Hospital Readmission Following Appendectomy, Cholecystectomy, and Herniorrhaphy

Brian C Hill, MD, Saad A Shebrain, MBBCh, FACS, Leandra H Burke, MPA, CCRP, Shivani Shah, MD, Ethan J Maltz. Western Michigan University School of Medicine.

INTRODUCTION: Hospital readmissions are known to occur after surgery. We conducted a retrospective case review on a cohort of patients who had appendectomy, cholecystectomy, or hernia repair and were subsequently readmitted to the hospital within 30 days. Our objective was to find common variables, present at the time of surgery, which may help to identify patients at higher risk for readmission after surgery.

METHODS AND PROCEDURES: We examined records of patients who underwent appendectomy, cholecystectomy, or herniorrhaphy at either of two community hospitals. Of 2,119 patients undergoing surgery between January 01, 2011 and April 30, 2012 (N=2,119), 6.80% (n=144) patients were subsequently readmitted within 30 days.
For the cohort of readmitted patients (n=144), we examined 51 variables covering demographic information; insurance status; pain level; comorbities; medication use; discharge considerations; intraoperative events; and the length of hospital stay.
Data was de-identified and tabulated in Microsoft Excel. Data analysis, including basic descriptive statistics and Wilcoxon two sample tests, was completed with SAS version 9.3 software.

RESULTS: The cohort was comprised of 60 males and 84 females, with an average age of 45.94 years (StD ±22.15 years). 51.88% of patients held private insurance (n=69), 38.35% had government insurance (n= 61), and 9.77% were self-pay (n=13). Insurance data was not available for 11 patients.
The mean BMI value was 30 (StD ±9); 45 patients were overweight (BMI 25 – 29.9), and 49 patients were obese (BMI≥30). 61.11 %( n=88) had at least one of the following co-morbidities: CHF, CAD, hypertension, COPD, asthma, diabetes, renal impairment, chronic kidney disease, depression, or dementia. 29.86% (n=43) were on pain medication prior to surgery.
As for the surgical procedures, n=27 underwent hernia repair (2 of these were laparoscopic); n= 27 underwent appendectomy (24 laparoscopic); and n=87 had cholecystectomy (82 laparoscopic). 6.25% (n=9) experienced an intraoperative event, including 1 conversion of a cholecystectomy from lap to open procedure.
35.41% (n=51) were discharged the same day of surgery; 34.03% (n=49) required a short hospital stay (<24 hours), and 24.31% completed a long stay following surgery (>24 hours). 27 patients were on antibiotics 24 hours post-op, and 6 patients experienced wound problems.
Since 65.28% of the readmitted patients were overweight or obese (n= 94), we were curious to investigate the effect of this variable on surgery. Of 35 open procedures, only 3 were performed on overweight or obese patients (BMI ≥25). The mean operative time for the overweight and obese patients was 98.08 minutes, as opposed to 75.97 minutes for normal weight patients (p=.1045).

CONCLUSION: The majority of patients in our cohort were overweight or obese. We found that our overweight patients experienced longer intraoperative times, on average, than non-overweight patients. It is well-known that obesity can be attributed to a number of health conditions, including diabetes, hypertension, CHF, and gallstones, which could conceivably impact surgery and subsequent recovery. This study continues to track 30-day readmissions, in order to identify patients most at risk for readmission, and take measures to reduce readmission rates in this population in the future.

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