Readmission After Resections of the Colon and Rectum: Predictors of a Costly and Common Outcome.

BACKGROUND: Readmission rates are a measure of surgical quality and an object of clinical and regulatory scrutiny. Despite increasing efforts to improve quality and contain cost, 6% to 25% of patients are readmitted after colorectal surgery. OBJECTIVE: The aim of this study is to define the predictors and costs of readmission following colorectal surgery. DESIGN: This is a retrospective cohort study of patients undergoing elective and nonelective colectomy and/or proctectomy in the Healthcare Cost and Utilization Project Florida State Inpatient Database 2007 to 2011. Readmission is defined as inpatient admission within 30 days of discharge. Univariate analyses were performed of sex, age, Elixhauser score, race, insurance type, procedure, indication, readmission diagnosis, cost, and length of stay. Multivariate analysis was performed by logistic regression. Sensitivity analysis of nonemergent admissions was conducted. SETTINGS: This study was conducted in Florida acute-care hospitals. PATIENTS: Patients undergoing colectomy and proctectomy from 2007 to 2011 were included. INTERVENTION(S): There were no interventions. MAIN OUTCOME MEASURE(S): The primary outcomes measured were readmission and the cost of readmission. RESULTS: A total of 93,913 patients underwent colectomy; 14.7% were readmitted within 30 days. From 2007 to 2011, readmission rates remained stable (14.6%-14.2%, trend p = 0.1585). After multivariate adjustment, patient factors associated with readmission included nonwhite race, age <65, and a diagnosis code other than neoplasm or diverticular disease (p < 0.0001). Patients with Medicare or Medicaid were more likely to be readmitted than those with private insurance (p < 0.0001). Patients with longer index admissions, those with stomas, and those undergoing all procedures other than sigmoid or transverse colectomy were more likely to be readmitted (p < 0.0001). High-volume hospitals had higher rates of readmission (p < 0.0001). The most common reason for readmission was infection (32.9%). Median cost of readmission care was $7030 (intraquartile range, $4220-$13,247). Fistulas caused the most costly readmissions ($15,174; intraquartile range, $6725-$26,660). LIMITATIONS: Administrative data and retrospective design were limitations of this study. CONCLUSIONS: Readmissions rates after colorectal surgery remain common and costly. Nonprivate insurance, IBD, and high hospital volume are significantly associated with readmission.

Appendicitis in the modern era: universal problem and variable treatment.

BACKGROUND: Acute appendicitis is the second most common gastrointestinal diagnosis mandating urgent operation in the U.S. The current state of adult appendectomy, including patient and hospital characteristics, complications, and predictors for complications, are unknown. METHODS: Retrospective review of U.S. Nationwide Inpatient Sample 2003-2011 for appendectomy in ≥18-year-olds was performed. Primary outcomes measures included postoperative complications, length of stay, and patient mortality. Categorical variables were analyzed by χ2, trend analyses by Cochran-Armitage. Multivariable logistic regression was performed to adjust for predictors of developing complications. RESULTS: 1,663,238 weighted appendectomy discharges occurred. Over the study period, complications increased from 3.2 to 3.8% (p < 0.0001), but the overall mortality decreased from 0.14 to 0.09% (p < 0.0001) and mean LOS decreased from 3.1 to 2.6 days (p < 0.0001). The proportion of laparoscopic appendectomy increased over time, 41.7-80.1% (p < 0.0001). Patients were increasingly older (≥65 years: 9.4-11.6%, p < 0.0001), more obese (3.8-8.9%, p < 0.0001), and with more comorbidities (Elixhauser score ≥3: 4.7-9.8%, p < 0.0001). After adjustment, independent predictors for postoperative complications included: open surgery (OR 1.5, 95% C.I. 1.4-1.5), male sex (OR 1.6, 95% CI 1.5-1.6), black race (vs. white: OR 1.5, 95% CI 1.4-1.6), perforated appendix (OR 2.8, 95% CI 2.7-3.0), greater comorbidity (Elixhauser ≥3 vs. 0, OR 11.3, 95% CI 10.5-12.1), non-private insurance status (vs. private: Medicaid OR 1.3, 95% CI 1.2-1.4; Medicare OR 1.7, 95% CI 1.6-1.8), increasing age (>52 years vs. ≤27: OR 1.3; 95% CI 1.2-1.4), and hospital volume (vs. high: low OR 1.2; 95% CI 1.1-1.3). Predictors of laparoscopic appendectomy were age, ethnicity, insurance status, comorbidities, and hospital location. CONCLUSIONS: Laparoscopic appendectomy is increasing but is unevenly deployed across patient groups. Appendectomy patients were increasingly older, with more comorbidities and with increasing rates of obesity. Black patients and patients with public insurance had less utilization of laparoscopy and inferior outcomes.

Surgical management of chronic pancreatitis: current utilization in the United States.

