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Early discharge and readmission after colorectalresection
Rebecca L. Hoffman, MD,a,* Edmund K. Bartlett, MD,a Clifford Ko, MD,b
Najjia Mahmoud, MD,a Giorgos C. Karakousis, MD,a
and Rachel R. Kelz, MD, MSCEa
aDepartment of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PennsylvaniabDepartment of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, California
a r t i c l e i n f o
Article history:
Received 4 January 2014
Received in revised form
31 January 2014
Accepted 11 February 2014
Available online xxx
Keywords:
Early discharge
Readmission
Colon
Colorectal
Surgery
Laparoscopic
ACS NSQIP
* Corresponding author. Department of SurgeStreet, Philadelphia, PA 19104. Tel.: þ1 267 2
E-mail address: [email protected] (R.L0022-4804/$ e see front matter ª 2014 Elsevhttp://dx.doi.org/10.1016/j.jss.2014.02.006
a b s t r a c t
Background: Emphasis on the provision of high quality, cost-effective healthcare has meant
increasing efforts at reducing postoperative length of stay while reducing 30-d readmission
rates. The aim of this study was to identify factors associated with early discharge (ED) and
to evaluate the effectof ED on readmission after colorectal resection.
Materials and methods: We identified all inpatients aged �18 y who underwent a colorectal
resection in the American College of Surgeons National Surgical Quality Improvement
Program Participant Use File, 2011. ED was defined as a length of stay �25th percentile by
procedure (rectal resection, open colectomy, and laparoscopic colectomy). Multivariate
logistic regression was used to identify factors significantly associated with ED and read-
mission. A subset analysis was performed by procedure type.
Results: Of 28,532 patients, 2171 (7%) underwent rectal resection, 14,976 (52%) underwent
open colectomy, and 11,385 (40%) underwent laparoscopic colectomy with an ED on or
before postoperative days 5, 5, and 3, respectively. The overall cohort included patients
with a mean age of 61 y. A total of 52% were women and 37% were colorectal cancer pa-
tients. Age >65 y, recent steroid use, simultaneous ostomy creation, nonelective surgery,
need for reoperation, and a postoperative occurrence before discharge were significantly
associated with a reduced likelihood of ED. The overall rate of readmission was 12%. Pa-
tients who were discharged early were significantly less likely to be readmitted (odds ratio,
0.77; 95% confidence interval, 0.70e0.84).
Conclusions: In the appropriate patient population, ED after colorectal surgery may be
implemented without any adverse effect on readmission rates.
ª 2014 Elsevier Inc. All rights reserved.
1. Introduction suggested that early discharge (ED) was associated with
A national emphasis on the provision of high quality, cost-
effective health care has meant increasing efforts at
reducing postoperative length of stay (LOS) while simulta-
neously reducing 30-d readmission rates. Early research
ry, Perelman School of M75 3290; fax: þ1 215 662 7. Hoffman).ier Inc. All rights reserved
increased rates of readmission. Therefore, concerns exist
among surgeons that the inability to monitor patients’ clinical
progress and detect complications would result in higher
readmission rates and occurrences diagnosed after discharge
[1e3].
edicine at the University of Pennsylvania, 4 Maloney, 3400 Spruce983.
.
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1e82
Colorectal surgery provides a primemodel for investigating
the effects of ED on patient outcomes and readmission
because of the frequency of procedures performed and the
significant rates of postoperative occurrences (POs). Accord-
ingly, recent data have been published regarding the rela-
tionship among LOS, ED, and readmissions after colorectal
surgery. Single-institution experiences have demonstrated
the benefits of early recovery pathways after colorectal sur-
gery with little to no effect on readmission rates [4e7]. At the
population level, however, LOS has decreased after colon
surgery, whereas readmission rates have increased over the
last two decades [8].
The recent addition of 30-d readmission information to the
American College of Surgeons National Surgical Quality
Improvement Program (ACS NSQIP) [9] provides a new op-
portunity to evaluate ED and readmission rates. In this study,
we sought to identify factors associated with ED and evaluate
the effect of ED on readmission after colorectal resection.
