infection (UTI), deep venous thrombosis (DVT) nd bcteremi. The negtive dignostic workup ctegory included those ptients redmitted with symptoms for whom no underlying dignosis ws identified fter detiled evlution. The other ctegory included dmission for chest

3 144 HPB pin, ketocidosis, dehydrtion, constiption nd unrelted procedures. Sttisticl nlyses Sttisticl nlyses were performed using SAS sttisticl softwre (SAS Enterprise Guide 4.3; SAS Institute Inc., Cry, NC, USA). Demogrphic, pre-opertive, intr-opertive nd post-opertive fctors were evluted s predictors of redmission in univrite nlyses. Student s t-test nd chi-squre were used to nlyse continuous nd ctegoricl outcomes, respectively. A multivrite logistic regression ws performed using fctors of significnce from the univrite nlyses while controlling for ptient ge, gender, pre-opertive comorbidities nd disese pthology. Survivl nlysis ws performed using non-prmetric Kpln Meier methodology. All outcomes were considered sttisticlly significnt when P < Results Two hundred fifty-seven (257) ptients underwent PD t our institution between Jnury 2006 nd September In-hospitl mortlity ws 1.9% (n = 5, Fig. 1). Redmission rtes were 19.7% (50/254) within 30 dys, 24.0% (59/246) within 90 dys, 27.4% (63/230) within 6 months nd 37.4% (73/195) within 1 yer from index dischrge. The number of ptients decresed s those who died were excluded nd not ll ptients in the cohort hd reched the indicted length of follow-up t the time of nlysis. Twenty-three (8.9%) ptients required multiple redmissions. There ws no sttisticl difference in ge, gender, pre- or intr-opertive fctors between ptients requiring redmission within 30 dys from index dischrge nd their non-redmitted counterprts (Tble 2). The post-opertive complictions identified during index hospitliztion included delyed gstric emptying (n = 73, 28.4%), pncretic fistul (n = 40, 15.6%), surgicl site infection (n = 23, 8.9%), urinry trct infection (n = 17, 6.6%), bdominl bscess (n = 12, 4.7%) nd hemorrhge (n = 8, 3.1%) with 18 dditionl complictions occurring in less thn 3% of the study popultion (Fig. 1). One hundred fifty-nine ptients (61.9%) experienced t lest one post-opertive compliction. Those not redmitted were less likely to hve experienced post-opertive compliction reltive to their redmitted counterprts (58.9% versus 74%, P = 0.049). Redmitted ptients experienced reltively higher rtes of pncretic fistule, delyed gstric emptying nd surgicl site infections, but these trends filed to rech sttisticl significnce (Tble 3). In multivrite logistic regression controlling for ptient ge, gender, pre-opertive comorbidities nd disese pthology, the presence of ny postopertive compliction ws ssocited with redmission with n odd rtio (OR) of 2.02 [95% confidence intervl (CI) ] (Tble 4). Figure 1 Post-opertive complictions during index hospitliztion (% of ll opertions, n = 257). *Post-opertive deths: 3 deths within 30 dys of opertion, 2 dditionl deths during index hospitliztion >30 dys fter opertion (1.2% 30-dy mortlity, 1.9% in-hospitl mortlity). **Other (n = 1 for ech compliction noted): cerebrl vsculr ccident, deep vein thrombosis, portl vein thrombus, pulmonry embolus, pseudoneurysm without hemorrhge, biliry obstruction, bowel necrosis, decubitus ulcer, sepsis from indeterminte source nd compliction from n unrelted procedure. DGE, delyed gstric emptying; SSI, surgicl site infection; MI, myocrdil infrction

