Preventing Prolonged Ileus, Anastomotic Leaks Could Reduce Readmissions in CRC

Reducing readmissions could be done by targeting specific risk factors, including preventing prolonged ileus, increasing the use of minimally invasive surgery (MIS), and preventing anastomotic leaks in patients with colorectal cancer (CRC) who get surgery, according to a study published in the Journal of Surgical Research.

Readmissions in patients with CRC are both common and costly in the United States, amounting to more than 10% of all CRC patients getting readmitted within 30 days of hospital discharge and costing the country an estimated $300 million annually. Studies have not previously covered how to change the readmission burden if the risk factors were modified in any way. This study aimed to calculate the effect of changes in risk factors that could be modified as a way to reduce the 30-day readmission rate in patients with CRC.

Colorectal Cancer | Image credit: SciePro - stock.adobe.com

Data from the American College of Surgeons’ National Surgical Quality Improvement Program from the years 2012-2020 were used for this study, specifically the participant use file and targeted colectomy file. Hospital medical records were used to obtain preoperative patient characteristics, preoperative laboratory results, intraoperative procedure characteristics, surgical complications, and 30-day postoperative readmissions. Patients were included if they had a resection for colon cancer, with or without obstruction. Patients were excluded if they had died or if their American Society of Anesthesiologists (ASA) physical status was class V.

Any readmission to the same or another hospital for any reason within 30 days of surgery was included as a readmission. Risk factors included patient demographic characteristics, comorbidities, surgical complications, biomarkers of underlying disease, behavior-related variables, and treatment-related variables for colon cancer. Patients were excluded if they had missing data for readmission, had an ASA of 5, died during their in-patient stay, had missing data for ASA, a length of stay that was more than 20 days, had missing sex or age, or had missing duration of surgery.

There were 111,691 patients with colon cancer who were included in the study. Male patients made up 51.0% of the study population and 28.0% were aged 75 years and older, with those aged 65 to 74 years making up 26.8% and those aged 55 to 64 years making up 23.2%. A total of 10.0% of patients were readmitted within 30 days of surgery and the mean length of stay was 5.9 days.

Prolonged ileus and switching from open to MIS procedures were the factors with the largest effect on readmission (relative reduction [RR], 28.0%); prevention of anastomotic leaks were also found to have a large effect on readmission rates (RR, 6.2%). Other factors included antibiotics use (RR, 5.4%), preventing sepsis (RR, 4.5%), treating preoperative anemia (RR, 5.3%), and preventing surgical site infections (RR, 3.5%).

Although these were the biggest factors that had an effect on readmissions, there were other smaller factors that made a difference as well. Preventing C Difficile (RR, 1.8%), deep infections (RR, 1.5%), smoking cessation (RR, 1.1%), improving functional status (RR, 0.8%), stroke (RR, 0.8%), myocardial infarctions (RR, 1.1%), and pulmonary embolisms (RR, 1.7%) were all risk factors associated with reducing readmissions. A sensitivity analysis confirmed these findings.

There were some limitations to this study. The readmission rate was likely underestimated based on the definition from the CMS, as the database used collects data up to 30 days after resection rather than up to 30 days after discharge. Bias due to unmeasured or mismeasured confounders were possible. Data that covered the reason for readmission were not available.

Efforts to reduce readmissions in patients with CRC who had surgery should be focused on preventing prolonged ileus, increasing the use of MIS, and preventing anastomotic leaks. Aiming efforts in these areas could maximize the ability to reduce readmissions.

Reference

Schootman M, Li C, Ying J, Orcutt ST, Laryea J. Maximizing readmission reduction in colon cancer patients. J Surg Res. Published online December 13, 2023. doi:10.1016/j.jss.2023.11.047