BACKGROUND: Surgical intervention is uncommon in chronic pancreatitis. Literature largely describes single institution or international experiences. This study describes US-based chronic pancreatitis surgical management. METHODS: Retrospective analysis of chronic pancreatitis patients in the Healthcare Cost and Utilization Project Florida State Inpatient Database 2007-2011. Patients with malignancy or congenital abnormalities were excluded. Univariate analysis using the chi-square test. The number of readmissions, inpatient length of stay and cost using Wilcoxon's signed-rank test. Multivariate analysis of surgery by logistic regression. RESULTS: Twenty-one thousand four hundred and forty-five patients with chronic pancreatitis. 10.8% (2 307) underwent surgery including 1652 cholecystectomies, 564 drainage procedures and 498 pancreatectomies. Procedures decreased from 12.1% to 8.3% over time (P < 0.001), but intervention within 3 months increased (7.2% to 8.4%; P = 0.017). 15.3% (3 278) had pancreatic cysts/pseudocysts and 43.4% (9 312) had diabetes. The median numbers of admissions were 2 [interquartile range (IQR) 1,5] and 3 (IQR 2,7) among non-surgical and surgical patients, respectively (P < 0.001). Predictors of surgery were fewer co-morbidities, private insurance, and either diabetes mellitus or pancreatic cyst/pseudocyst. CONCLUSION: Chronic pancreatitis leads to numerous inpatient readmissions, but surgical intervention only occurs in a minority of cases. Complicated patients are more likely to undergo surgery. The complexities of chronic pancreatitis management warrant early multidisciplinary evaluation and ongoing consideration of surgical and non-surgical options.

Outcomes in operative management of pancreatic cancer.

Pancreatic cancer is a highly lethal malignancy that often presents at an advanced stage. Surgical resection can prolong survival and offers the only potential for cure. However, pancreatectomy is associated with significant morbidity and mortality. This article reviews perioperative outcomes, post-resection long-term survival, and innovations in the surgical management of pancreatic cancer.

Patient selection and the volume effect in pancreatic surgery: unequal benefits?

BACKGROUND: The volume effect in pancreatic surgery is well established. Regionalization to high-volume centres has been proposed. The effect of this proposal on practice patterns is unknown. METHODS: Retrospective review of pancreatectomy patients in the Nationwide Inpatient Sample 2004-2011. Inpatient mortality and complication rates were calculated. Patients were stratified by annual centre pancreatic resection volume (low <5, medium 5-18, high >18). Multivariable regression model evaluated predictors of resection at a high-volume centre. RESULTS: In total, 129,609 patients underwent a pancreatectomy. The crude inpatient mortality rate was 4.3%. 36.0% experienced complications. 66.5% underwent a resection at high-volume centres. In 2004, low-, medium- and high-volume centres resected 16.3%, 24.5% and 59.2% of patients, compared with 7.6%, 19.3% and 73.1% in 2011. High-volume centres had lower mortality (P < 0.001), fewer complications (P < 0.001) and a shorter median length of stay (P < 0.001). Patients at non-high-volume centres had more comorbidities (P = 0.001), lower rates of private insurance (P < 0.001) and more non-elective admissions (P < 0.001). DISCUSSION: In spite of a shift to high-volume hospitals, a substantial cohort still receives a resection outside of these centres. Patients receiving non-high-volume care demonstrate less favourable comorbidities, insurance and urgency of operation. The implications are twofold: already disadvantaged patients may not benefit from the high-volume effect; and patients predisposed to do well may contribute to observed superior outcomes at high-volume centres.

Pacific patients' reasons for attending the emergency department of Counties Manukau for non-urgent conditions.

AIM: To determine Pacific patients' reasons for Emergency Department (ED) use for non-urgent conditions by Pacific people at Counties Manukau Health. METHODS: Patients who self-presented to Counties Manukau ED with a non-urgent condition in June 2019 were surveyed. Responses to open-ended questions were analysed using a general inductive approach, in discussion with key stakeholders. RESULTS: Of 353 participants with ethnicity reported, 139 (39%) were Pacific, 66 (19%) Maori and 148 (42%) were non-Maori non-Pacific, nMnP. A total of 58 (42%) of Pacific participants had been to their general practitioner prior to presenting to the ED; this proportion was similar for Maori (19 [30%]) and nMnP (59 [40%]) (p=0.215). The most common reasons for ED attendance among Pacific (as well as other) participants were 1) advice by a health professional (41%, 95% CI 33-50%), 2) usual care unavailable (28%, 20-36%), 3) symptoms not improving (21%, 14-28%), and 4) symptoms too severe to be managed elsewhere (19%, 12-26%). CONCLUSIONS: Multiple reasons underlie non-urgent use of EDs by Pacific and other ethnic groups. These reasons need to be considered simultaneously in the design, implementation, and evaluation of multi-dimensional initiatives that discourage non-urgent use of EDs to ensure that such initiatives are effective, equitable, and unintended consequences are avoided.

Surgery for chronic pancreatitis: the role of early surgery in pain management.