Fig. 1 e Selection of the study cohort.
2. Methods
We performed a retrospective study of prospectively collected
data from the ACS NSQIP Participant Use File (PUF) data set
from 2011. The ACS NSQIP PUF contains data on 442,149 cases
collected from 315 academic and community-based hospitals
located around the United States. A trained Surgical Clinical
Reviewer captures data on 252 variables, including preopera-
tive risk factors, intraoperative variables, and 30-
d postoperative morbidity and mortality outcomes. Patients
aged �18 y undergoing major surgical procedures (both
inpatient and outpatient) are included using an 8-d cycle
sampling procedure. All variables collected in the ACS NSQIP
are predefined in the NSQIP PUF 2011 user guide [10].
We identified all inpatients aged �18 y who underwent
colorectal resection in the 2011 ACS NSQIP PUF. Colorectal
resectionwas defined using Common Procedural Terminology
codes for both open and laparoscopic procedures, including
44140e44147, 44150, 44151, 44155e44158, 44160, 44204e44208,
44210e44212, 45110e45114, 45116, 45119e45123, 45126, 45135,
45136, 45395, and 45397. Patients missing information on LOS
and thosewith a LOS recorded as�0 dwere excluded from the
analysis. In addition, patients who were listed as still in the
hospital and those who died during the initial inpatient hos-
pitalization were excluded (Fig. 1).
Patient demographic characteristics including age, sex,
and race were abstracted from the NSQIP database, as was
information regarding preoperative comorbidities and
whether the procedure was performed electively or emer-
gently. Heart disease was assigned for all patients with a
recorded history of congestive heart failure, myocardial
infarction, percutaneous coronary intervention or stenting,
and/or angina. A history of colorectal cancer was defined
using a postoperative International Classification of Diseases,
Ninth Edition (ICD-9) diagnosis code of 153, 153.0, 154, 154.0, or
197.7. The simultaneous creation of an ostomy was deter-
mined using the Common Procedural Technology codes
44141, 44143, 44144, 44146, 44188, 44206, 44208, 44320, 44322,
44340, 44345, 44346, 45110, 45395, 44150, 44151, 44156, 44157,
44158, 44211, and 44187.
To examine the effects of patient complications on the
likelihood of ED and that of readmission, patients were clas-
sified by the presence or absence of any PO. Information
regarding POs, including cardiac, respiratory, infectious, renal
and neurologic events, and an unplanned return to the oper-
ating room was noted. More specifically, POs categorized as
wound complication (superficial skin infection, deep surgical
site infection, or fascial dehiscence), organ space infection,
sepsis (sepsis or septic shock), renal (progressive renal failure
or acute renal failure requiring dialysis), venous thrombo-
embolism (deep vein thrombosis or pulmonary embolism),
respiratory (pneumonia, intubation for greater than 48 h, or
reintubation), bleeding (hemorrhage requiring transfusion of
at least 4 U of blood), neurologic (stroke or coma), urinary tract
infection, or cardiac (myocardial infarction or arrest requiring
resuscitation) were abstracted directly from the ACS NSQIP
PUF, and patients were classified by occurrence status: no
occurrence, any occurrence before hospital discharge, and
any occurrence after hospital discharge.
The primary outcome variable was procedure-specific ED.
The secondary outcome of interest was 30-d readmission. LOS
was defined as the number of days from the index operation to
hospital discharge (to home or any facility). Because it is
commonly acknowledged that differences in LOS exist by
procedure, procedure-specific EDwas defined as an LOS�25th
percentile for rectal resection, open colectomy, and laparo-
scopic colectomy, respectively [11,12]. ED was reported as a
binary outcome. Readmission refers to an admission to any
hospital within 30 d of the principal surgical procedure, as
defined within the NSQIP PUF.
Descriptive statistics were performed. Patient and proce-
dure characteristics were examined by ED status using the
Student t and chi-square tests, as appropriate. Multivariate
logistic regression was used to identify factors significantly
associated with ED. The association between ED and
Table 1e Patient characteristics for the overall cohort andby discharge status.