4 HPB 145 Tble 2 Ptient chrcteristics strtified by 30-dy redmission Chrcteristic No redmission (n = 207) Redmission (n = 50) P Pre-opertive fctors Age, yers, men (SD) 64.4 (11.3) 65.3 (13.7) Femle, n (%) 83 (40.1) 24 (48.0) Hypertension, n (%) 94 (45.4) 21 (43.9) Coronry rtery disese, n (%) 31 (14.9) 3 (6.1) Dibetes, n (%) 50 (24.2) 10 (20.4) Current tobcco use, n (%) 28 (13.5) 4 (8.0) Intr-opertive fctors Estimted blood loss > 500 ml, n (%) 112 (54.1) 28 (56.0) Vessel reconstruction, n (%) 22 (10.6) 2 (4.0) Pylorus preservtion, n (%) 160 (77.3) 36 (72.0) Pthology Mlignnt, n (%) 157 (75.9) 35 (70.0) Tble 3 Fctors ssocited with 30-dy redmission No Redmission (n = 207) Redmission (n = 50) P Any compliction, n (column %) 122 (58.9) 37 (74.0) Pncretic fistul, n (column %) 30 (14.5) 10 (20.0) Delyed gstric emptying, n (column %) 57 (27.5) 17 (34.0) Surgicl site infection, n (column %) 16 (7.7) 7 (14.0) Other compliction, n (column %) 55 (26.6) 19 (38.0) Disposition Home, n (row %) 175 (83.3) 35 (16.7) Home helth cre services, n (row %) 15 (65.2) 8 (34.8) Nursing/rehbilittion fcilityx, n (row %) 12 (63.2) 7 (36.8) Index Hospitliztion LOS, men (medin, rnge) 14.4 (11.0, 6 116) 18.0 (11.0, 7 92) Cumultive LOS, men (medin, rnge) 15.9 (11.0, 6 122) 30.3 (26.0, 8 153) <0.001 Other: urinry trct infection (UTI), bscess, hemorrhge, pneumoni, myocrdil infrction (MI), respirtory distress, dysrhythmi, deth, colitis, bile lek, chyle lek, cerebrl vsculr ccident, deep vein thrombosis, portl vein thrombus, pulmonry embolus, pseudoneurysm without hemorrhge, biliry obstruction, bowel necrosis, decubitus ulcer, sepsis from indeterminte source nd compliction from n unrelted procedure. Tble 4 Multivrite logistic regression for predictors of 30-dy redmission Odds rtio 95% Confidence Intervl Any post-opertive compliction Non-routine dischrge Controlled for ge, gender, coronry rtery disese (CAD), dibetes mellitus (DM), hypertension (HTN), tobcco use, mlignnt disese. The level of cre required t index dischrge ws ssocited with redmission. After routine dischrge to home, ptients hd lower rtes of 30-dy redmission compred with ptients dischrged with home helth services nd s well s those dischrged to nursing/rehbilittion fcilities (16.7%, 34.8%, 36.8%, P = 0.018; Tble 3). Multivrite logistic regression controlling for ptient ge, gender, pre-opertive comorbidities nd disese pthology, subsequently found non-routine dischrge (dischrge with home helth services or dischrge to nursing or rehb fcility) to be ssocited with 30-dy redmission with n OR of 2.69 (95% CI ) (Tble 4). The medin LOS for index dmission ws 11.0 dys in both the redmitted nd non-redmitted groups with the men LOS 18.0 versus 14.4 dys, respectively (P = 0.066; Tble 3). The men cumultive LOS (i.e. the summed LOS of index redmission nd ll subsequent redmissions within 1 yer of index dischrge) ws, not surprisingly, significntly longer for ptients requiring redmission within 30 dys of index dischrge (30.3 versus 15.9 dys, P < ; Tble 3). Indictions for redmission included procedure-relted complictions (n = 33, 66.0%), generl post-opertive complictions (n = 7, 14.0%), negtive fever workup (n = 4, 8.0%) nd other (n = 6, 12.0%) (Tble 5).

