Accepted Manuscript Risk of and Factors Associated with Readmission After a Sentinel Attack of Acute Pancreatitis Kishore Vipperla, Georgios I. Papachristou, Jeffrey Easler, Venkata Muddana, Adam Slivka, David C. Whitcomb, Dhiraj Yadav
PII: DOI: Reference:
S1542-3565(14)00670-3 10.1016/j.cgh.2014.04.035 YJCGH 53816
To appear in: Clinical Gastroenterology and Hepatology Accepted Date: 29 April 2014 Please cite this article as: Vipperla K, Papachristou GI, Easler J, Muddana V, Slivka A, Whitcomb DC, Yadav D, Risk of and Factors Associated with Readmission After a Sentinel Attack of Acute Pancreatitis, Clinical Gastroenterology and Hepatology (2014), doi: 10.1016/j.cgh.2014.04.035. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. All studies published in Clinical Gastroenterology and Hepatology are embargoed until 3PM ET of the day they are published as corrected proofs on-line. Studies cannot be publicized as accepted manuscripts or uncorrected proofs.
ACCEPTED MANUSCRIPT
CGH-D-14-00062 - Revision 2 Title: Risk of and Factors Associated with Readmission After a Sentinel Attack of Acute Pancreatitis
1 1
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Short Title: Readmissions after sentinel acute pancreatitis Kishore Vipperla, 1Georgios I. Papachristou, 1Jeffrey Easler, 1Venkata Muddana, 1Adam Slivka, David C. Whitcomb, 1Dhiraj Yadav
Drs. Yadav and Papachristou co-directed this project 1
SC
Division of Gastroenterology & Hepatology, University of Pittsburgh Medical Center, Pittsburgh, PA
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Word Count: Abstract with keywords– 327 (approved by Dr Novak); Text (with table and figure legends including footnotes and references) - 3990 Conflict of Interest: The authors report no conflicts relevant to this manuscript. Funding: None.
Acknowledgement: Presented in part at the Digestive Diseases Week 2013 and published in abstract form in Gastroenterology 2013;144(5):Suppl 1, Page S-272-273.
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Address for Correspondence: Dhiraj Yadav MD MPH Associate Professor Division of Gastroenterology & Hepatology University of Pittsburgh Medical Center 200 Lothrop Street, M2, C-wing Pittsburgh, PA 15213 Tel: 412 648 9825 Fax: 412 383 8992 e-mail: [email protected]
Authorship criteria and contributions: Kishore Vipperla: Study design, data collection, data interpretation, revising the article, final approval of the version to be published. Jeffrey Easler, Venkata Muddana: Data collection, data interpretation, revising the article, final approval of the version to be published. Adam Slivka, David C. Whitcomb: Data interpretation, revising the article, final approval of the version to be published. Georgios I. Papachristou, MD: Study design and supervision, data interpretation, revising the article, final approval of the version to be published. Dhiraj Yadav: Study design and supervision, data analysis and interpretation, drafting and revising the article, final approval of the version to be published.
ACCEPTED MANUSCRIPT
Abstract: Background & Aims: Few data are available on how many patients are readmitted to the hospital after attacks of acute pancreatitis. We aimed to determine the risk and factors that
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determine early (within 30 days) and late (after 30 days) readmission of patients with acute pancreatitis.
Methods: In a retrospectively study, we collected and analyzed data on 127 surviving patients
SC
(median age, 53 years; 52% male; 83% white) hospitalized at the University of Pittsburgh Medical Center for a sentinel attack of acute pancreatitis, enrolled in the Severe Acute
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Pancreatitis Study from June 2003 through April 2010, and had follow up data. Information was collected on demographics, clinical profile, risk score at discharge (based on a recently developed scoring system), and details of readmissions during follow up (median 36 months). Results: Of the 127 patients, 52% were transfers from another care center and 32% required
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admission to the intensive care unit. Etiologies for pancreatitis were biliary (47%), idiopathic (13%), alcohol associated (12%), and others (28%). Pancreatic necrosis (28%), persistent organ failure (27%), and peripancreatic fluid collections (19%) were common. The median length of
EP
stay was 9 days. A total of 108 readmissions occurred, for 43 patients (34%). Early readmissions (n=21) occurred more frequently for patients with smoldering (ongoing) symptoms or local
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complications than for those without. Late readmissions (n=22) occurred more frequently for patients with recurrent pancreatitis than for those without. Male sex, alcohol-associated disease, and severe disease increased the risks of readmission and recurrence. Risk for readmission was lower among non-transferred patients (23%) and patients without necrosis or organ failure (16%). Risk for readmission increased with the number of points on the weighted scoring system.
