EARLY VS LATE READMISSION IN PANCREATICODUODENECTOMY PATIENTS: RECOGNIZING COMPREHENSIVE COST TO GUIDE BUNDLED PAYMENT PLANS AND HOSPITAL RESOURCE ALLOCATION
Alexandra Acher*1,2, Patrick B. Schwartz1, Christopher C. Stahl1, James Barrett1, Taylor Aiken1, Sean Ronnekleiv-Kelly1, Rebecca M. Minter1, Glen Leverson1, Daniel E. Abbott1
1General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; 2Huntsman Cancer Institute/University of Utah, Salt Lake City, UT
Introduction: Postoperative complications are associated with increased readmission and cost. We sought to identify relationships between types of postoperative complications, timing of readmission, and cost of readmission in patients undergoing pancreaticoduodenectomy (PD) in an academic center.
Methods: Hospital cost data from operative date to postoperative day 90 were merged with 2008-2018 NSQIP data. Early readmission was defined as within 30 days of surgery and late readmission as between 30 to 90 days from surgery. Regression analysis for early and late readmission was performed controlling for patient comorbidities and surgeon.
Results: Of 232 patients included in the analysis, 58 (25%) were readmitted: 30 (52%) as early readmissions, 17 (29%) as late readmissions, and 11 (19%) as both early and late readmissions. The mean (+/- SD) cost for early and late readmissions was $18,365 +/- $20,262 and $24,965 +/- $34,435 respectively. Early readmission was associated with index stay complication of DVT (p = 0.01), delayed gastric emptying (p<0.01), and Grade B PFs (p = 0.03); the most common early readmission diagnoses were complications of delayed gastric emptying (n = 11, 27%) and Grade B PF requiring percutaneous drainage (n = 11, 27%). High-cost early readmissions were related to prolonged hospitalization for delayed gastric emptying, bowel motility issues, and DVT-treatment related GI bleeding (Table 1). In contrast, late readmission was associated with previous readmission (p<0.01), index diagnoses of organ space infections (p=0.01), postoperative bleeding (p=0.02), and wound infection (p = 0.04). The most common late readmission diagnoses were small bowel obstruction requiring operative intervention (n = 3, 11%), intra-abdominal infection related to inadequately drained PF (n = 4, 14%), and failure to thrive (n = 4, 14%). High-cost late readmissions were related to operative intervention for bowel obstructions and long hospitalization. (Table 1).
Conclusion: Early and late readmission following pancreaticoduodenectomy vary in both etiology and cost. Early readmission and cost is driven by complications requiring intervention (percutaneous drainage, endoscopy, TPN), while late readmission is driven by difficult to treat prior complications with cost driven by long hospitalizations and operative intervention. These temporal trends should be factored into transitional care programs to anticipate patient needs. As hospital systems and insurers work toward bundled payment plans for comprehensive episodes of care, there should be awareness that late readmissions for PD occur frequently and are a significant source of resource utilization.
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