5 146 HPB Tble 5 Primry dignosis t 30-dy redmission n (%) Procedure-cpecific compliction 33 (66.0) PO intolernce 18 (36.0) Pncretic fistul/bscess/phlegmon 13 (26.0) Hemorrhge 1 (2.0) Cholngitis 1 (2.0) Generl post-opertive complictions 7 (14.0) SSI 4 (8.0) UTI 1 (2.0) DVT 1 (2.0) Bcteremi 1 (2.0) Negtive fever workup 4 (8.0) Other 6 (12.0) Other: Negtive workup for chest pin, ketocidosis, dehydrtion, constiption, liver filure, unrelted procedure. UTI, urinry trct infection; SSI, surgicl site infection; DVT, deep vein thrombosis. Tble 6 Chrcteristics of redmissions with length of sty (LOS) 1 2 dys (n = 9) Ptient Redmission LOS (d) Time from index dischrge to Redmission Dx redmission (dys) Fever Fever Fever UTI SSI Cholngitis PO intolernce Chest pin Unrelted procedure Negtive dignostic workup. UTI, urinry trct infection; SSI, surgicl site infection; PO, per os. The medin LOS for the redmissions ws 6 dys (rnge 1 32). Of 50 ptients redmitted within 30 dys, 9 (18.0%) hd redmission LOS of 1 to 2 dys. Indictions for these redmissions included fever with negtive workup (n = 3), n UTI (n = 1), cholngitis (n = 1), SSI (n = 1), PO intolernce (n = 1), chest pin with negtive workup (n = 1) nd n unrelted procedure (n = 1) (Tble 6). Therefore, 4 out of 9 ptients redmitted for just 1 to 2 dys were redmitted for dignostic evlution of symptoms (fever nd chest pin) without identifiction of specific dignosis. Kpln Meier survivl nlysis reveled no discernible difference in survivl for those redmitted reltive to the nonredmitted cohort (Fig. 2, Tble 7). This held true for ptients with both benign nd mlignnt disese. Tble 7 Kpln Meier survivl curves, number t risk Discussion Benign, redmitted Benign, not redmitted Mlignnt, redmitted Mlignnt, not redmitted In the current study, 19.7% of ll ptients undergoing PD were redmitted within 30 dys of index dischrge. Redmission ws ssocited with the occurrence of ny post-opertive compliction nd with the level of cre required t dischrge. Redmitted ptients hd longer men index LOS reltive to their nonredmitted counterprts, lthough this trend filed to rech sttisticl significnce (18.0 versus 14.4 dys, P = 0.066). Nine ptients (18.0% of the redmitted ptients) hd redmission LOS of 1 2 dys, four (8.0%) of whom were ultimtely dischrged fter negtive dignostic workup. There ws no difference in survivl between the redmitted nd non-redmitted ptients during the study period. The findings of the present study re consistent with the reports by Emick et l. (2006) nd Kent et l. (2011) both of whom found redmission fter PD to be ssocited with post-opertive complictions during the index hospitliztion. 2,13 In the current study, 80% of ll redmissions were for indictions relted to the opertion (66% procedure specific nd 14% generl postopertive) compred with 65% in the Kent et l. study (47% procedure specific nd 18% generl post-opertive). 2 Also congruent with the existing literture ws the trend towrds longer index LOS for the ptients requiring redmission. Emick et l.reported n increse in the men index LOS for redmitted ptients (13.8 versus 11.6 dys, P = 0.02), n observtion confirmed in two lrge dministrtive dtbse reviews, suggesting tht the shorter index hospitliztion, or premture dischrge, is not primrily responsible for redmission fter PD (Tble 1). 3,4,13 Our observtion of higher rte of redmission in ptients dischrged with home helth services nd those dischrged to skilled nursing/rehb fcilities is consistent with two previous reports. 2,14 Specificlly, in prospective study of 266 ptients undergoing mjor intr-bdominl procedures (including oesophgel, gstric, intestinl, liver nd pncretic resections), Mrtin et l. reported 27% rte of redmission within 90 dys from the index opertion. 14 Among the 72 ptients who were redmitted, 62% were dischrged with home helth services nd 19% to subcute rehbilittion s opposed to only 11% nd 10% of their non-redmitted counterprts (P < ). 14 In ddition, only 25% of ptients who got redmitted were seen by the treting physicin before the redmission. 14 These findings my certinly suggest tht dischrge resources re being ppropritely llocted to sicker ptients (i.e. those more likely to be redmitted).

