Abstract
Background
Readmission rates have been targeted for cost/reimbursement control. Our goal was to identify causes for readmission and delineate the pattern of early and late readmission.
Methods
Between 2011 and 2012, a total of 490 patients underwent pancreaticoduodenectomy, distal pancreatectomy or central pancreatectomy. Logistic regression was used to identify predictors of readmission. K-medoids clustering was performed to identify the major readmission subgroups.
Results
Median postoperative length of stay (LOS) was 7 days, and the 30- and 90-day readmission rates were 23 and 29 %, respectively. The most common cause for 30-day readmissions was procedure-related infections (58 %), while the most common cause for 31–90-day readmissions was failure to thrive and chemotherapy-related symptoms (38 %). Independent predictors of 30-day readmissions were central pancreatectomy, discharge with a drain, pancreatic duct <3 mm, previous abdominal surgery, and postoperative LOS. Independent predictors for 31–90-day readmissions were age and preoperative serum carcinoembryonic antigen. Cancer-related covariates were more common in the 31–90-day readmission group. Postoperative carbohydrate antigen 19-9 levels were twofold higher in the 31–90-day readmission group compared with the no readmission group (p = 0.03). K-medoids clustering identified a subgroup where 74 % of readmissions occur at a median of 7 days after discharge.
Conclusions
Readmissions after pancreatic operations are procedure-related in the first 30 days, but those after this period are influenced by the natural history of the underlying diagnosis. The readmission penalty policy should account for the timing of readmission and the natural history of the underlying disease and procedure. Early follow-up for patients at high risk for readmission may minimize early readmissions.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Medicare Payment Advisory Commission. Payment policy for inpatient readmissions. Report to the Congress: promoting greater efficiency in Medicare. http://www.medpac.gov/documents/jun07_entirereport.pdf. Accessed 8 Nov 2013.
Centers for Medicare and Medicaid Services. Fact sheet: quality measures for reporting in fiscal year 2009 for 2010 update. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/downloads/HospitalRHQDAPU200808.pdf. Accessed 8 Nov 2013.
Readmissions Reduction Program. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed 8 Nov 2013.
Reddy DM, Townsend CM Jr, Kuo YF, et al. Readmission after pancreatectomy for pancreatic cancer in Medicare patients. J Gastrointest Surg. 2009;13(11):1963–74; discussion 74–5.
Yermilov I, Bentrem D, Sekeris E, et al. Readmissions following pancreaticoduodenectomy for pancreas cancer: a population-based appraisal. Ann Surg Oncol. 2009;16(3):554–61.
Gawlas I, Sethi M, Winner M, et al. Readmission after pancreatic resection is not an appropriate measure of quality. Ann Surg Oncol. 2013;20(6):1781–7.
Schneider EB, Hyder O, Wolfgang CL, et al. Patient readmission and mortality after surgery for hepato-pancreato-biliary malignancies. J Am Coll Surg. 2012;215(5):607–15.
Zhu ZY, He JK, Wang YF, et al. Multivariable analysis of factors associated with hospital readmission following pancreaticoduodenectomy for malignant diseases. Chin Med J (Engl). 2011;124(7):1022–5.
Fong ZV, Ferrone CR, Thayer SP, et al. Understanding hospital readmissions after pancreaticoduodenectomy: can we prevent them? A 10-year contemporary experience with 1,173 patients at the Massachusetts General Hospital. J Gastrointest Surg. 2014;18(1):144–5.
Tsai TC, Joynt KE, Orav EJ, et al. Variation in surgical-readmission rates and quality of hospital care. N Engl J Med. 2013;369(12):1134–42.
Hyder O, Dodson RM, Nathan H, et al. Influence of patient, physician, and hospital factors on 30-day readmission following pancreatoduodenectomy in the United States. JAMA Surg. 2013;148(12):1095–102.
Park J, Pillarisetty VG, Brennan MF, et al. Electronic synoptic operative reporting: assessing the reliability and completeness of synoptic reports for pancreatic resection. J Am Coll Surg. 2010;211(3):308–15.
Correa-Gallego C, Brennan MF, D’Angelica M, et al. Operative drainage following pancreatic resection: analysis of 1122 patients resected over 5 years at a single institution. Ann Surg. 2013;258(6):1051–8.
Vin Y, Sima CS, Getrajdman GI, et al. Management and outcomes of postpancreatectomy fistula, leak, and abscess: results of 908 patients resected at a single institution between 2000 and 2005. J Am Coll Surg. 2008;207(4):490–8.
Kent TS, Sachs TE, Callery MP, Vollmer CM Jr. Readmission after major pancreatic resection: a necessary evil? J Am Coll Surg. 2011;213(4):515–23.
Ahmad SA, Edwards MJ, Sutton JM, et al. Factors influencing readmission after pancreaticoduodenectomy: a multi-institutional study of 1302 patients. Ann Surg. 2012;256(3):529–37.
Emick DM, Riall TS, Cameron JL, et al. Hospital readmission after pancreaticoduodenectomy. J Gastrointest Surg. 2006;10(9):1243–52; discussion 52–3.
Leichtle SW, Kaoutzanis C, Mouawad NJ, et al. Classic Whipple versus pylorus-preserving pancreaticoduodenectomy in the ACS NSQIP. J Surg Res. 2013;183(1):170–6.
NCCN Guidelines® for pancreatic adenocarcinoma. http://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf. Accessed Nov 2013.
Distler M, Pilarsky E, Kersting S, Grutzmann R. Preoperative CEA and CA 19-9 are prognostic markers for survival after curative resection for ductal adenocarcinoma of the pancreas: a retrospective tumor marker prognostic study. Int J Surg. 2013;11(10):1067–72.
Kanda M, Fujii T, Takami H, et al. The combination of the serum carbohydrate antigen 19-9 and carcinoembryonic antigen is a simple and accurate predictor of mortality in pancreatic cancer patients. Surg Today. (Epub 9 Oct 2013).
Haas M, Heinemann V, Kullmann F, et al. Prognostic value of CA 19-9, CEA, CRP, LDH and bilirubin levels in locally advanced and metastatic pancreatic cancer: results from a multicenter, pooled analysis of patients receiving palliative chemotherapy. J Cancer Res Clin Oncol. 2013;139(4):681–9.
Fong ZV, Winter JM. Biomarkers in pancreatic cancer: diagnostic, prognostic, and predictive. Cancer J. 2012;18(6):530–8.
Medicare claims processing manual. Chapter 12: physicians/nonphysician practitioners. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed 28 April 2014.
O’Reilly EM, Lowery MA. Postresection surveillance for pancreatic cancer performance status, imaging, and serum markers. Cancer J. 2012;18(6):609–13.
Acknowledgment
This study was funded in part by the Cancer Center core Grant P30 CA008748.
Conflict of interest
Eran Sadot, Murray F. Brennan, Ser Yee Lee, Peter J. Allen, Mithat Gönen, Jeffery S. Groeger, T. Peter Kingham, Michael I. D’Angelica, Ronald P. DeMatteo, William R. Jarnagin, and Yuman Fong declare that they have no conflicts of interests regarding this study.
Author information
Authors and Affiliations
Corresponding author
Additional information
Accepted for presentation at the 67th Annual Cancer Symposium of the Society of Surgical Oncology, Phoenix, AZ, USA, 12–15 March 2014.
Rights and permissions
About this article
Cite this article
Sadot, E., Brennan, M.F., Lee, S.Y. et al. Readmission After Pancreatic Resection: Causes and Causality Pattern. Ann Surg Oncol 21, 4342–4350 (2014). https://doi.org/10.1245/s10434-014-3841-0
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-014-3841-0