Valero Vicente, Grimm Joshua C, Kilic Arman, Lewis Russell L, Tosoian Jeffrey J, He Jin, Griffin James F, Cameron John L, Weiss Matthew J, Vollmer Charles M, Wolfgang Christopher L
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
Department of Surgery, The University of Pennsylvania School of Medicine, Philadelphia, PA.
J Am Coll Surg. 2015 Apr;220(4):701-13. doi: 10.1016/j.jamcollsurg.2014.12.038. Epub 2015 Jan 8.
Postoperative readmissions have been proposed by Medicare as a quality metric and can impact provider reimbursement. Because readmission after pancreatectomy is common, we sought to identify factors associated with readmission to establish a predictive risk scoring system.
A retrospective analysis of 2,360 pancreatectomies performed at 9 high-volume pancreatic centers between 2005 and 2011 was performed. Forty-five factors strongly associated with readmission were identified. To derive and validate a risk scoring system, the population was randomly divided into 2 cohorts in a 4:1 fashion. A multivariable logistic regression model was constructed and scores were assigned based on the relative odds ratio (OR) of each independent predictor. A composite Readmission after Pancreatectomy (RAP) score was generated and then stratified to create risk groups.
Overall, 464 (19.7%) patients were readmitted within 90 days. Eight pre- and postoperative factors, including earlier MI (OR = 2.03), American Society of Anesthesiologists class ≥ 3 (OR = 1.34), dementia (OR = 6.22), hemorrhage (OR = 1.81), delayed gastric emptying (OR = 1.78), surgical site infection (OR = 3.31), sepsis (OR = 3.10), and short length of stay (OR = 1.51) were independently predictive of readmission. The 32-point RAP score generated from the derivation cohort was highly predictive of readmission in the validation cohort (area under the receiver operating curve = 0.72). The low-risk (0 to 3), intermediate-risk (4 to 7), and high-risk (>7) groups correlated with 11.7%, 17.5%, and 45.4% observed readmission rates, respectively (p < 0.001).
The RAP score is a novel and clinically useful risk scoring system for readmission after pancreatectomy. Identification of patients with increased risk of readmission using the RAP score will allow efficient resource allocation aimed to attenuate readmission rates. It also has potential to serve as a new metric for comparative research and quality assessment.
医疗保险已将术后再入院作为一项质量指标，且其会影响医疗服务提供者的报销。由于胰腺切除术后再入院情况较为常见，我们试图确定与再入院相关的因素，以建立一个预测风险评分系统。
对2005年至2011年间在9家高容量胰腺中心进行的2360例胰腺切除术进行回顾性分析。确定了45个与再入院密切相关的因素。为了推导和验证风险评分系统，将研究人群以4:1的比例随机分为两个队列。构建了多变量逻辑回归模型，并根据每个独立预测因素的相对优势比（OR）分配分数。生成了一个综合的胰腺切除术后再入院（RAP）评分，然后进行分层以创建风险组。
总体而言，464例（19.7%）患者在90天内再次入院。八个术前和术后因素，包括较早发生的心肌梗死（OR = 2.03）、美国麻醉医师协会分级≥3级（OR = 1.34）、痴呆（OR = 6.22）、出血（OR = 1.81）、胃排空延迟（OR = 1.78）、手术部位感染（OR = 3.31）、脓毒症（OR = 3.10）和住院时间短（OR = 1.51）是再入院的独立预测因素。推导队列生成的32分RAP评分在验证队列中对再入院具有高度预测性（受试者工作特征曲线下面积 = 0.72）。低风险（0至3分）、中风险（4至7分）和高风险（>7分）组的观察到的再入院率分别为11.7%、1
