Risk factors of hospital readmission after radical cystectomy and urinary diversion: analysis of a large contemporary series Ahmed M. Harraz, Yasser Osman, Samer El-Halwagy, Mahmoud Laymon, Ahmed Mosbah, Hassan Abol-Enein and Atalla A. Shaaban Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
Objectives To determine the incidence, risk factors and causes of hospital readmission in a large series of patients who underwent radical cystectomy (RC) and urinary diversion.
Patients and Methods We retrospectively analysed the data of 1000 patients who underwent RC and urinary diversion between January 2004 and September 2009 in our tertiary referral centre. Patients stayed in hospital for 21 and 11 days for orthotopic and ileal conduit diversions, respectively. The primary outcome was the development of a complication requiring hospital readmission at ≤3 months (early) and >3 months (late). Causes of hospital readmissions were categorised according to frequency of readmissions. Predictors were determined using univariate and multivariate logistic regression models.
Results In all, 895 patients were analysed excluding 105 patients because of perioperative mortality and loss to follow-up. Early and late readmissions occurred in 8.6% and 11% patients, respectively. The commonest causes of first readmission were upper urinary tract obstruction (UUO, 13%) and pyelonephritis (12.4%) followed by intestinal obstruction (11.9%) and metabolic acidosis (11.3%). The development of
Introduction Radical cystectomy (RC) and urinary diversion is the optimal treatment for muscle-invasive bladder cancer [1]. Despite improvement in surgical techniques, the procedure remains complex and is associated with significant postoperative morbidity and mortality [2–4]. Hospital readmission after RC is a significant problem for patients and healthcare providers. In addition, readmission negates the savings from decreased inpatient stays, and undermines the quality of care given to patients during their first admission. Despite many studies extensively describing
BJU Int 2015; 115: 94–100 wileyonlinelibrary.com
postoperative high-grade complications (odds ratio [OR] 1.955; 95% confidence interval [CI] 1.254–3.046; P = 0.003) and orthotopic bladder substitution (OR 1.585; 95% CI 1.095–2.295; P = 0.015) were independent predictors for overall hospital readmission after RC. Postoperative high-grade complications (OR 2.488; 95% CI 1.391–4.450; P = 0.002), orthotopic bladder substitution (OR 2.492; 95% CI 1.423–4.364; P = 0.001) and prolonged hospital stay (OR 1.964; 95% CI:1.166–3.308; P = 0.011) were independent predictors for early readmission while hypertension (OR 1.670; 95% CI 1.007–2.769; P = 0.047) was an independent predictor for late readmission.
Conclusion Hospital readmissions are a significant problem after RC. In the present study, UUO, pyelonephritis, metabolic acidosis and intestinal obstruction were the main causes of readmission. Orthotopic bladder substitution and development of postoperative high-grade complications were significant predictors for overall readmission.
Keywords radical cystectomy, complications, hospital readmission, morbidity
postoperative morbidity after RC, very few have addressed the issue of hospital readmission in detail [5]. Furthermore, most previous reports only captured readmission at ≤3 months of surgery [2,5,6]. Therefore, extending the hospital readmission analysis beyond the 3-month period provides a more complete understanding of the morbidity of RC. In addition, advances in post-acute care and the introduction of minimally invasive surgery have significantly decreased hospital stays [7]. Nevertheless, it is not clear whether decreased hospital stay has influenced hospital readmission rates or not. Thus, given the magnitude of the problem and its clinical significance we decided to investigate the incidence, causes © 2014 The Authors BJU International © 2014 BJU International | doi:10.1111/bju.12830 Published by John Wiley & Sons Ltd. www.bjui.org
Risk factors of hospital readmission after RC and urinary diversion
and risk factors of hospital readmission (early and late) in 1000 patients who underwent RC and urinary diversion, after they had been discharged catheter-free, from a tertiary referral centre.
