Analysis IDs trends in post-cystectomy readmissions

May 16, 2014

Continent urinary diversion and postoperative complications were found to be independent predictors of hospital readmission following radical cystectomy in an analysis from the University of Wisconsin, Madison.

Editor's note: This article has been updated since its original publication to include additional study data and commentary from the author/presenter.

Orlando, FL-Continent urinary diversion and postoperative complications were found to be independent predictors of hospital readmission following radical cystectomy in an analysis from the University of Wisconsin, Madison.

Presented at the AUA annual meeting in Orlando, FL, the retrospective study analyzed data collected in the American College of Surgeons National Surgical Quality Improvement Program. It included 610 patients who underwent radical cystectomy in 2011, of whom 139 (22.8%) were readmitted to the hospital within 30 days of their operation.

A large number of variables were considered as potential predictors of readmission, including demographic descriptors and preoperative clinical and disease-related characteristics, along with various operative and postoperative features. In multivariate analysis, postoperative complications and age <60 years were identified as independent risk factors for readmission.

However, findings from further stratification of patients by age and urinary diversion type showed that the counterintuitive association between younger age and readmission risk was accounted for by the fact that patients <60 years were significantly more likely than their older counterparts to receive a continent urinary diversion (46% vs. 17%), said senior author Tracy M. Downs, MD, associate professor of urology at the University of Wisconsin School of Medicine and Public Health.

Dr. Downs explained that the study was undertaken in recognition of recent health care legislation penalizing hospitals for readmitting patients within 30 days and the growing focus on value-based care. The investigators reasoned that understanding predictors of readmission would enable reformative actions and also equip providers with information to bring to the table in policy discussions.

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Dr. Downs“By allowing us to stratify patients into low/intermediate or high-risk groups for readmission, we believe these data can lead to the development of discharge pathways to provide providers and patients resources for decreasing readmission rates. Additionally, this study provides data that can allow health care administrators to understand that several complex factors must be considered when understanding readmission rates following radical cystectomy,” said Dr. Downs.

“Heterogeneity describes bladder cancer, but also readmission rates following radical cystectomy. One size does not fit all.”

Demographic data showed that the study population had a mean age of 68 years and was predominantly male (80%), Caucasian (79%), and had an ileal conduit (79%).

“In trying to stratify the population by age, we found that we had to use a threshold of 60 years in order to have enough patients in the neobladder/continent urinary diversion group to have sufficient statistical power for our analysis,” Dr. Downs explained.

Age <60 years predicted a 1.8-fold increased risk of readmission. When patients were further stratified by urinary diversion type, age <60 years remained a significant risk factor for readmission only among patients receiving continent diversions, being associated with a 2.7-fold increased risk in this subgroup.

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Readmission risk rises with complications

In terms of complications, the multivariate analysis found that the risk of readmission increased successively as the number of postoperative complications increased. Patients with a single complication had a 2.5-fold increased risk of readmission, while the risk of readmission was increased about 11-fold in those with two or more complications.

Dr. Downs noted the findings from this retrospective multicenter study should now be validated in single-institution series from centers with large radical cystectomy populations and ideally using prospectively collected data. Ultimately, the investigators hope the findings can be applied to creating a risk calculator for use in counseling patients about their anticipated postoperative course as well as to develop strategies that will prevent hospital readmissions.

“There is a lot of talk about personalizing medicine from a genomic standpoint, but research like ours allows us to talk about personalization from a clinical outcomes standpoint. Understanding the complications that increase risk of readmission is a first step toward individualizing care practices that may successfully avoid patient readmissions,” Dr. Downs said.UT

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