Patientcharacteristics
Overallcohort,n (%)
Earlydischarge
Notdischarged
early
Pvalue
N 28,532 8641 (30) 19,891 (70)
Age (y, mean � SD) 61.1 � 15.6 58.4 � 14.8 62.3 � 15.8 <0.01
Sex
Female 14,912 (52) 4537 (53) 10,375 (52)
Male 13,557 (48) 4090 (47) 9467 (48) 0.64
j o u rn a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1e8 3
readmission was investigated using univariate and multivar-
iate logistic regression to adjust for potential confounders.
Independent logistic regression models were developed to
examine the association between ED and readmission for
each of the procedure groups with adjustment for potential
confounders. All statistical analyses were performed using
STATA, version 12.1 (STATA Corp, College Station, TX). This
study was reviewed by the Institutional Review Board of the
University of Pennsylvania and deemed exempt from
continuing review (IRB#818956).
Race <0.01
Caucasian 22,459 (79) 7066 (82) 15,393 (77)
Black 2525 (9) 633 (7) 1892 (10)
Asian 723 (3) 243 (3) 480 (2)
Other 2825 (10) 699 (8) 2126 (11)
Ethnicity-hispanic 1396 (5) 439 (5) 957 (5) <0.01
Comorbidities
Smoke 5139 (18) 1512 (18) 3627 (18) 0.14
Diabetes 4187 (15) 1045 (12) 3142 (16) <0.01
Hypertension 13,958 (49) 3756 (43) 10,202 (51) <0.01
COPD 1595 (6) 294 (3) 1301 (7) <0.01
Ascites 320 (1) 38 (0.4) 282 (1) <0.01
BMI � 30 8621 (31) 2546 (30) 6075 (31) <0.01
Heart disease 1329 (5) 274 (3) 1055 (5) <0.01
Acute renal
failure
153 (0.5) 9 (0.1) 144 (0.7) <0.01
Dialysis 241 (0.8) 36 (0.4) 205 (1) <0.01
Cerebrovascular
disease
654 (2) 126 (1) 528 (3) <0.01
Steroid use 2147 (8) 508 (6) 1639 (8) <0.01
Bleeding
disorder
1357 (5) 215 (2) 1142 (6) <0.01
Colorectal
cancer
10,624 (37) 3243 (38) 7381 (37) 0.50
Intraoperative factors
Ostomy 6983 (24) 1345 (16) 5638 (28) <0.01
Emergent
surgery
3976 (14) 625 (7) 3351 (17) <0.01
Complications
Return to OR 1501 (5) 195 (2) 1306 (7) <0.01
No complication 19,875 (74) 7357 (88) 12,518 (68) <0.01
PO before
discharge
4755 (18) 273 (3) 4482 (24) <0.01
PO after
discharge
2253 (8) 778 (9) 1475 (8) <0.01
Readmission 3325 (12) 839 (10) 2486 (13) <0.01
BMI ¼ body mass index; SD ¼ standard deviation.
3. Results
Of 31,267 colorectal procedures included in the data set, 28,532
(91%) patients were included in the study. Patient character-
istics can be viewed in Table 1. In the overall cohort, the me-
dian LOS was 6 d (range, 1e130). A total of 7% (n ¼ 2171) of
patients underwent rectal resection, 52% (n ¼ 14,976) under-
went an open colectomy, and 40% (n ¼ 11,385) underwent a
laparoscopic colectomy. Within these three groups, the me-
dian surgical LOSs were 7 d for rectal resections and open
colectomies, and 4 d for laparoscopic colectomies. Procedure-
specific ED, defined as an LOS �25th percentile, corresponded
to a day of discharge on or before postoperative day 5 for pa-
tients undergoing a rectal resection, day 5 for patients un-
dergoing an open colon resection, and day 3 for patients
undergoing a laparoscopic colectomy (see Fig. 2).