Patients and Methods We retrospectively analysed 1000 patients who underwent RC and urinary diversion between January 2004 and September 2009 in our tertiary referral centre. The study received our Internal Review Board approval with consent waived because of its retrospective nature. We included patients who completed ≥3 months follow-up, while those who were lost to follow-up or died during the perioperative period were excluded. All data were retrieved from our dedicated database. Patients demographics included age, gender and associated comorbidities. The morbidity was adjusted for age using the age-adjusted Charlson Comorbidity index (CCI) [8]. Patients were diagnosed with chronic kidney disease (CKD) at the time of surgery if they had an estimated GFR (eGFR) of 35 kg/m2 and hypoalbuminaemia as an albumin level of 3 months, respectively. Metabolic acidosis was diagnosed if the patients had a blood pH of 3 months. Late readmissions (>3 months of hospital discharge) occurred in 100 (11%) patients at a median (range) of 17.5 (4–79) months. The main causes of first readmission after hospital discharge were UUO (13%) and pyelonephritis (12.4%) followed by intestinal obstruction (11.9%) and metabolic acidosis (11.3%). Metabolic acidosis and UUO were the most common causes of second readmissions, while metabolic acidosis continued to be the principal cause for patients that had three or more readmissions. Table 1 lists the causes of readmissions. There was no significant difference between causes of readmissions in the early vs late periods apart from pyelonephritis that was significantly associated with early readmission (P < 0.001). The differences between causes of early and late readmissions are shown in Table 2. Predictors of Hospital Readmissions after RC The association between various perioperative parameters and overall hospital readmission rate is shown in Table 3. Neither
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© 2014 The Authors BJU International © 2014 BJU International
UUO: No Yes Pyelonephritis: No Yes Metabolic acidosis: No Yes Intestinal obstruction: No Yes
Early (≤3 months)
Late (>3 months)
24
68 (44.4) 9 (37.5)
85 (55.6) 15 (62.5)
22
58 (37.4) 19 (86.4)
97 (62.6) 3 (13.6)
23
65 (42.2) 12 (52.2)
89 (57.8) 11 (47.8)
24
69 (45.1) 8 (33.3)
84 (54.9) 16 (66.7)
P
0.523
35 kg/m ; †21 days for orthotopic and >11 days in ileal conduit diversions. 2
P
RC is a technically demanding procedure with associated significant morbidity. Therefore, the anticipated complication rate should extend beyond hospital discharge to include hospital readmission. Generally, decreasing hospital readmission rates is now one of the goals of healthcare providers and hospital administrators [11]. In Western countries, the development of efficient post-hospital discharge healthcare system allows early hospital discharge but it is not evident whether this affects hospital readmission rates or not. In addition, the relationship between hospital stays and readmission rates remain underestimated in the literature. In the present cohort, we included 1000 patients within a 5-year period, as during this era we had a fixed postoperative patient-care policy that entailed limiting patients discharge until they become catheter-free (21 and 11 days for orthotopic and ileal conduit urinary diversions, respectively). This is because we unfortunately lack an efficient home or skilled nursing or intermediate care facilities that can attend to our patients after hospital discharge. Jacobs et al. [12] investigated 30-day readmission rates for 9035 RC patients and related them to hospital stay. The authors documented a decrease in inpatient stay from an average of 15.4 to 12.1 days over an approximately 14-year period, representing a relative reduction of 21%. This decline in inpatient stay did not affect the 30-day hospital readmission rates; nevertheless, it was significantly associated with increased use of intermediate or nursing healthcare facilities. Based on our present series, we found that the development of postoperative high-grade complications was an independent predictor for overall and early hospital readmission. This can explain the relatively lower rate for early hospital readmission of 8.6% compared with an average of 25–27% in previous studies [5,12,13]. This is mostly attributable to the difference in inpatient-stay policies and the difference in study designs. In addition, our present cohort had relatively younger patients with lower BMIs and a © 2014 The Authors BJU International © 2014 BJU International
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Harraz et al.
Table 4. Univariate and multivariate analyses for significant predictors of overall, early and late hospital readmissions in 895 patients who underwent RC Univariate
Overall hospital readmissions Anaemia Diversion Loop Orthotopic Others Obesity PO complications Early readmissions Diversion Loop Orthotopic Others Hospital stay PO complications Late readmissions Haemoglobin deficit Anaemia Hypertension PO complications
Multivariate
OR (95% CI)
P
OR (95% CI)
P
0.682 (0.491–0.949)
0.023
0.751 (0.533–1.058)
0.102
Referent 1.708 (1.193–2.444) 1.294 (0.469–0.357) 1.781 (1.051–3.016) 2.036 (1.32–3.141)
0.014 0.003 0.619 0.032 0.001
1.585 (1.095–2.295) 1.197 (0.426–3.366) 1.537 (0.893–2.645) 1.955 (1.254–3.046)
0.015 0.732 0.121 0.003
Referent 2.257 (1.304–3.906) 1.467 (0.322–6.682) 2.269 (1.411–3.647) 3.32 (1.947–5.662)
0.004 0.621 0.001
Objectives To determine the incidence, risk factors and causes of hospital readmission in a large series of patients who underwent radical cystectomy (RC) and urinary diversion.