ACCEPTED MANUSCRIPT
Conclusions: About one third of patients hospitalized for acute pancreatitis are readmitted, usually due to smoldering symptoms, local complications, or recurrent attacks. Studies are
etiology of acute pancreatitis, can reduce the risk for readmission.
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KEY WORDS: pancreas, inflammation, prognostic factor, outcome
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needed to determine whether individualized discharge planning, with consideration of the
ACCEPTED MANUSCRIPT
Background: With implementation of the Affordable Care Act, significant changes are expected to occur over the next few years in the way healthcare is delivered in the United States. An
RI PT
important emphasis of the new health care law is to provide high quality care at the lowest
possible cost. Inpatient care accounts for the bulk of health care costs, and readmissions after hospitalization are common. Therefore, identification of the risk and reasons for readmissions,
SC
and addressing them can potentially reduce hospitalizations and healthcare costs.
Acute Pancreatitis (AP) is the most common pancreas disorder, requiring hospitalization
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in almost all patients1. In fact, AP is now the leading cause of gastrointestinal tract related hospital admissions in the United States2. However, there is paucity of data on the risk of and reasons for readmissions after an episode of AP. Focused studies have evaluated the functional consequences after severe AP3-7. Two single center studies evaluated the risk of readmissions in
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all AP patients, and developed a weighted scoring system to identify patients at high-risk of readmission8, 9.
We recently analyzed population-based data from Allegheny County, Pennsylvania in
EP
patients hospitalized for first-attack of AP from 1996-200510, 11. We found the overall risk of readmissions to be 22%. Readmissions were common in younger patients and those who were
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male, black and had alcohol etiology. Due to limitations of administrative data, we were unable to know the precise reasons for readmissions. Since we determined the risk of admissions only on a yearly basis, we were unable to know the risk and reasons of early and late readmissions. The aim of our current study was to evaluate the risk and determinants of readmission after a sentinel attack of AP in a well-established, prospectively ascertained cohort of AP
ACCEPTED MANUSCRIPT
patients. We also evaluated the performance of the weighted scoring system recently proposed to determine the risk of readmissions in AP patients8, 9.
RI PT
Methods Severe Acute Pancreatitis Study (SAPS)
SAPS is an ongoing prospective observational study at the University of Pittsburgh
SC
Medical Center (UPMC) designed to study the role of patient, diseaseand genetic factors that affect the severity of AP. Data from this study on the role of clinical scoring systems in disease
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severity has been published12, 13. The study protocol is approved by the Institutional Review Board of the University of Pittsburgh and a written informed consent was obtained from all patients prior to study enrollment.
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Patient cohort
Between June 2003-April 2010, in three one-year periods, SAPS enrolled 256 AP patients of varying severity from two tertiary care hospitals of the UPMC system (UPMC-
EP
Presbyterian, UPMC-Shadyside). All patients were enrolled within 24 hours of admission or transfer from another institution(s) after obtaining an informed consent from patients or their
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designated surrogates. AP diagnosis was based on presence of two of the following three features: abdominal pain characteristic of AP, serum pancreatic enzyme elevation to ≥3 times the upper limit of normal, and characteristic findings of AP on abdominal computed tomography (CT) scan.
ACCEPTED MANUSCRIPT
Since the present study focuses on readmissions, we limited the study cohort to patients who were admitted with their first AP attack, had no prior history of CP, survived the index
RI PT
admission and had data available on follow up.
