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OPTIMIZING POST-HEPATECTOMY CARE PATHWAYS: INDEX HOSPITALIZATION FACTORS ASSOCIATED WITH 90-DAY READMISSIONS
Anneliese N. Hierl
*, Elsa M. Arvide, Esther N. Dekker, Brittany C. Fields, Laura R. Prakash, Yun Shin Chun, Hop S. Tran Cao, Timothy E. Newhook, Jean-Nicolas Vauthey, Ching-Wei D. Tzeng
The University of Texas MD Anderson Cancer Center, Houston, TX
Background: Although risk-stratified post-hepatectomy pathways (RSPHP) reduce hospital length of stay (LOS), readmission rates remain unchanged. This study aimed to assess intraoperative and index hospitalization factors that are associated with 90-day readmissions.
Methods: This is a single-institution retrospective cohort study of consecutive hepatectomy patients from 01/2017-03/2024. Data were abstracted from electronic health records and a prospectively maintained database, where faculty and advanced practice providers prospectively graded 90-day complications according to the ACCORDION classification during biweekly meetings. Cases were restricted to those with indications for colorectal cancer, hepatocellular carcinoma, cholangiocarcinoma, and gallbladder cancer.
Results: A total of 1534 patients were included in the study, categorized into four groups: minimally invasive surgery (MIS) (n=217, 14%), low-intermediate risk open (n=469, 31%), high-risk open (n=406, 26%), and combination (n=442, 29%). The 90-day readmission rates were 2.6% (5/189), 20% (38/189), 41% (77/189), and 37% (69/189), respectively. RSPHP are defined as MIS, low-risk (Kawaguchi–Gayet Classification [KG] 1 or 2), high-risk (KG 3), and combination surgery (hepatectomy with simultaneous colectomy).
Intraoperative factors associated with readmission on univariate analysis were: cholangiocarcinoma (OR 1.68, p=0.021), gallbladder cancer (OR 0.11, p=0.030), KG 3 (OR 2.27, p<0.001), MIS (OR 0.27, p=0.006), high-risk open surgery (OR 2.65, p<0.001), combination surgery (OR 2.10, p<0.001), estimated blood loss (EBL)
> 200 ml (OR 2.14, p<0.001), case duration
> 335 min (OR 2.57, p<0.001), and Pringle time
> 72 min (OR 1.40, p=0.045).
Index stay factors associated with readmission on univariate analysis were: computed tomography during index stay (OR 2.42, p<0.001), peak creatinine
> 2 mg/dL (OR 2.52, p=0.086), peak INR
> 1.3 (OR 1.75, p=0.001), peak total bilirubin mg/dL
> 2.9 (OR 2.37, p=0.001), and LOS >2 days beyond expected median (OR 2.36, p<0.001), and operative drain present on discharge (OR 3.23, p<0.001).
A clinically relevant model was created with multivariate regression to identify patients at highest risk for readmission. These factors were: case duration
> 335 min (OR 1.93, p=0.001), EBL
> 200 mL (OR 1.47, p=0.047), LOS >2 days beyond expected median (OR 1.82, p<0.001), peak total bilirubin
> 2.9 (OR 1.55, p=0.099), and drain present on discharge (OR 2.40, p=0.003).
Conclusion: Across all care pathways, patients with longer case durations, greater EBL, high peak bilirubin, and LOS >2 days beyond expected median, should be considered for further inpatient optimization and close outpatient follow-up to mitigate readmission risk.
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