Ozgur Akgul

The impact of a malignant diagnosis on the pattern and outcome of readmission after liver and pancreatic surgery: An analysis of the nationwide readmissions database

Reducing readmissions is an important quality improvement metric. We sought to investigate patterns of 90‐day readmission after hepato‐pancreatic (HP) procedures.

Impact of histological subtype on the prognosis of patients undergoing surgery for colon cancer

The effect of the histological subtype on the prognosis of patients undergoing surgery for colon cancer (CC) is not completely understood.

Impact of Post-Discharge Disposition on Risk and Causes of Readmission Following Liver and Pancreas Surgery

BackgroundThe relationship between the post-discharge settings and the risk of readmission has not been well examined. We sought to identify the association between discharge destinations and readmission rates after liver and pancreas surgery.MethodsThe 2013–2015 Medicare-Provider Analysis and Review (MEDPAR) database was reviewed to identify liver and pancreas surgical patients. Patients were subdivided into three groups based on discharge destination: home/self-care (HSC), home with home health assistance (HHA), and skilled nursing facility (SNF). The association between post-acute settings, readmission rates, and readmission causes was assessed.ResultsAmong 15,141 liver or pancreas surgical patients, 60% (nu2009=u20099046) were HSC, 26.9% (nu2009=u20094071) were HHA, and 13.4% (nu2009=u20092024) were SNF. Older, female patients and patients with ≥u20092 comorbidities, ≥u20092 previous admissions, an emergent index admission, an index complication, and ≥u20095-day length of stay were more likely to be discharged to HHA or SNF compared to HSC (all Pu2009<u20090.001). Compared to HSC, HHA and SNF patients had a 34 and a 67% higher likelihood of 30-day readmission, respectively. The HHA and SNF settings were also associated with a 33 and a 69% higher risk of 90-day readmission. There was no association between discharge destination and readmission causes.ConclusionAmong liver and pancreas surgical patients, HHA and SNF patients had a higher risk of readmission within 30 and 90xa0days. There was no difference in readmission causes and discharge settings. The association between discharge setting and the higher risk of readmission should be further evaluated as the healthcare system seeks to reduce readmission rates after surgery.

Time to Readmission and Mortality Among Patients Undergoing Liver and Pancreatic Surgery

BackgroundThe impact of time to readmission (TTR) on post-discharge mortality has not been well examined. We sought to define the impact of TTR on postoperative mortality after liver or pancreas surgery.MethodsA retrospective cohort analysis of liver and pancreas surgical patients was conducted using 2013–2015 Medicare Provider Analysis and Review database. Patients were subdivided into TTR groups: 1–5xa0days, 6–15, 15–30, 31–60, 61–90, and no readmission. The association of index complication, readmission causes, TTR, and mortality was assessed.ResultsAmong 18,177 patients, a total of 4485 (24.7%) patients were readmitted within 90xa0days of discharge. Major causes for readmission differed across TTR groups. Patients readmitted within 1–15xa0days were more likely to be readmitted for postoperative infection compared with patients who had a late readmission (1–5xa0days: 63.1% vs. 6–15xa0days: 65.0% vs. 61–90xa0days: 39.3%; Pu2009<u20090.001). In contrast, causes of late readmissions were more likely related to gastrointestinal complications (1–5xa0days: 28.9% vs. 61–90xa0days: 39.7%; Pu2009<u20090.001). Compared with no readmission, 180-day mortality was highest among patients readmitted within 16–30xa0days (aOR 3.60; 95% CI 2.94–4.41). Among patients with index complications, patients who were readmitted within 1–5xa0days had a higher risk-adjusted 180-day mortality than late readmission (1–5xa0days: 37.3% vs. 61–90xa0days: 27.1%) (Pu2009<u20090.001).ConclusionsAmong patients who were readmitted, the incidence of mortality increased with TTR up to 60xa0days after discharge yet decreased thereafter. The relation of TTR and mortality was particularly pronounced among those patients who had an index complication. Future efforts should consider TTR when identifying specific approaches to decrease readmission.

