Timing of Discharge: a Key to Understanding the Reason for Readmission after Colorectal Surgery

Abstract

Purpose

There is a growing interest in surgery regarding the balance between appropriate hospital length of stay (LOS) and prevention of unnecessary readmissions. This study examines the relationship between postoperative LOS and unplanned readmission after colorectal resection, exploring whether patients discharged earlier have different readmission risk profiles.

Methods

Patients undergoing colorectal resection were selected by Common Procedural Terminology (CPT) code from the 2012 ACS National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified by LOS quartile. Kaplan-Meier analysis was used to examine characteristics associated with 30-day unplanned readmission. Factors with a p < 0.1 were included in the Cox proportional hazards model. Subsequently, chi-square analysis compared LOS, patient, and perioperative factors with the primary reason for readmission. Factors with a p < 0.2 were included in a multivariable logistic regression for each readmission reason.

Results

For 33,033 patients undergoing colorectal resection, the overall 30-day unplanned readmission rate was 11 %. After adjusting for patient and perioperative factors, a postoperative LOS ≥8 days was associated with a 55 % increase in the relative hazard of readmission. Patients with a ≤3-day LOS were more likely to be readmitted with ileus/obstruction (odds ratio (OR): 1.8, p = 0.001) and pain (OR: 2.2, p = 0.007). LOS was not significantly associated with readmission for intraabdominal infection or medical complications.

Conclusions

Patients with longer LOS and complicated hospital courses continue to be high risk post-discharge, while straightforward early discharges have a different readmission risk profile. More targeted readmission prevention strategies are critical to focusing resource utilization for colorectal surgery patients.

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Correspondence to Kristin N. Kelly.

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Discussion

Dr. Scott R. Steele (Fort Lewis, WA): I would like to congratulate Dr. Kelly and associates on a very well-written study evaluating the association of timing of discharge and readmission after colorectal surgery. In this changing climate of health care, where coverage and reimbursement for complications and readmission may be radically altered, as well an increased focus on appropriate utilization management of all hospital resources including bed occupancy, studies such as these are increasingly important. As expected, a longer LOS reflects a more complicated hospital course with overall higher readmission rates, while early discharge mirrors higher rates of readmission for “failure to thrive” reasons (e.g., pain and ileus). By identifying these risk factors, we have highlighted potentially modifiable metrics that may aid both in counseling and interventions prior to (or even after) discharge. A few questions: (1) While there was no way to identify those institutions with and without enhanced recovery pathways, should we be altering our data collection to account for this in light of the emerging data demonstrating improved outcomes? (2) Despite the associations you identified in your paper, is there really anything we can do to predict or do anything about readmission based on LOS—i.e., if patients are “ready for discharge” by whatever criteria the surgeon utilizes, are we changing our practice patterns at all to reflect an attempt to impact your findings? While you recommend targeted interventions for distinct complications such as dehydration or follow-up phone calls for everyone, how do these interventions relate to your study specifically regarding LOS and readmission?

Closing Discussant

Dr. Kelly: Thank you very much Dr. Steele for the comments and questions.

To address your first question regarding data collection on enhanced recovery pathways, we agree that having this information would be incredibly useful for examining outcomes. Certainly, we can infer from our data that the patients with 2–3-day stays were more likely to have received an enhanced recovery protocol, but there is no way of knowing this for sure. To examine the full effects of these protocols on length of stay and postoperative outcomes, we would ideally like to collect information on which patients were included, the specific components, and whether it was successfully completed.

Your second point regarding predicting readmission with length of stay is an excellent one, and as mentioned before, we do not believe that this should be treated as a modifiable factor. Rather, we believe it highlights the fact that postoperative course should be an important consideration in terms of readmission and other outcomes. Patients qualifying for early discharge by their surgeon’s criteria will likely need different discharge strategies and resources than those patients with longer lengths of stay. Moving forward, more research is needed examining the role of discharge criteria and planning as they relate to surgical outcomes and quality.

Appendices

Appendices

Table 5 Colorectal resection CPT codes
Table 6 Cox proportional hazard model: factors associated with 30-day unplanned readmissions

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Kelly, K.N., Iannuzzi, J.C., Aquina, C.T. et al. Timing of Discharge: a Key to Understanding the Reason for Readmission after Colorectal Surgery. J Gastrointest Surg 19, 418–428 (2015). https://doi.org/10.1007/s11605-014-2718-7

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Keywords

  • Colorectal surgery
  • Unplanned readmission
  • Length of stay
  • Readmission timing
  • Readmission reason