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C-REACTIVE PROTEIN AS A PREDICTOR OF READMISSION AFTER COLORECTAL SURGERY
Nicole Chaumont*1, Anna Johnson1, Emilie C. Barnes1, Rebecca F. Brown1, Paula D. Strassle1,2, Alessandro Fichera1, Mark Koruda1, Timothy S. Sadiq1
1Surgery, University of North Carolina, Chapel Hill, NC; 2Epidemiology, University of North Carolina, Maastricht, Netherlands
BACKGROUND. Postoperative infectious complications are common after colorectal surgery, and are a driver for significant morbidity and mortality, increased readmission rates and higher healthcare costs. Elevated postoperative C-reactive protein (CRP) has been shown to be an early indicator of postoperative infections in patients after colorectal surgery. The literature suggests that low postoperative CRP levels allow for safe and early discharge, but it's value in predicting readmission has not been explored thoroughly. The aim of this study was to evaluate the utility of early postoperative CRP levels within an enhanced recovery after surgery (ERAS) pathway to predict infectious complications and readmissions following colorectal surgery.
METHODS. We performed a retrospective observational study at a large academic medical center. All patients undergoing colorectal surgery within a specialized surgical unit between July 2015 and December 2016 were included. Postoperative day (POD) 3 CRP levels were obtained routinely as part of an ERAS protocol. A chart review was conducted to extract demographic information, intraoperative details and postoperative course. Infections were categorized into surgical site infection, intra-abdominal abscess, bacteremia, pneumonia, urinary tract infection and C. difficile infection. Multivariable Cox proportional hazards regression was used to assess the effect of POD 3 CRP (categorized as <140 mg/L and ≥140 mg/L) on postoperative infections, adjusting for age, gender, preoperative diagnosis, ASA class, surgical approach, surgeon and the presence of an anastomosis.
RESULTS. We included 234 patients in the study (255 individual operations and hospital stays). The most common indications for surgery included inflammatory bowel disease (51%), cancer (24%) and diverticulitis (7%). Within 30 days of discharge postoperative infectious complications occurred in 23% of patients and 14% required readmission within 30 days. One hundred and eleven patients (44%) had a CRP ≥140 mg/L. Patients with a CRP ≥140 mg/L were significantly more likely to be diagnosed with an infection (35% vs. 22%, p=.0002) or be readmitted (19% vs. 10%, p=.04). After adjusting for patient and surgical characteristics, patients with a CRP ≥140 mg/L were over twice as likely to get an infection (HR 2.43, 95% CI 1.38, 4.27, p=0.002), but no significant difference was seen in the incidence of readmission (HR 1.73, 95% CI 0.83, 3.61, p=.15). For infectious complications, the negative predictive value of POD 3 CRP ≥140 mg/L was 85% and the positive predictive value was 33%.
CONCLUSIONS. After colorectal surgery, POD 3 CRP ≥140 mg/L is predictive of infectious complications. This provides a valuable adjunct to clinical assessment when considering early discharge within the context of an ERAS protocol. POD 3 CRP ≥140 mg/L is not predictive of 30-day readmissions.
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