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FAILURE TO PERFORM CHOLECYSTECTOMY DURING INDEX ADMISSION IS ASSOCIATED WITH HIGHER READMISSION RATES AND WORSE OUTCOMES IN PATIENTS WITH CHOLEDOCHOLITHIASIS: ANALYSIS OF NATIONWIDE READMISSIONS
Kaveh Hajifathalian*1, Amit Mehta1, Kartik Sampath1, Sundaram Vinay2, David L. Carr-Locke1, Brett E. Fortune1, Reem Z. Sharaiha1, SriHari Mahadev1
1Weill Cornell Medicine/New York Presbyterian, NEW YORK, NY; 2Cedars Sinai, Los Angles, CA

Background
Timing of cholecystectomy in patients with choledocholithiasis is controversial. Cholecystectomy is frequently postponed to be done electively after the index admission. We evaluated the effects of timing of cholecystectomy on readmission rates and clinical outcomes for patients admitted with choledocholithiasis or cholangitis.
Methods
This is a longitudinal cohort study using the Nationwide Readmissions Database (NRD) for 2013 and 2014. The NRD is a national sample of all-payer inpatient discharges which allows following patients across time and institutions. We included patients who had an index admission with a diagnosis of choledocholithiasis or cholangitis, and compared patients who did or did not have a cholecystectomy during the index admission for 90-day non-elective readmission rates and in-hospital mortality during readmission. Patients who had hepatic, pancreatobiliary, or periampullary malignancies were excluded. As decision to perform a cholecystectomy is influenced by patients' clinical condition and available resources, patients were matched for an a priori set of variables including age, gender, income, presence and severity of comorbidities using Elixhauser comorbidity index, cancer or chemotherapy, septicemia, shock, need for mechanical ventilation or transfusion, acute myocardial infarction or stroke, pneumonia, urinary tract infection or renal failure, and length of stay during index admission, type of disposition, and hospital type. Sensitivity analysis was performed by excluding patients with cholangitis and evaluating patients with only choledocholithiasis.
Results
99,990 patients had an index admission with choledocholithiasis or cholangitis and were included in the study. 49% of these underwent cholecystectomy during their index admission. After matching, patients who underwent cholecystectomy during index admission had a 12% decrease in risk of 90-day readmission compared to patients who did not (95%CI -11 to -13%, P<0.001; Figure 1). When 90-day readmission outcomes were compared, patients who did cholecystectomy had significantly lower in-hospital mortality (Absolute risk difference -1.5%, 95%CI -0.7 to -2.3%, P<0.001), septicemia, and shorter length of stay, compared to patients who did not do cholecystectomy (Table 1). Finally, cholecystectomy showed a similar association with lower in-hospital mortality in sensitivity analysis after excluding patients with cholangitis (Absolute risk difference -1.3%, 95%CI -0.5 to -2.0%, P=0.002).
Conclusion
In a national retrospective matched cohort analysis, failure to perform cholecystectomy during the index admission was associated with higher non-elective readmission rates and worse outcomes in patients with choledocholithiasis or cholangitis. These findings suggest a benefit for early cholecystectomy for these patients during the initial admission.


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