Shah Puja M, Johnston Lily, Sarosiek Bethany, Harrigan Amy, Friel Charles M, Thiele Robert H, Hedrick Traci L
1 Department of Surgery, University of Virginia, Charlottesville, Virginia 2 Enhanced Recovery Program, University of Virginia, Charlottesville, Virginia 3 Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.
Dis Colon Rectum. 2017 Feb;60(2):219-227. doi: 10.1097/DCR.0000000000000748.
Hospital readmission rates are an increasingly important quality metric since enactment of the 2012 Hospital Readmissions Reduction Program. The proliferation of enhanced recovery protocols and earlier discharge raises concerns for increased readmission rates.
We evaluated the effect of enhanced recovery on readmissions and identified risk factors for readmission.
This study involved implementation of a multidisciplinary enhanced recovery protocol.
It was conducted at a large academic medical center PATIENTS:: All patients undergoing elective colorectal surgery between 2011 and 2015 at our center were included.
This cohort study compared patients before and after enhanced recovery initiation, looking at 30-day readmission as the primary outcome. A multivariable logistic regression model identified predictors of 30-day readmission. Kaplan-Meier analysis identified differences in time to readmission.
A total of 707 patients underwent colorectal procedures between 2011 and 2015, including 383 patients before enhanced recovery protocol was implemented and 324 patients after enhanced protocol was implemented. Length of stay decreased from a median 5 days to a median 4 days before and after enhanced recovery implementation (p < 0.0001). Thirty-day readmission decreased from 19% (72/383) in the pre-enhanced recovery pathway to 12% (38/324) in the enhanced recovery pathway (p = 0.009). Twenty-one percent (21/99) of patients who underwent ileostomy were readmitted before enhanced recovery implementation compared with 19% (18/93) of patients who underwent ileostomy after enhanced recovery implementation (p = 0.16). Multivariable logistic regression identified ileostomy as increasing the risk of readmission (p = 0.04), whereas enhanced recovery protocol decreased the risk of readmission (p = 0.006).
The study is limited because it was conducted at a single institution and used a before-and-after study design.
These data suggest that use of a standardized enhanced recovery protocol significantly reduces length of stay and readmission rates in an elective colorectal surgery population. However, the presence of an ileostomy maintains a high association with readmission, serving as a significant burden to patients and providers alike. Ongoing efforts are needed to further improve the management of patients undergoing ileostomy in the outpatient setting after discharge to prevent readmissions.
自2012年医院再入院率降低计划颁布以来，医院再入院率已成为一项日益重要的质量指标。强化康复方案的增多以及更早出院引发了对再入院率上升的担忧。
我们评估了强化康复对再入院的影响，并确定了再入院的风险因素。
本研究涉及实施多学科强化康复方案。
在一家大型学术医疗中心进行。
纳入了2011年至2015年期间在我们中心接受择期结直肠手术的所有患者。
这项队列研究比较了强化康复开始前后的患者，将30天再入院作为主要观察指标。多变量逻辑回归模型确定了30天再入院的预测因素。Kaplan-Meier分析确定了再入院时间的差异。
2011年至2015年期间共有707例患者接受了结直肠手术，其中383例患者在强化康复方案实施前，324例患者在强化方案实施后。强化康复实施前后住院时间中位数从5天降至4天（p<0.0001）。30天再入院率从强化康复前途径的19%（72/383）降至强化康复途径的12%（38/324）（p=0.009）。强化康复实施前接受回肠造口术的患者中有21%（21/99）再次入院，而强化康复实施后接受回肠造口术的患者中有19%（18/93）再次入院（p=0.16）。多变量逻辑回归确定回肠造口术会增加再入院风险（p=0.04），而强化康复方案会降低再入院风险（p=0.006）。
本研究存在局限性，因为它是在单一机构进行的，且采用了前后对照研究设计。
这些数据表明，使用标准化的强化康复方案可显著缩短择期结直肠手术患者的住院时间并降低再入院率。然而，回肠造口术的存在与再入院仍有高度关联，这对患者和医护人员来说都是一项重大负担。需要持续努力进一步改善出院后门诊环境下回肠造口术患者的管理，以防止再入院。