Of all patients, 30% (n ¼ 8641) were discharged early. The
overall readmission rate was 12% (n ¼ 3325) with 17% (n ¼ 346)
of rectal resection patients, 15% (n ¼ 2027) of open colectomy
patients, and 10% (n ¼ 1048) of patients undergoing a laparo-
scopic colon resection requiring a readmission. There were
8280 (29%) patients who experienced a PO. Complete infor-
mation regarding the timing of the PO was available for 7008
patients, and 4755 (68%) experienced the event before
discharge. Despite having a PO diagnosed before discharge,
26% of the patients were discharged early.
In a multivariate analysis of the overall cohort done to
identify factors associated with ED, ages 65e79 y (odds ratio
[OR], 0.75; 95% confidence interval [CI], 0.64e0.87) and >80 y
(OR, 0.50; 95% CI, 0.41e0.60), chronic obstructive pulmonary
disease (COPD; OR, 0.60; 95% CI, 0.49e0.75), history of cere-
brovascular accident (OR, 0.63; 95% CI, 0.42e0.94), recent ste-
roid use (OR, 0.80; 95% CI, 0.68e0.95), nonelective surgery (OR,
0.58; 95% CI, 0.50e0.68), simultaneous ostomy creation (OR,
0.65; 95% CI, 0.58e0.72), need for reoperation (OR, 0.57; 95% CI,
0.44e0.73), and a PO before discharge (OR, 0.13; 95% CI,
0.11e0.16) were significantly associated with a reduced like-
lihood of ED. Simultaneous ostomy creation and a PO before
dischargewere the only covariates that remained significantly
associated with a reduced likelihood of ED in the threemodels
developed for the subset analysis by procedure type. In the
two independentmodels developed for open and laparoscopic
colectomy, age>80 y, a history of COPD, a procedure classified
as emergent, and the need for reoperation were also signifi-
cantly associated with a reduced likelihood of ED. Recent
steroid use was significantly associated with a reduced like-
lihood of ED in only the laparoscopic colectomy model (see
models in Appendix A).
Of the patients in the overall cohort who were discharged
early, 10% were readmitted versus 13% of patients who were
not discharged early (P< 0.01). The proportion of patients that
were readmitted after rectal resection differed significantly by
ED status (14% ED versus 17% not ED; P ¼ 0.02). The same was
true for those undergoing open colon resection (12% ED versus
14% not ED; P � 0.01) and among patients undergoing lapa-
roscopic colon resection (7% ED versus 10% not ED; P� 0.01; see
Table 2 for unadjusted ORs).
In the multivariate model after adjustment for potential
confounders, ED patients remained significantly less likely to
be readmitted after colorectal resection than patients dis-
charged later in the postoperative course (OR, 0.80; 95% CI,
0.70e0.93). In the subset analysis, after adjustment for
Fig. 2 e Median LOS by procedure type. Procedure-specific
ED was defined as an LOS £25th percentile. (For
interpretation of the references to color in this figure, the
reader is referred to the web version of this article).
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1e84
potential confounders, ED remained significantly associated
with a reduced likelihood of readmission in the laparoscopic
colectomy cohort (OR, 0.55; 95% CI, 0.41e0.73) but did not
reach significance for patients undergoing open colectomies
(OR, 0.88; 95% CI; 0.73e1.07) or rectal resections (OR, 0.82; 95%
CI, 0.52e1.30). The simultaneous creation of an ostomy was
significantly associated with a reduced likelihood of read-
mission in patients undergoing rectal resection (OR, 0.60; 95%
CI, 0.39e0.93) and significantly associated with an increased
likelihood of readmission for patients undergoing a colon
resection (laparoscopic: OR, 1.56; 95% CI, 1.08e2.25 and open:
OR, 1.24; 95% CI, 1.04e1.48). The need for emergent surgery
was not associatedwith readmission in the overall cohort (OR,
0.87; 95% CI, 0.72e1.06) or after any specific procedure. The
most highly significant predictors of readmission in the
overall model were POs diagnosed both before (OR, 1.53; 95%
CI, 1.29e1.81) and after discharge (OR, 14.51; 95% CI;
12.41e16.97). A PO diagnosed after discharge was associated
with readmission regardless of procedure type, whereas a PO
diagnosed before discharge increased readmission risk after
all procedures except laparoscopic colectomy (Table 2).
