Choice of Hospital for Readmissions Influences Mortality Risk in Men with Urologic Cancer

Patients with urologic cancer who are readmitted after a surgery to a second hospital and not to their original hospital are more likely to have complications than patients readmitted to their original surgical hospital, according to findings presented at the 2015 Genitourinary Cancers Symposium.

“Approximately 1 in 10 patients will require hospital readmission within 90 days of a major urologic cancer surgery,” said lead investigator Jasmir G. Nayak, MD, Department of Urology, University of Washington, Seattle, “and up to 40% of these patients will present to a secondary hospital.”

Although 40% may sound innocuous, the choice of hospital could mean the difference between life and death, according to Dr Nayak’s analysis.

“For patients undergoing surgery in a high-volume center,” he cautioned, “complications managed at secondary hospitals are almost 7 times more likely to be associated with mortality.”

Urologic cancer surgery is often linked with significant morbidity and mortality. Although outcomes vary among hospitals, this may be partly attributed to differences in failure-­to-rescue complications.

“Given the regional variation in urologic surgery,” said Dr Nayak, “the institution that patients present to for complication management may affect outcomes. Specifically, presenting to a different hospital than where surgery took place may result in healthcare that is less familiar and thus less prepared to properly identify and manage complications.”

This retrospective analysis was based on 1998-2007 and 2009-2013 data from the Washington State Comprehensive Hospital Abstract Reporting System. The sample size consisted of 31,498 surgeries (including radical prostatectomy, radical cystectomy, radical nephrectomy, and partial nephrectomy) with 10% (N = 3113) of readmissions occurring within 90 days of surgery.

Of the 3113 total readmissions, 1196 patients were diagnosed with a “rescuable” complication.

“Complication rates were based on readmission diagnoses,” said Dr Nayak, “and included cardiac, respiratory, bleed, sepsis, venothrombotic event, or renal failure.”

Complication rates were the highest for patients who had undergone radical cystectomy or radical nephrectomy, but these rates differed between those patients admitted to primary versus secondary hospitals.

“For those patients readmitted to secondary hospitals following radical cystectomy, the FTR [failure-to-rescue] rate was 9.1% compared with 7.4% for those readmitted to their primary hospital,” said Dr Nayak.

Overall, the complications rate was 6.1% for patients readmitted to secondary hospitals compared with 4.1% for those readmitted to their original surgical hospital.

“Conversely,” Dr Nayak elaborated, “when surgery is performed in a low-volume center, there is a trend towards a protective benefit of having complications managed at an alternate institution.”

He noted that the reasons for these disparities warrant further investigation.

“Understanding the impact that site of readmission has on health outcomes will inform clinical behaviors around discharge disposition and patient transfers in order to ensure optimization of healthcare value after major cancer surgery,” he concluded.

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