Surgical Procedures in Health Professional Shortage Areas: Impact of a Surgical Incentive Payment Plan

Introduction: The Affordable Care Act established a Center for Medicare/Medicaid Services based 10% reimbursement bonus for general surgeons in Health Professional Shortage Areas. We sought to assess the impact of the Affordable Care Act Surgery Incentive Payment on surgical procedures performed in Health Professional Shortage Areas. Methods: Hospital utilization data from the California Office of Statewide Health Planning and Development between January 1, 2006, and December 31, 2015, were used to categorize hospitals according to Health Professional Shortage Area location. A difference‐in‐differences analysis measured the effect of the Surgery Incentive Payment on year‐to‐year differences for inpatient and outpatient surgical procedures by hospital type pre‐ (2006–2010) versus post‐ (2011–2015) Surgery Incentive Payment implementation. Results: Among 409 unique hospitals that performed surgical procedures for at least 1 year of the study period, 2 performed surgery in a designated Health Professional Shortage Area. The two Health Professional Shortage Area ‐designated hospitals were located in a rural area, were non‐teaching hospitals, and had 196 and 202 hospital beds, respectively. After the enactment of the Surgery Incentive Payment, while non‐ Health Professional Shortage Areas had only a modest relative decrease in total inpatient procedures (Pre‐Surgery Incentive Payment: 4,666,938 versus Post‐Surgery Incentive Payment: 4,451,612; &Dgr;−4.6%), the proportional decrease in inpatient surgical procedures at Health Professional Shortage Area hospitals was more marked (Pre‐Surgery Incentive Payment: 25,830 versus Post‐Surgery Incentive Payment: 21,503; &Dgr;−16.7%). In contrast, Health Professional Shortage Area hospitals proportionally had a greater increase in total outpatient procedures (Pre‐Surgery Incentive Payment: 17,840 versus Post‐Surgery Incentive Payment: 22,375: &Dgr;+25.4%) versus non‐ Health Professional Shortage Area hospitals (Pre‐Surgery Incentive Payment: 5,863,300 versus Post‐Surgery Incentive Payment: 6,156,138; &Dgr;+4.9%). Based on the difference‐in‐differences analysis, the increase in the trend of surgical procedures at Health Professional Shortage Area hospitals was much more notable after Surgery Incentive Payment implementation (&Dgr;+75.2%). Conclusion: The Medicare Surgery Incentive Payment program was associated with an increase in the number of surgical procedures performed at Health Professional Shortage Area hospitals relative to non‐Health Professional Shortage Area hospitals during the study period, reversing the trend from negative to positive.

The Impact of Discharge Timing on Readmission Following Hepatopancreatobiliary Surgery: a Nationwide Readmission Database Analysis

ObjectiveDecreasing hospital length-of-stay (LOS) may be an effective strategy to reduce costs while also improving outcomes through earlier discharge to the non-hospital setting. The objective of the current study was to define the impact of discharge timing on readmission, mortality, and charges following hepatopancreatobiliary (HPB) surgery.MethodsThe Nationwide Readmissions Database (NRD) was used to identify patients undergoing HPB procedures between 2010 and 2014. Length of stay (LOS) was categorized as early discharge (4–5xa0days), routine discharge (6–9xa0days), and late discharge (10–14xa0days). Univariable and multivariable analyses were utilized to identify factors associated with 90-day readmission.ResultsA total of 28,114 patients underwent HPB procedures. Overall median LOS was 7xa0days (IQR 5–11); 10,438 (37.1%) patients had an early discharge, while 13,665 (48.6%) and 4011 (14.3%) patients had a routine or late discharge. The probability of early discharge increased over time (referent 2010: 2011–4% (OR 1.04, 95% CI 0.96–1.15) vs. 2012–10% (OR 1.10, 95% CI 1.01–1.20) vs. 2013–21% (OR 1.21, 95% CI 1.11–1.32) vs. 2014–32% (OR 1.32, 95% CI 1.21–1.44)) (pu2009<u20090.001). Early discharge was associated with insurance status, diagnosis (benign vs. malignant disease), general health, and overall hospital volume (all pu2009<u20090.05). Among patients who had an early discharge, 30- and 90-day readmission was 11.5 and 17.4%, respectively. In contrast, 30- and 90-day readmission was 16.9 and 24.7%, respectively, among patients who had a routine discharge group (pu2009<u20090.001). Among patients readmitted within 90xa0days, in-hospital mortality was similar among patients who had early (nu2009=u200943, 2.4%) versus routine discharge (nu2009=u200965, 1.9%). Median charges were lower among patients who had an early versus routine versus late discharge (