In the overall cohort, factors associated with both a
decreased likelihood of ED and an increased likelihood of
readmission include age >65 y, a history of COPD, recent
steroid use, the simultaneous creation of an ostomy, and a PO
diagnosed before discharge.
4. Discussion
Numerous single-institution reports have commented on the
relationship between ED and readmission using colorectal
surgery as the prototypical example [4e7]. Here, we report the
results of our multi-institutional study of colorectal surgery
patients demonstrating that patient and procedure factors
influenced the likelihood of successful ED, and that ED after
colorectal resection was not associated with an increased risk
of readmission before and after adjustment for potential
confounders. Moreover, we found that EDwas associatedwith
a reduced likelihood of readmission in the overall cohort and
among patients undergoing laparoscopic colon resection with
no difference in the likelihood of readmission after ED among
those undergoing rectal surgery and open colon resection.
Furthermore, we found that a history of significant comor-
bidities, such as recent steroid use and the need for an
emergent operation, and operative factors, such as the
simultaneous creation of an ostomy and a PO diagnosed
before discharge, negatively influenced the likelihood of ED.
In surgery, the national emphasis on quality improvement
and cost containment in healthcare has translated into the
need to facilitate expeditious discharge without affecting the
rate of readmission. The addition of 30-d readmission to the
2011 ACS NSQIP database afforded us the opportunity to test
this balancing act on a national scale. We defined ED using a
procedure-specific LOS �25th percentile. This definition was
conceived after Collins et al. [13], in an analysis of risk factors
for a prolonged LOS using the Veterans Administration Sur-
gical Quality Improvement Program, using an LOS of �75th
percentile to represent “prolonged.” Hendren et al. [14], in an
analysis of ED and readmission in Medicare colon cancer
patients, used a cutoff of 5 d for ED, based on the single-
institution studies of enhanced recovery pathways. Our defi-
nition of early, meaning patients discharged on or before days
5, 5, and 3 for rectal resection, open colectomy, and laparo-
scopic colectomy, respectively, proved to be consistent with
previous studies, which used ED protocols, where early was
defined by an LOS of 2e5 d [1,15,16].
Operative and postoperative factors have been shown to
have the most influence on LOS after major surgery [13]. The
odds of an ED in this study were significantly reduced when
patients’ surgery was classified as emergent, or if patients
experienced a PO. Preoperative patient factors also influence
the likelihood of ED after surgery. Although there was no
difference in ED by sex, the chance of being discharged early
dropped dramatically with increasing age such that patients
>65 y were 30% less likely and those 80 y and older were half
as likely to be discharged early. However, in a study of elderly
patients undergoing open colon resection, DiFronzo et al. [17]
demonstrated the safe implementation of an early recovery
pathway when discharge occurred on postoperative day 3.
The relative reluctance to discharge elderly patients and pa-
tients with a history of serious comorbidities, such as COPD,
steroid use, and new ostomies, may be reflective of appro-
priate patient selection for ED, but may also be reflective of
fears of readmission in an era when readmission is a quality
indicator.
Our findings support the wealth of single-institution
studies demonstrating that ED and readmission are compat-
ible. Readmission rates in these studies, when patients are
discharged early, vary from 11%e16% [14,18] and are compa-
rable, if not improved, to traditional recovery LOS. The rate of
readmission for patients discharged early (10%) in our large
sample was significantly lower than patients discharged after
a longer LOS (13%). Even when controlling for preoperative
comorbidities, the risk of readmission after ED was 20% less
likely than it was for patients discharged after a longer LOS. To
our knowledge, this is only the second study to examine this
relationship between ED and readmission in a large multi-
institutional data set. In a 2011 study by Hendren et al. [14],
an analysis of 477,000Medicare patients across 6 y determined
that readmission rates were not increased with ED. Our study
builds on that work by expanding the study population to
Table 2 e Univariate and multivariate odds ratios of factors associated with readmission after colorectal resection in theoverall cohort and by procedure group.