6 HPB 147 () Kpln meier curve, benign disese (b) Kpln meier curve, mlignnt disese Censored + Censored Survivl probbility (15/50) Redmitted Not redmitted (5/30) (4/18) Follow-up, months (Smple size redmitted/not redmitted) 60 (1/1) Survivl probbility (35/157) Redmitted Not redmitted (20/49) (8/16) Follow-up, months (Smple size redmitted/not redmitted) 60 (1/5) Figure 2 Kpln Meier survivl curves: () Ptients with benign disese, show no difference in survivl when strtified by 30-dy redmission (Log-Rnk Chi-Squre = 0.02, P = 0.88); (b) ptients with mlignnt disese, show no difference in survivl when strtified by 30-dy redmission (Log-Rnk chi-squre = 1.51, P = 0.22) However, closer communiction with the next level of cregivers nd more intensified outptient follow-up pper resonble strtegies for the timely identifiction nd mngement of postopertive problems tht my eventully led to rehospitliztion. Of ll 30-dy redmissions in the present study, 18.0% (9/50) hd LOS of 2 dys or less. Four of these ptients (8.0% of ll redmissions) underwent negtive dignostic workup nd were dischrged without intervention. Kent et l. reported tht of ll ptients redmitted fter mjor pncretic resection, 14% presented with some element of clinicl concern, but inptient dignostic evlution filed to identify specific dignosis or compliction. 2 Perhps this smll frction of redmitted ptients could be evluted in the outptient setting or in 23-h observtionl unit nd then rehospitlized if dignostic evlution points to specific dignosis mndting inptient cre. This pproch my prevent this smll frction (8 14%) of redmissions fter PD. The present study hs number of limittions worthy of discussion. The single institution design my limit the generlizbility of the results. Additionlly, the present study did not cpture redmissions to outside hospitls nd my hve underestimted the ctul rte of rehospitliztion fter PD. Interestingly, however, two recent dministrtive dtbse nlyses of ptients undergoing PD (cpturing redmission dt to ny hospitl) reported 30-dy redmission rtes of 16% nd 19%. 3,4 These dt, when compred with both the present study (19.7% 30-dy redmission rte) nd the single-institution study performed by Kent et l. (22.1% 30-dy redmission rte for PD ptients) suggest tht the mjority of redmissions within 30 dys of index dischrge occur t the index hospitl nd tht little 30-dy redmission dt re missed by single-institution studies. 2 Finlly, the low number (n = 9) of ptients who were redmitted for only 1 2 dys limit the bility to drw definitive conclusions regrding the preventbility of such short redmissions. It is undenible tht hospitl redmission is burden on the helth cre system. A recent nlysis of 11.8 million hospitlized Medicre beneficiries found n overll 30-dy redmission rte of roughly 20% (medicl nd surgicl ptients) t n nnul cost of $17.4 billion. 15 When the focus is mjor bdominl surgery, however, the issue of redmission s qulity metric is complex. In recent editoril, Brown et l. put forth the notion tht redmission of the post-surgicl ptient my led to the erly detection nd rescue of peri-opertive compliction in the setting of good clinicl judgment rther thn represent filed dischrge. 9 Moving forwrd, it is importnt for surgeons to sty engged in policy discussions to ensure tht novel qulity metrics ddress the issues s they pertin to surgicl ptients. In the cse of complex bdominl opertions, such s PD, the sfest nd most effective ptient cre my require reltively low threshold for redmission. Clerly, coordintion of cre is impertive prticulrly with ptients t risk for re-dmission. In ptients with complictions nd the need for extended cre post-dischrge, greter emphsis on post-dischrge instruction nd cre could be brought forwrd. While it is probbly true tht smll frction of redmissions fter PD my be preventble, we must pproch this mtter cutiously to void stigmtiztion of the necessry redmission. We s surgeons should t the very lest prticipte in the discussion s public policy is developed in this re. Conflicts of interest None declred.

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