Patients and Methods We retrospectively analysed the data of 1000 patients who underwent RC and urinary diversion between January 2004 and September 2009 in our tertiary referral centre. Patients stayed in hospital for 21 and 11 days for orthotopic and ileal conduit diversions, respectively. The primary outcome was the development of a complication requiring hospital readmission at ≤3 months (early) and >3 months (late). Causes of hospital readmissions were categorised according to frequency of readmissions. Predictors were determined using univariate and multivariate logistic regression models.
Results In all, 895 patients were analysed excluding 105 patients because of perioperative mortality and loss to follow-up. Early and late readmissions occurred in 8.6% and 11% patients, respectively. The commonest causes of first readmission were upper urinary tract obstruction (UUO, 13%) and pyelonephritis (12.4%) followed by intestinal obstruction (11.9%) and metabolic acidosis (11.3%). The development of
Introduction Radical cystectomy (RC) and urinary diversion is the optimal treatment for muscle-invasive bladder cancer [1]. Despite improvement in surgical techniques, the procedure remains complex and is associated with significant postoperative morbidity and mortality [2–4]. Hospital readmission after RC is a significant problem for patients and healthcare providers. In addition, readmission negates the savings from decreased inpatient stays, and undermines the quality of care given to patients during their first admission. Despite many studies extensively describing
BJU Int 2015; 115: 94–100 wileyonlinelibrary.com
postoperative high-grade complications (odds ratio [OR] 1.955; 95% confidence interval [CI] 1.254–3.046; P = 0.003) and orthotopic bladder substitution (OR 1.585; 95% CI 1.095–2.295; P = 0.015) were independent predictors for overall hospital readmission after RC. Postoperative high-grade complications (OR 2.488; 95% CI 1.391–4.450; P = 0.002), orthotopic bladder substitution (OR 2.492; 95% CI 1.423–4.364; P = 0.001) and prolonged hospital stay (OR 1.964; 95% CI:1.166–3.308; P = 0.011) were independent predictors for early readmission while hypertension (OR 1.670; 95% CI 1.007–2.769; P = 0.047) was an independent predictor for late readmission.
Conclusion Hospital readmissions are a significant problem after RC. In the present study, UUO, pyelonephritis, metabolic acidosis and intestinal obstruction were the main causes of readmission. Orthotopic bladder substitution and development of postoperative high-grade complications were significant predictors for overall readmission.
Keywords radical cystectomy, complications, hospital readmission, morbidity
postoperative morbidity after RC, very few have addressed the issue of hospital readmission in detail [5]. Furthermore, most previous reports only captured readmission at ≤3 months of surgery [2,5,6]. Therefore, extending the hospital readmission analysis beyond the 3-month period provides a more complete understanding of the morbidity of RC. In addition, advances in post-acute care and the introduction of minimally invasive surgery have significantly decreased hospital stays [7]. Nevertheless, it is not clear whether decreased hospital stay has influenced hospital readmission rates or not. Thus, given the magnitude of the problem and its clinical significance we decided to investigate the incidence, causes © 2014 The Authors BJU International © 2014 BJU International | doi:10.1111/bju.12830 Published by John Wiley & Sons Ltd. www.bjui.org
Risk factors of hospital readmission after RC and urinary diversion
and risk factors of hospital readmission (early and late) in 1000 patients who underwent RC and urinary diversion, after they had been discharged catheter-free, from a tertiary referral centre.