Variable Overall cohort, OR(95% CI) n ¼ 25,971
Rectal resection, OR(95% CI) n ¼ 1984
Open colon resection,OR (95% CI) n ¼ 13,721
Laparoscopic colonresection, OR (95% CI)
n ¼ 10,266
Univariate models
Discharge >25th
percentile
REF REF REF REF
Early discharge 0.77 (0.70e0.84) 0.84 (0.65e1.07) 0.82 (0.73e0.91) 0.64 (0.55e0.75)
Multivariate models
Discharge >25th
percentile
REF REF REF REF
ED 0.80 (0.69e0.93) 0.82 (0.52e1.30) 0.88 (0.73e1.07) 0.55 (0.41e0.73)
Age category (y)
18e39 REF REF REF REF
40e49 0.78 (0.61e1.00) 0.75 (0.37e1.52) 0.91 (0.64e1.30) 0.70 (0.45e1.09)
50e64 0.74 (0.60e0.92) 0.54 (0.29e1.01) 0.98 (0.72e1.33) 0.60 (0.41e0.89)
65e79 0.68 (0.54e0.86) 0.76 (0.39e1.49) 0.85 (0.62e1.17) 0.57 (0.37e0.86)
�80 0.70 (0.53e0.92) 0.60 (0.25e1.49) 0.88 (0.61e1.28) 0.53 (0.32e0.89)
Race
White REF REF REF REF
Black 1.24 (1.01e1.53) 1.04 (0.48e2.24) 1.12 (0.87e1.46) 1.62 (1.11e2.36)
Asian 0.87 (0.55e1.36) 1.12 (0.40e3.14) 0.92 (0.47e1.80) 0.71 (0.31e1.60)
Other 0.97 (0.80e1.89) 1.05 (0.57e1.92) 0.91 (0.70e1.18) 1.11 (0.77e1.62)
Comorbidities
Diabetes 1.20 (1.00e1.42) 0.97 (0.51e1.84) 1.12 (0.89e1.40) 1.37 (1.00e1.89)
Hypertension 1.00 (0.86e1.16) 1.17 (0.72e1.91) 1.04 (0.86e1.26) 0.91 (0.70e1.20)
COPD 1.35 (1.06e1.72) 2.28 (0.88e5.92) 1.33 (1.00e1.79) 1.17 (0.71e1.95)
Ascites 1.33 (0.79e2.26) d 1.39 (0.81e2.39) 0.67 (0.07e6.18)
BMI � 30 0.96 (0.68e1.36) 0.62 (0.25e1.52) 1.21 (0.77e1.90) 0.85 (0.42e1.75)
Heart disease 1.44 (1.16e1.78) 0.30 (0.11e0.83) 1.50 (1.15e1.96) 1.72 (1.15e2.57)
Acute renal failure 0.87 (0.41e1.86) d 0.89 (0.40e1.98) 0.88 (0.09e8.38)
Dialysis 1.65 (0.96e2.86) 22.75 (1.57e329.39) 1.39 (0.74e2.58) 1.91 (0.47e7.71)
Cerebrovascular
disease
1.18 (0.78e1.79) 11.22 (2.28e55.33) 0.90 (0.53e1.52) 1.54 (0.69e3.44)
Steroid use 1.50 (1.22e1.84) 1.03 (0.41e2.58) 1.39 (1.07e1.81) 1.94 (1.34e2.80)
Bleeding disorder 1.15 (0.87e1.52) 0.90 (0.20e4.02) 1.06 (0.77e1.46) 1.66 (0.92e3.00)
Intraoperative factors
Ostomy 1.30 (1.13e1.50) 0.60 (0.39e0.93) 1.24 (1.04e1.48) 1.56 (1.08e2.25)
Emergent surgery 0.87 (0.72e1.06) 0.95 (0.18e4.92) 0.87 (0.71e1.07) 0.66 (0.33e1.30)
Complications
Return to OR 0.26 (0.21e0.32) 0.22 (0.11e0.44) 0.34 (0.26e0.44) 0.14 (0.10e0.21)
No complication REF REF REF REF
Postoperative
occurrence before
discharge
1.53 (1.29e1.81) 2.46 (1.44e4.20) 1.54 (1.25e1.90) 0.97 (0.66e1.44)
Postoperative
occurrence after
discharge
14.51 (12.41e16.97) 23.89 (14.32e39.84) 14.48 (11.75e17.83) 12.17 (9.12e16.23)
REF ¼ reference.
