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Readmission and Risk Factors for Readmission Following Esophagectomy for Esophageal Cancer

  • 2014 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Introduction

Readmission after esophagectomy for esophageal cancer has not been systematically evaluated.

Study Objective

The objectives of this study were to determine national 30-day readmission rates after esophagectomy for esophageal cancer and evaluate risk factors associated with readmission.

Methods

Retrospective review of the 2011–2012 National Surgical Quality Improvement Program dataset was performed to identify patients who underwent elective esophagectomy for esophageal cancer.

Results

One thousand sixty-eight patients satisfied study criteria. One hundred and thirty-five patients were admitted within 30 days resulting in a readmission rate of 12.6 %. Patients with a history of pulmonary disease were 3.9 times more likely to be readmitted. Patients who developed postoperative wound-related complications were 9 times more likely to be readmitted than patients who did not develop wound-related complications. Increasing length of hospital stay was associated with a marginal but significant decrease in risk of readmission.

Conclusions

National 30-day readmission rate after esophagectomy for esophageal cancer is around 12.6 %. Risk factors associated with 30-day readmission include history of pulmonary disease, postoperative wound-related complications, and length of hospital stay.

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Author information

Authors and Affiliations

  1. Creighton University, Omaha, NE, USA

    Abhishek Sundaram, Ananth Srinivasan, Sarah Baker & Sumeet K. Mittal

Authors
  1. Abhishek Sundaram
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  2. Ananth Srinivasan
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  3. Sarah Baker
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  4. Sumeet K. Mittal
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Corresponding author

Correspondence to Sumeet K. Mittal.

Additional information

Discussant

Dr. Sharon M. Weber (Madison, WI): I congratulate the authors on a well presented study and very nicely written MS.

Using NSQIP to evaluate readmission introduces a number of biases—the largest of which is the difference in the definition of the 30d window--for the Medicare Hospital Readmission Reduction Program this is defined as 30d after discharge. Because NSQIP only collects readmission data over a shorter time period, inclusive of 30d following surgery, readmission rates are not comparable. This is likely part of the reason your 12 % readmission rate was lower than expected compared to other series of patients undergoing complex cancer surgery, in which the rate is around 20 %. In addition, the NSQIP time point of 30d following surgery creates issues with immortal person-time bias—the patient can only be readmitted after they have been discharged, so patients who have died are excluded. How did you handle the statistical analysis to account for person-time bias?

In addition, the time at risk for readmission is shorter for those with a longer LOS. Thus your analysis of LOS and its impact on readmission is problematic and I would caution you to not overextend your conclusions, as many other studies have shown longer LOS is associated with increased risk of readmission, due to its strong association with postoperative complications.

Many other studies have clearly shown that, for surgical patients, complications are the main driver of readmissions. It is helpful to understand the relationship of post-discharge complications, since this allows one to focus on those that are potentially actionable in order to concentrate efforts to decrease the readmission rate. Did you evaluate the time to readmission following discharge, to understand the drivers of readmission in the early period post-discharge? This might help focus readmission reduction interventions on the drivers of early post-discharge readmission. Finally, it is clearly a worthwhile endeavor to assess the risk factors for readmission, but ultimately the goal is to decrease unnecessary readmissions. What interventions is your group pursuing as a result of this research?

Closing Discussant

Dr. Sundaram: Thank you Dr. Weber for your insightful questions. The NSQIP does collect readmission data from the date of admission. The readmission rate in our study is probably an underestimate of the true readmission rate, as even though NSQIP tries to capture readmissions at both the index hospital and other hospitals, some readmissions will be missed. One of the objectives of this study was to analyze risk factors for readmission. It is logical that complications drive readmissions. Thus identification of complications associated with readmission would allow for modification of risk factors associated with these complications, thus impacting readmission. In our study we analyzed the incidence of 30 day and post discharge complications. It was evident that patients who were readmitted had a higher incidence of wound related complications and venous thromboembolic events. Thus prevention of these complications could potentially reduce the readmission rate. However, this is a preliminary study. Future studies should focus on prevention strategies and how these impact readmission. The study has made us cognizant of the fact that a vast majority of our esophagectomy patients develop complications after discharge. We have instituted several measures to combat wound related complications. All our esophagectomy patients receive 72 hrs. of perioperative antibiotics. They are placed on a tight control insulin drip to prevent fluctuations in their glucose levels in the immediate post-operative period. We are looking at how best we can optimize our post discharge surveillance, such that patients who develop complications are identified early so that these complications can be treated without adding further to the morbidity associated with the procedure.

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Sundaram, A., Srinivasan, A., Baker, S. et al. Readmission and Risk Factors for Readmission Following Esophagectomy for Esophageal Cancer. J Gastrointest Surg 19, 581–586 (2015). https://doi.org/10.1007/s11605-015-2756-9

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  • DOI: https://doi.org/10.1007/s11605-015-2756-9

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