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Original Investigation |

Influence of Patient, Physician, and Hospital Factors on 30-Day Readmission Following Pancreatoduodenectomy in the United States

Omar Hyder, MD1; Rebecca M. Dodson, MD1; Hari Nathan, MD, PhD1; Eric B. Schneider, PhD1; Matthew J. Weiss, MD1; John L. Cameron, MD1; Michael A. Choti, MD1; Martin A. Makary, MD1; Kenzo Hirose, MD1; Christopher L. Wolfgang, MD, PhD1; Joseph M. Herman, MD, MSc2; Timothy M. Pawlik, MD, MPH, PhD1
[+] Author Affiliations
1Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
2Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA Surg. 2013;148(12):1095-1102. doi:10.1001/jamasurg.2013.2509.
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Importance  It is not known whether hospital and surgeon volumes have an association with readmission among patients undergoing pancreatoduodenectomy.

Objective  To evaluate patient-, surgeon-, and hospital-level factors associated with readmission.

Design, Setting, and Participants  Retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)–Medicare data with cases diagnosed from January 1, 1998, to December 31, 2005, and followed up until December 2007. Population-based cancer registry data were linked to Medicare data for the corresponding patients. A total of 1488 unique individuals who underwent a pancreatoduodenectomy were identified.

Interventions  Undergoing pancreatoduodenectomy at hospitals classified by volume of pancreatoduodenectomy procedures performed at the facility were either very-low, low, medium, or high volume. Undergoing pancreatoduodenectomy by surgeons classified by volume of pancreatoduodenectomy procedures performed by the surgeon were either very-low, low, medium, or high volume.

Main Outcomes and Measures  In-hospital morbidity, mortality, and 30-day readmission were examined.

Results  The median age was 74 years, and 1436 patients (96.5%) had a least 1 medical comorbidity. Patients were treated by 575 distinct surgeons at 298 distinct hospitals. Length of stay was longest (median, 17 days) and 90-day mortality highest (17.2%) at very-low-volume hospitals (P < .001). Among all pancreatoduodenectomy patients, 292 (21.3%) were readmitted within 30 days of discharge. There was no effect of surgeon volume and a modest effect of hospital volume (odds ratio for highest- vs lowest-volume quartiles, 1.85; 95% CI, 1.22-2.80; P = .02). The presence of significant preoperative medical comorbidities was associated with an increased risk for hospital readmission after pancreatoduodenectomy. A comorbidity score greater than 13 had a pronounced effect on the chance of readmission following pancreatoduodenectomy (odds ratio, 2.06; 95% CI, 1.56-2.71; P < .001). The source of variation in readmission was primarily attributable to patient-related factors (95.4%), while hospital factors accounted for 4.3% of the variability and physician factors for only 0.3%.

Conclusions and Relevance  Nearly 1 in 5 patients are readmitted following pancreatoduodenectomy. While variation in readmission is, in part, attributable to differences among hospitals, the largest share of variation was found at the patient level.

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Figure 1.
Length of Stay (LOS) and Mortality Associated With the Index Admission and the Readmission Stratified by Pancreatoduodenectomy Procedural Hospital Volume

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Figure 2.
Length of Stay (LOS) and Mortality Associated With the Index Admission and the Readmission Stratified by Pancreatoduodenectomy Procedural Surgeon Volume

aP value for comparison <.05.

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