Bold indicates statistical significance. For all covariates listed in italics, the reference group was the cohort of patients without the factor.
j o u rn a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1e8 5
include younger patients and through the use of ACS NSQIP
data that are not subject to the limitations inherent to
administrative claims [19,20]. In fact, just over half (56%) of
patients included in our study cohort were younger than 65 y.
This may explain our ability to identify a reduced risk of
readmission among the ED cohort undergoing laparoscopic
colon resection when compared with that shown by Hendren
et al.[14]
Enhanced recovery pathways have been developed to
facilitate ED after colorectal surgery. Improvements in patient
satisfaction, decreased postoperative morbidity and mortal-
ity, and decreased costs are among the benefits of enhanced
recovery initiatives in procedures ranging from esoph-
agectomy to pulmonary lobectomy, and to intestinal surgery
[21e23]. Yet despite the endorsement of well-defined, evi-
dence-based protocols [24,25], there is still relative reluctance
with which early recovery pathways are used. In a national
survey of general and colorectal surgeons, less than one third
incorporated formal clinical care pathways into practice [26].
To our knowledge, this is the first study that uses the ACS
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1e86
NSQIP sample to identify factors associated with ED and to
provide evidence of a reduced risk of readmission after ED.
The fact that our findings using amulti-institutional sample of
colorectal patients agree with the reports of numerous single-
institution trials, and provide a complementary population to
Medicare ED and readmission data, may provide a significant
impetus for the potential adoption of standardized post-
operative recovery pathways to facilitate the ED of appropri-
ately selected patients.
Our study has several important limitations. First, this
study is subject to selection bias, in that the patientswhowere
discharged early were clearly a different group of patients
than those of the traditional LOS cohort. This selection bias
does, however, allow us to generalize about the group of pa-
tients who were, in a multi-institutional sample, deemed safe
by their physician for discharge at an earlier postoperative
date. Furthermore, the selection bias has no influence on the
readmission status of the patients, and therefore should not
influence the significance of our results. Additionally, this
study suffers the limitations characteristic of any study using
large registry data. We are unable to determine social factors
that may influence the likelihood of discharge, adjust for
intraoperative technical difficulty, surgeon practice prefer-
ence, and hospital case mix and practice patterns. Finally, we
do not have information regarding the use of an enhanced
recovery or fast track protocols. Therefore, we cannot vouch
for the safety of these pathways per se, but can only use our
definition of ED as the closest possible surrogate for the indi-
vidual level data that we lack.
5. Conclusions
One third of patients in the ACS NSQIP PUF undergoing major
colorectal surgery are now discharged in less than 5 d. In the
appropriate patient population, ED after colorectal surgery
may be implemented without any adverse effect on read-
mission rates. The information learned from this study can be
used to inform surgeons about the key relationships among
patient characteristics, ED, and readmission. In doing so, it
may facilitate an increased interest in the adoption of
enhanced recovery pathways.
Acknowledgment
Author contributions: R.L.H. and R.R.K. contributed to the
conception and design. R.L.H., E.K.B., C.K., N.M., G.C.K., and
R.R.K. did the analysis and interpretation. R.L.H. and R.R.K.
collected data. R.L.H. and R.R.K. wrote the article. E.K.B.,
C.K., N.M., G.C.K., and R.R.K. did the critical appraisal and
revision.
Disclosure
The authors reported no proprietary or commercial interest in
any product mentioned or concept discussed in this article.
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Appendix A e Multivariable odds ratios of factors associated with ED after colorectal resection in the overall cohort and byprocedure type.
