Causes, Timing, Hospital Costs and Perioperative Outcomes of Index vs Nonindex Hospital Readmissions after Radical Cystectomy: Implications for Regionalization of Care

Abstract

Purpose-To compare the timing, causes, hospital costs, and perioperative outcomes of index vs. non-index hospital readmissions following radical cystectomy.Materials and Methods-The 2013 Nationwide Readmissions Database was queried for bladder cancer patients undergoing cystectomy. Sociodemographic characteristics, hospital costs, and causes of readmission were compared among index and non-index readmitted patients. Univariable and multivariable logistic regression models were used to identify predictors of nonindex readmissions, mortality during the first readmission, and subsequent readmission.Results-Among 4991 patients identified, 29%(1447/4991) and 11%(571/4991) experienced an index and non-index readmission, respectively. Compared to index readmissions, non-index readmissions were more likely late readmissions (p<0.001) of older patients (p=0.047) that had cystectomies at higher volume hospitals (p=0.02) and were readmitted to hospitals located in less populated areas (p<0.001). Compared to index readmissions, the percentage of non-index readmissions for cardiovascular complications was higher (7.6% vs. 2.9%, p=0.003) while the percentage of non-index readmissions for gastrointestinal (6.0% vs. 11.0%, p=0.04) Disclosures: NonePublisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. HHS Public Access Author Manuscript Author ManuscriptAuthor Manuscript Author ManuscriptConclusions-This nationally representative study of cystectomy patients demonstrated comparable perioperative outcomes and hospital costs between index and non-index readmitted RC patients, which supports the continued regionalization of cystectomy care.

Characterising ‘bounce‐back’ readmissions after radical cystectomy

“…In RC patients specifically, our present results align well with prior analyses of Medicare data that found GI, urinary, and infection amongst the most common readmissions diagnoses and that the highest intensity readmission episodes are more likely in patients with earlier, rapid readmissions [8,23]. Other recent work has shown that readmissions to hospitals other than that which performed the RC were more likely to occur later in the readmissions period, although this effect was predominantly observed after the 30 day period used in our present study [24]. Lastly, as readmissions have been linked to postoperative complications, it was recently demonstrated that the significant majority of these complications occur very early in the postoperative period [25].…”

Hospitalisation and readmission costs after radical cystectomy in a nationally representative sample: does urinary reconstruction matter?

“…Additionally, the NCDB is not population‐based or designed to create national estimates and only includes unplanned readmissions within 30 days to the index institution . We have previously shown that almost one‐third of all readmissions after RC are at non‐index hospitals, suggesting that many admissions may be missed within the NCDB . The NRD, in contrast, includes readmissions up to 90‐days follow‐up and those at non‐index hospitals within the same State of treatment, making it a better estimate of national readmission rates.…”

“…Urinary diversion was defined as incontinent (ileal conduit, 56.51, 56.71) or continent (orthotopic neobladder or continent cutaneous reservoir, 57.87). The current ICD‐9 coding schema does not differentiate between orthotopic neobladder or continent cutaneous reservoir, so these were included together as continent diversions, similar to previous studies . We elected to only compare those patients with a bowel diversion and thus patients with a ureterocutaneostomy were not included.…”

“…Ultimately, the decision on type of diversion is based on patient and surgeon preference, cancer‐specific factors, and medical comorbidities. The overwhelming majority of patients with bladder cancer will choose an ileal conduit with estimates between 70% and 95% .…”

“…Radical cystectomies with urinary diversion is a morbid operation with overall complication rates ranging from 19% to 64% and readmission rates ranging from 25% to 41% . Continent diversions are technically difficult, requiring longer operative times, which are associated with higher operating room hospital costs .…”