Index versus Non-index Readmission After Hepato-Pancreato-Biliary Surgery: Where Do Patients Go to Be Readmitted?

54,476 [IQR 40,053–79,100] vs.

A Comparison of Open and Minimally Invasive Surgery for Hepatic and Pancreatic Resections Among the Medicare Population

75,192 [IQR 53,296–113,123] vs.

Synergistic Effects of Perioperative Complications on 30-Day Mortality Following Hepatopancreatic Surgery

115,061 [IQR 79,162–171,077], respectively) (pu2009<u20090.001).ConclusionsEarly discharge after HPB surgery was not associated with increased 30- or 90-day readmission. Overall 90-day in-hospital mortality following a readmission was comparable among patients with an early, routine, and late discharge, while median charges were lower in the early discharge group.

Incremental costs and outcomes of hepatectomy with vs without colon resection for metastatic cancer

IntroductionThe Center for Medicare and Medicaid Services (CMS) has identified readmission as an important quality metric. With an increased emphasis on regionalization of complex hepato-pancreato-biliary (HPB) surgery to high-volume centers, care of readmitted HPB patients may be fragmented if readmission occurs at a non-index hospital. We sought to define the proportion of HPB readmissions, as well as evaluate outcomes, that occur at an index versus non-index hospitals and to identify factors associated with non-index hospital readmission.MethodsThe National Readmissions Database (NRD) was used to identify patients who underwent major HPB surgery between 2010 and 2015. Factors associated with readmission at 30 and 90xa0days at index versus non-index hospitals were analyzed. Differences in mortality and complications were analyzed among patients readmitted to index versus non-index hospitals.ResultsA total of 49,080 patients underwent HPB surgery (liver nu2009=u200927,081, 55%; pancreas nu2009=u200914,787, 30%; biliary nu2009=u20097212, 15%). Overall, 6643 (14%) and 11,709 (24%) patients were readmitted within 30 and 90xa0days, respectively. Among all first readmissions, 18 and 21% were to a non-index hospital within the first 30 and 90xa0days, respectively. On multivariable analysis, factors associated with readmission to a non-index hospital included age (OR 1.19, 95% CI 1.05, 1.34), pancreatic cancer (OR 1.40, 95% CI 1.14, 1.34) and ≥u20093 comorbidities (OR 1.34, 95% CI 1.10, 1.63), while procedures on the pancreas (OR 0.69, 95% CI 0.61, 0.80), private insurance (OR 0.77, 95% CI 0.68, 0.87), initial admission at a large hospital (OR 0.77, 95% CI 0.65, 0.91), and initial admission length of stay >u20097xa0days (OR 0.77, 95% CI 0.69, 0.86) were associated with decreased odds of a non-index hospital readmission (all pu2009<u20090.05). Patients readmitted to a non-index hospital had higher inpatient mortality (3.7 vs. 2.7%, pu2009=u20090.010).ConclusionsRoughly 1 in 5 patients were readmitted to a non-index hospital where the initial HPB operation had not taken place. Readmission to a non-index hospital was associated with higher overall in-hospital mortality. The impact of regionalization of HPB care relative to site of subsequent readmission may have important implications for patients.