Patients and Methods We retrospectively analysed 1000 patients who underwent RC and urinary diversion between January 2004 and September 2009 in our tertiary referral centre. The study received our Internal Review Board approval with consent waived because of its retrospective nature. We included patients who completed ≥3 months follow-up, while those who were lost to follow-up or died during the perioperative period were excluded. All data were retrieved from our dedicated database. Patients demographics included age, gender and associated comorbidities. The morbidity was adjusted for age using the age-adjusted Charlson Comorbidity index (CCI) [8]. Patients were diagnosed with chronic kidney disease (CKD) at the time of surgery if they had an estimated GFR (eGFR) of 35 kg/m2 and hypoalbuminaemia as an albumin level of 3 months, respectively. Metabolic acidosis was diagnosed if the patients had a blood pH of 3 months. Late readmissions (>3 months of hospital discharge) occurred in 100 (11%) patients at a median (range) of 17.5 (4–79) months. The main causes of first readmission after hospital discharge were UUO (13%) and pyelonephritis (12.4%) followed by intestinal obstruction (11.9%) and metabolic acidosis (11.3%). Metabolic acidosis and UUO were the most common causes of second readmissions, while metabolic acidosis continued to be the principal cause for patients that had three or more readmissions. Table 1 lists the causes of readmissions. There was no significant difference between causes of readmissions in the early vs late periods apart from pyelonephritis that was significantly associated with early readmission (P < 0.001). The differences between causes of early and late readmissions are shown in Table 2. Predictors of Hospital Readmissions after RC The association between various perioperative parameters and overall hospital readmission rate is shown in Table 3. Neither
96
© 2014 The Authors BJU International © 2014 BJU International
UUO: No Yes Pyelonephritis: No Yes Metabolic acidosis: No Yes Intestinal obstruction: No Yes
Early (≤3 months)
Late (>3 months)
24
68 (44.4) 9 (37.5)
85 (55.6) 15 (62.5)
22
58 (37.4) 19 (86.4)
97 (62.6) 3 (13.6)
23
65 (42.2) 12 (52.2)
89 (57.8) 11 (47.8)
24
69 (45.1) 8 (33.3)
84 (54.9) 16 (66.7)
P
0.523
35 kg/m ; †21 days for orthotopic and >11 days in ileal conduit diversions. 2
P
RC is a technically demanding procedure with associated significant morbidity. Therefore, the anticipated complication rate should extend beyond hospital discharge to include hospital readmission. Generally, decreasing hospital readmission rates is now one of the goals of healthcare providers and hospital administrators [11]. In Western countries, the development of efficient post-hospital discharge healthcare system allows early hospital discharge but it is not evident whether this affects hospital readmission rates or not. In addition, the relationship between hospital stays and readmission rates remain underestimated in the literature. In the present cohort, we included 1000 patients within a 5-year period, as during this era we had a fixed postoperative patient-care policy that entailed limiting patients discharge until they become catheter-free (21 and 11 days for orthotopic and ileal conduit urinary diversions, respectively). This is because we unfortunately lack an efficient home or skilled nursing or intermediate care facilities that can attend to our patients after hospital discharge. Jacobs et al. [12] investigated 30-day readmission rates for 9035 RC patients and related them to hospital stay. The authors documented a decrease in inpatient stay from an average of 15.4 to 12.1 days over an approximately 14-year period, representing a relative reduction of 21%. This decline in inpatient stay did not affect the 30-day hospital readmission rates; nevertheless, it was significantly associated with increased use of intermediate or nursing healthcare facilities. Based on our present series, we found that the development of postoperative high-grade complications was an independent predictor for overall and early hospital readmission. This can explain the relatively lower rate for early hospital readmission of 8.6% compared with an average of 25–27% in previous studies [5,12,13]. This is mostly attributable to the difference in inpatient-stay policies and the difference in study designs. In addition, our present cohort had relatively younger patients with lower BMIs and a © 2014 The Authors BJU International © 2014 BJU International
97
Harraz et al.
Table 4. Univariate and multivariate analyses for significant predictors of overall, early and late hospital readmissions in 895 patients who underwent RC Univariate
Overall hospital readmissions Anaemia Diversion Loop Orthotopic Others Obesity PO complications Early readmissions Diversion Loop Orthotopic Others Hospital stay PO complications Late readmissions Haemoglobin deficit Anaemia Hypertension PO complications
Multivariate
OR (95% CI)
P
OR (95% CI)
P
0.682 (0.491–0.949)
0.023
0.751 (0.533–1.058)
0.102
Referent 1.708 (1.193–2.444) 1.294 (0.469–0.357) 1.781 (1.051–3.016) 2.036 (1.32–3.141)
0.014 0.003 0.619 0.032 0.001
1.585 (1.095–2.295) 1.197 (0.426–3.366) 1.537 (0.893–2.645) 1.955 (1.254–3.046)
0.015 0.732 0.121 0.003
Referent 2.257 (1.304–3.906) 1.467 (0.322–6.682) 2.269 (1.411–3.647) 3.32 (1.947–5.662)
0.004 0.621 0.001
