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30-Day Readmission After Laparoscopic Sleeve Gastrectomy - a Predictable Event?
Monica Sethi*, Manish Parikh, John K. Saunders, Aku Ude Welcome, Karan S. Patel, Eduardo Somoza, Bradley F. Schwack, Marina Kurian, George a. Fielding, Christine Ren-Fielding
Department of Surgery, NYU School of Medicine, New York, NY
Background: 30-day readmission post-bariatric surgery is used as a metric for surgical quality and patient care, and can also result in reductions in hospital reimbursement. As laparoscopic sleeve gastrectomy (LSG) has become a popular bariatric procedure, we sought to examine the factors driving 30-day readmissions after LSG.
Methods: This is a retrospective review of a prospective database from two institutions. All LSG procedures and 30-day readmissions between March 2012 and June 2014 were reviewed. Readmitted and non-readmitted patients were compared with regards to their demographics, medical history, and index admissions. Patients readmitted with malaise were compared to those readmitted with technical complications. Univariate and multivariate logistic regression models were used to assess the impact of various factors on the risk of readmission.
Results: From March 2012 to June 2014, 1257 patients underwent LSG, and 45 (3.6%) patients required 30-day readmissions. Of the 45 readmitted patients, twenty-one (46.7%) were readmitted with malaise (emesis, dehydration, non-specific abdominal pain), nineteen (42.2%) with technical complications (leak, bleed, mesenteric vein thrombosis), four (8.9%) with other postoperative complications (UTI), and one (2.2%) for an unrelated reason. Factors associated with an increased risk of readmission include age, insulin dependent diabetes, COPD, hyperlipidemia, psychiatric history, high-risk medications (e.g. anticoagulants), polypharmacy, reoperation, ICU care, length of stay (LOS), and highest pain score on day of discharge from the index admission (Table1). On adjusted multivariate analysis, pain score and index LOS remained independent predictors of readmission. Although patients readmitted with malaise were similar to patients readmitted for technical complications, patients with malaise were more likely female (95.2% malaise vs. 68.4% technical, p=0.026), whereas those with technical complications were more likely to show signs of systemic illness (52.6% technical vs. 19% malaise, p=0.046) and had longer readmissions (11d technical vs. 3.7d malaise, p=0.027). Patients requiring a 30-day readmission had 124 times the odds of being readmitted again than those who were not readmitted within 30 days (95% CI 17.799-966.729, p<0.001).
Conclusions: The 30-day readmission rate after LSG is 3.6%, with near equal contributions from malaise and technical complications. LOS and pain score, among other factors, can be helpful in identifying patients at increased risk for 30-day readmissions, but predictors for specific readmission types are not as clear. Educating patients at risk for readmission on techniques to manage benign abdominal pain and dehydration in an outpatient setting should be considered, so that readmissions can be limited to those requiring acute inpatient management for technical complications.
Table 1: Comparison of Readmitted and Non-readmitted Patients
| Patient and Index Admission Factors | Not Readmitted
N=1212 | Readmitted
N=45 | p-value | | Female | 972 (80.2%) | 37 (82.2%) | 0.738 | | Age; mean [SD] | 40.1 [11.5] | 43.8 [13.1] | 0.034¥ | Race
White
Black
Hispanic
Asian | | | 0.053 | | 263 (22.7%) | 17 (39.5%) | | 161 (13.9%) | 6 (14.0%) | | 722 (62.2%) | 19 (44.2%) | | 14 (1.2%) | 1 (2.3%) | | Diabetes | 268 (22.1%) | 12 (26.7%) | 0.471 | | Insulin Dependent Diabetes | 74 (6.1%) | 7 (15.6%) | 0.011¥ | | Smoker | 166 (13.7%) | 5 (11.1%) | 0.619 | | Chronic Obstructive Pulmonary Disease | 3 (0.2%) | 2 (4.4%) | 0.012¥ | | Obstructive Sleep Apnea | 146 (12.0%) | 9 (20.0%) | 0.111 | | Gastroesohpageal Reflux Disease | 220 (18.2%) | 12 (26.7%) | 0.148 | | Myocardial Infarction History | 15 (1.2%) | 1 (2.2%) | 0.444 | | Hyperlipidemia | 217 (17.9%) | 15 (33.3%) | 0.009¥ | | High-risk Medications* | 48 (21.3%) | 16 (35.6%) | 0.041¥ | | Psychiatric History* | 28 (12.6%) | 13 (28.9%) | 0.005¥ | | Polypharmacy* | 56 (24.9%) | 19 (42.2%) | 0.018¥ | | Previous Foregut Surgery* | 105 (8.7%) | 7 (15.6%) | 0.111 | | Length of Stay in Days; mean [SD] | 2.2 [0.98] | 3.5 [4.24] | 0.05¥ | | Re-op During Index Admission* | 0 (0.0%) | 2 (4.4%) | 0.027¥ | | Intensive Care Unit During Index Admission* | 1 (0.4%) | 4 (8.9%) | 0.029¥ | | Leak | 2 (0.2%) | 11 (24.4%) | 0.000¥ | | Highest Pain Score on Discharge Day from Index Admission*; mean [SD] | 4.1 [2.76] | 5.3 [2.35] | 0.007¥ | | Additional Readmissions (Within 4 Months of Surgery)* | 1 (0.4%) | 16 (35.6%) | 0.000¥ |
*Data obtained for readmissions and random controls in a 1:5 ratio; ¥Significant p-value (p≤0.05); Abbreviations: SD (standard deviation)
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