Index admission
Data during index admission was collected prospectively and included detailed
SC
information on demographic, clinical, laboratory and radiographic parameters. For patients transferred to our institution, pertinent information from outside records generated prior to
M AN U
admission was obtained by contacting the transferring center. Clinical and laboratory parameters were used to determine a variety of severity scores (Ranson, Acute Physiology and Chronic Health Evaluation II [APACHE-II], Bedside index of severity in AP [BISAP]). Organ failure was defined by the presence of shock (systolic blood pressure
PII: DOI: Reference:
S1542-3565(14)00670-3 10.1016/j.cgh.2014.04.035 YJCGH 53816
To appear in: Clinical Gastroenterology and Hepatology Accepted Date: 29 April 2014 Please cite this article as: Vipperla K, Papachristou GI, Easler J, Muddana V, Slivka A, Whitcomb DC, Yadav D, Risk of and Factors Associated with Readmission After a Sentinel Attack of Acute Pancreatitis, Clinical Gastroenterology and Hepatology (2014), doi: 10.1016/j.cgh.2014.04.035. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. All studies published in Clinical Gastroenterology and Hepatology are embargoed until 3PM ET of the day they are published as corrected proofs on-line. Studies cannot be publicized as accepted manuscripts or uncorrected proofs.
ACCEPTED MANUSCRIPT
CGH-D-14-00062 - Revision 2 Title: Risk of and Factors Associated with Readmission After a Sentinel Attack of Acute Pancreatitis
1 1
RI PT
Short Title: Readmissions after sentinel acute pancreatitis Kishore Vipperla, 1Georgios I. Papachristou, 1Jeffrey Easler, 1Venkata Muddana, 1Adam Slivka, David C. Whitcomb, 1Dhiraj Yadav
Drs. Yadav and Papachristou co-directed this project 1
SC
Division of Gastroenterology & Hepatology, University of Pittsburgh Medical Center, Pittsburgh, PA
M AN U
Word Count: Abstract with keywords– 327 (approved by Dr Novak); Text (with table and figure legends including footnotes and references) - 3990 Conflict of Interest: The authors report no conflicts relevant to this manuscript. Funding: None.
Acknowledgement: Presented in part at the Digestive Diseases Week 2013 and published in abstract form in Gastroenterology 2013;144(5):Suppl 1, Page S-272-273.
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Address for Correspondence: Dhiraj Yadav MD MPH Associate Professor Division of Gastroenterology & Hepatology University of Pittsburgh Medical Center 200 Lothrop Street, M2, C-wing Pittsburgh, PA 15213 Tel: 412 648 9825 Fax: 412 383 8992 e-mail: [email protected]
Authorship criteria and contributions: Kishore Vipperla: Study design, data collection, data interpretation, revising the article, final approval of the version to be published. Jeffrey Easler, Venkata Muddana: Data collection, data interpretation, revising the article, final approval of the version to be published. Adam Slivka, David C. Whitcomb: Data interpretation, revising the article, final approval of the version to be published. Georgios I. Papachristou, MD: Study design and supervision, data interpretation, revising the article, final approval of the version to be published. Dhiraj Yadav: Study design and supervision, data analysis and interpretation, drafting and revising the article, final approval of the version to be published.
ACCEPTED MANUSCRIPT
Abstract: Background & Aims: Few data are available on how many patients are readmitted to the hospital after attacks of acute pancreatitis. We aimed to determine the risk and factors that
RI PT
determine early (within 30 days) and late (after 30 days) readmission of patients with acute pancreatitis.
Methods: In a retrospectively study, we collected and analyzed data on 127 surviving patients
SC
(median age, 53 years; 52% male; 83% white) hospitalized at the University of Pittsburgh Medical Center for a sentinel attack of acute pancreatitis, enrolled in the Severe Acute
M AN U
Pancreatitis Study from June 2003 through April 2010, and had follow up data. Information was collected on demographics, clinical profile, risk score at discharge (based on a recently developed scoring system), and details of readmissions during follow up (median 36 months). Results: Of the 127 patients, 52% were transfers from another care center and 32% required
TE D
admission to the intensive care unit. Etiologies for pancreatitis were biliary (47%), idiopathic (13%), alcohol associated (12%), and others (28%). Pancreatic necrosis (28%), persistent organ failure (27%), and peripancreatic fluid collections (19%) were common. The median length of
EP
stay was 9 days. A total of 108 readmissions occurred, for 43 patients (34%). Early readmissions (n=21) occurred more frequently for patients with smoldering (ongoing) symptoms or local
AC C
complications than for those without. Late readmissions (n=22) occurred more frequently for patients with recurrent pancreatitis than for those without. Male sex, alcohol-associated disease, and severe disease increased the risks of readmission and recurrence. Risk for readmission was lower among non-transferred patients (23%) and patients without necrosis or organ failure (16%). Risk for readmission increased with the number of points on the weighted scoring system.