Variable Overall cohort, OR(95% CI) n ¼ 25,971
Rectal resection, OR(95% CI) n ¼ 1984
Open colon resection, OR(95% CI) n ¼ 13,721
Laparoscopic colonresection, OR (95% CI)
n ¼ 10,266
Age categories (y)
18e39 REF REF REF REF
40e49 1.04 (0.88e1.23) 1.60 (0.97e2.63) 0.85 (0.67e1.08) 1.20 (0.91e1.58)
50e64 1.00 (0.87e1.16) 1.26 (0.82e1.94) 0.78 (0.63e0.97) 1.26 (0.99e1.60)
65e79 0.75 (0.64e0.87) 0.82 (0.50e1.34) 0.61 (0.48e0.76) 0.90 (0.70e1.17)
�80 0.50 (0.41e0.60) 0.67 (0.35e1.28) 0.40 (0.30e0.52) 0.50 (0.35e0.71)
Race
White REF REF REF REF
Black 0.72 (0.62e0.84) 0.25 (0.13e0.50) 0.79 (0.65e0.97) 0.64 (0.49e0.84)
Asian 0.91 (0.71e1.17) 0.78 (0.40e1.51) 1.11 (0.74e1.69) 0.84 (0.58e1.22)
Other 0.70 (0.62e0.80) 0.65 (0.43e0.98) 0.61 (0.50e0.73) 0.80 (0.65e0.98)
Comorbidities
Diabetes 0.91 (0.80e1.03) 0.96 (0.61e1.52) 1.03 (0.86e1.22) 0.76 (0.61e0.93)
Hypertension 0.95 (0.86e1.04) 1.26 (0.91e1.76) 0.89 (0.78e1.01) 0.97 (0.84e1.13)
COPD 0.60 (0.49e0.75) 0.49 (0.21e1.11) 0.56 (0.42e0.74) 0.63 (0.43e0.91)
Ascites 0.75 (0.46e1.24) d 0.74 (0.43e1.28) 0.40 (0.09e1.84)
BMI � 30 0.96 (0.75e1.23) 0.98 (0.49e1.96) 0.98 (0.72e1.35) 1.28 (0.77e2.14)
Heart disease 0.90 (0.76e1.07) 1.04 (0.57e1.91) 0.74 (0.59e0.94) 1.11 (0.84e1.46)
Acute renal
failure
0.85 (0.32e2.28) d 0.59 (0.17e2.02) 4.29 (0.53e34.85)
Dialysis 0.57 (0.31e1.07) 1.15 (0.08e16.2) 0.51 (0.24e1.09) 0.50 (0.14e1.84)
Cerebrovascular
disease
0.63 (0.42e0.94) 0.20 (0.03e1.76) 0.61 (0.37e1.01) 0.80 (0.37e1.71)
Steroid use 0.80 (0.68e0.95) 1.33 (0.68e2.59) 0.94 (0.75e1.19) 0.62 (0.46e0.84)
Bleeding
disorder
0.84 (0.65e1.08) 1.21 (0.44e3.32) 0.85 (0.62e1.17) 0.69 (0.42e1.13)
Intraoperative factors
Ostomy 0.65 (0.59e0.73) 0.54 (0.41e0.72) 0.50 (0.44e0.58) 0.45 (0.33e0.61)
Emergent
surgery
0.58 (0.50e0.68) 0.34 (0.06e1.84) 0.50 (0.42e0.59) 0.51 (0.32e0.81)
Complications
Return to OR 0.57 (0.44e0.73) 0.82 (0.39e1.69) 0.52 (0.37e0.73) 0.58 (0.36e0.92)
No
complication
REF REF REF REF
PO before
discharge
0.14 (0.11e0.16) 0.11 (0.06e0.20) 0.13 (0.10e0.16) 0.08 (0.04e0.13)
PO after
discharge
0.99 (0.85e1.14) 0.69 (0.45e1.06) 1.03 (0.85e1.25) 0.81 (0.61e1.06)
BMI ¼ body mass index; REF ¼ reference.
Bold indicates statistical significance. For all covariates listed in italics, the reference group was the cohort of patients without the factor.
Appendix
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1e88