OBJECTIVES: To examine if surgery performed for pain of chronic pancreatitis (CP) within 3 years diagnosis has greater odds of achieving complete pain relief than later surgery and to find optimal surgical timing for attaining pain relief in CP. METHODS: Retrospective review of records at a tertiary institution 2003 to 2011 for CP where the operative indication was pain. Outcomes were pain-free status, opioid use, and pancreatic insufficiency at 3-year follow-up. Univariate analysis by Fisher exact tests. Receiver operating curve to calculate cutoff threshold time for surgery. RESULTS: Outcomes for 66 patients were included. Median preoperative CP duration was 28 months (interquartile range, 12, 67). Twenty-six patients (39.4%) were free of pain at the 3-year follow-up. Thirty-four patients (51.5%) were opioid users at follow-up. Postoperatively, 34 patients (51.5%) demonstrated endocrine, and 32 patients (48.5%) demonstrated exocrine insufficiency. The optimal cutoff point for preoperative CP duration was 26.5 months (area under the curve, 0.66). Shorter duration of CP before surgery was a predictor of pain-free status and reduced postoperative opioid use at follow-up. CONCLUSIONS: Results from a single institution analysis suggest early surgical intervention of 26.5 months or less of diagnosis is associated with improved pain control, and optimal timing for surgery may be earlier than previously thought.

Predictors of severe and critical acute pancreatitis: a systematic review.

BACKGROUND: Persistent organ failure and infected pancreatic necrosis are major determinants of mortality in acute pancreatitis, but there is a gap in the literature assessing the best available predictors of these two determinants. The purpose of this review was to investigate the utility of predictors of persistent organ failure and infected pancreatic necrosis in patients with acute pancreatitis, both alone and in combination. METHODS: We performed a systematic search of the literature in 3 databases for prospective studies evaluating predictors of persistent organ failure, infected pancreatic necrosis, or both, with strict eligibility criteria. RESULTS: The best predictors of persistent organ failure were the Japanese Severity Score and Bedside Index of Severity in Acute Pancreatitis when the evaluation was performed within 48h of admission, and blood urea nitrogen and Japanese Severity Score after 48h of admission. Systemic Inflammation Response Syndrome was a poor predictor of persistent organ failure. The best predictor of infected pancreatic necrosis was procalcitonin. CONCLUSIONS: Based on the best available data, it is justifiable to use blood urea nitrogen for prediction of persistent organ failure after 48h of admission and procalcitonin for prediction of infected pancreatic necrosis in patients with confirmed pancreatic necrosis. There is no predictor of persistent organ failure that can be justifiably used in clinical practice within 48h of admission.

Systematic review of early surgery for chronic pancreatitis: impact on pain, pancreatic function, and re-intervention.

BACKGROUND: Surgical intervention has traditionally been reserved as the last management option for pain in chronic pancreatitis. Recently, there has been a call for surgery to be offered earlier in the disease process. The objectives of this review were to evaluate the effect of early surgery on postoperative pain, pancreatic function, and re-intervention rates in chronic pancreatitis. METHODS: A systematic literature search through EMBASE, Cochrane Review, and PubMed from January 1950 to January 2014 was conducted. Citations found in relevant papers are hand-searched. Data which could be pooled were analyzed using Revman (v5.2). Risk of bias analysis was conducted. RESULTS: Of the 2,886 potentially eligible studies identified, 11 studies met the inclusion criteria. There was large heterogeneity in the study designs, and studies were conducted over a lengthy time span. Seven studies examined pain, three studies examined pancreatic function, and three studies examined rates of re-intervention. Meta-analysis of the three studies with comparative raw data regarding complete pain relief showed that early surgery was associated with an increased likelihood of complete postoperative pain relief (RR = 1.67, 95% CI 1.09-2.56, p = 0.02). Early surgery was also associated with reduced risk of pancreatic insufficiency and low re-intervention rates. CONCLUSIONS: Data from this study supports considering early surgery for pain management in patients with chronic pancreatitis, with the potential of a reduced risk of pancreatic insufficiency and the need for further intervention. Further prospective randomized studies are warranted comparing early surgery against conservative step-up approaches.

The epidemiology of recurrent miscarriage: a descriptive study of 1214 prepregnant women with recurrent miscarriage.

AIMS: To describe the characteristics of the prepregnant population attending the Recurrent Miscarriage Clinic (RMC) at the National Women's Hospital (NWH), Auckland, between 1986 and 2003, and to compare them with the overall obstetric booking population of the hospital. METHODS: The identifying details of 1214 prepregnant women attending the RMC were obtained. Both hospital and RMC records, which were kept separately, were retrospectively reviewed for demographic information and results of diagnostic investigations. Data from Auckland residents who attended the clinic were compared with data from all Auckland women booking or delivering at NWH. RESULTS: RMC attendees were older than the general NWH population, but had similar parity. Clinic attendees had a higher incidence of personal and family history of antepartum haemorrhage, fetal abnormalities, stillbirths and neonatal deaths than reported rates for the general population. Chromosomal anomalies were detected in 86 women, reproductive tract anomalies were found in 142 women, and polycystic ovarian syndrome was detected in 49 women. The majority (52.7%) of women had no identifiable cause for recurrent miscarriage detected. CONCLUSIONS: These data support the concept of women with recurrent miscarriage being at high risk for adverse obstetric outcomes including fetal abnormalities, stillbirths and neonatal deaths, even when the pregnancies are ongoing. We conclude that recurrent miscarriage is different from subfertility, and provide information of use in planning care for such women.