ACCEPTED MANUSCRIPT
Conclusions: About one third of patients hospitalized for acute pancreatitis are readmitted, usually due to smoldering symptoms, local complications, or recurrent attacks. Studies are
etiology of acute pancreatitis, can reduce the risk for readmission.
AC C
EP
TE D
M AN U
SC
KEY WORDS: pancreas, inflammation, prognostic factor, outcome
RI PT
needed to determine whether individualized discharge planning, with consideration of the
ACCEPTED MANUSCRIPT
Background: With implementation of the Affordable Care Act, significant changes are expected to occur over the next few years in the way healthcare is delivered in the United States. An
RI PT
important emphasis of the new health care law is to provide high quality care at the lowest
possible cost. Inpatient care accounts for the bulk of health care costs, and readmissions after hospitalization are common. Therefore, identification of the risk and reasons for readmissions,
SC
and addressing them can potentially reduce hospitalizations and healthcare costs.
Acute Pancreatitis (AP) is the most common pancreas disorder, requiring hospitalization
M AN U
in almost all patients1. In fact, AP is now the leading cause of gastrointestinal tract related hospital admissions in the United States2. However, there is paucity of data on the risk of and reasons for readmissions after an episode of AP. Focused studies have evaluated the functional consequences after severe AP3-7. Two single center studies evaluated the risk of readmissions in
TE D
all AP patients, and developed a weighted scoring system to identify patients at high-risk of readmission8, 9.
We recently analyzed population-based data from Allegheny County, Pennsylvania in
EP
patients hospitalized for first-attack of AP from 1996-200510, 11. We found the overall risk of readmissions to be 22%. Readmissions were common in younger patients and those who were
AC C
male, black and had alcohol etiology. Due to limitations of administrative data, we were unable to know the precise reasons for readmissions. Since we determined the risk of admissions only on a yearly basis, we were unable to know the risk and reasons of early and late readmissions. The aim of our current study was to evaluate the risk and determinants of readmission after a sentinel attack of AP in a well-established, prospectively ascertained cohort of AP
ACCEPTED MANUSCRIPT
patients. We also evaluated the performance of the weighted scoring system recently proposed to determine the risk of readmissions in AP patients8, 9.
RI PT
Methods Severe Acute Pancreatitis Study (SAPS)
SAPS is an ongoing prospective observational study at the University of Pittsburgh
SC
Medical Center (UPMC) designed to study the role of patient, diseaseand genetic factors that affect the severity of AP. Data from this study on the role of clinical scoring systems in disease
M AN U
severity has been published12, 13. The study protocol is approved by the Institutional Review Board of the University of Pittsburgh and a written informed consent was obtained from all patients prior to study enrollment.
TE D
Patient cohort
Between June 2003-April 2010, in three one-year periods, SAPS enrolled 256 AP patients of varying severity from two tertiary care hospitals of the UPMC system (UPMC-
EP
Presbyterian, UPMC-Shadyside). All patients were enrolled within 24 hours of admission or transfer from another institution(s) after obtaining an informed consent from patients or their
AC C
designated surrogates. AP diagnosis was based on presence of two of the following three features: abdominal pain characteristic of AP, serum pancreatic enzyme elevation to ≥3 times the upper limit of normal, and characteristic findings of AP on abdominal computed tomography (CT) scan.
ACCEPTED MANUSCRIPT
Since the present study focuses on readmissions, we limited the study cohort to patients who were admitted with their first AP attack, had no prior history of CP, survived the index
RI PT
admission and had data available on follow up.
Index admission
Data during index admission was collected prospectively and included detailed
SC
information on demographic, clinical, laboratory and radiographic parameters. For patients transferred to our institution, pertinent information from outside records generated prior to
M AN U
admission was obtained by contacting the transferring center. Clinical and laboratory parameters were used to determine a variety of severity scores (Ranson, Acute Physiology and Chronic Health Evaluation II [APACHE-II], Bedside index of severity in AP [BISAP]). Organ failure was defined by the presence of shock (systolic blood pressure
