Department of Urology, University of California-San Francisco, San Francisco, California.
Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
J Urol. 2020 Mar;203(3):546-553. doi: 10.1097/JU.0000000000000522. Epub 2019 Sep 3.
Implementing episode based payment models requires a detailed understanding of health care utilization throughout the 90-day postoperative episode. This includes nonindex hospital readmissions, which currently do not exist for patients treated with radical prostatectomy. We compared the causes, costs and predictors of index vs nonindex hospital readmissions after radical prostatectomy.
We identified patients with prostate cancer who underwent radical prostatectomy from 2010 to 2014 in the Nationwide Readmissions Database. Sociodemographic factors, hospital costs and causes of 90-day readmissions were compared between index and nonindex hospital readmissions. Multivariable regression models were used to determine whether nonindex readmissions were more costly than index readmission for several causes of readmission and also to identify predictors of nonindex readmissions.
Of the 214,473 patients treated with radical prostatectomy 12,316 (5.7%) experienced a 90-day readmission and 4,283 (30.6%) had a nonindex readmission. Nonindex readmissions were more likely for complications which were cardiovascular specific (16.6% vs 10.3%) and nonradical prostatectomy specific (49.4% vs 32.8%, each p <0.01). On multivariable modeling readmission costs were significantly higher for nonindex vs index readmissions ($10,751 vs $10,113, p <0.01). Cardiovascular and electrolyte related nonindex readmissions ($12,995 vs $10,108, p <0.001, and $4,962 vs $3,179, p=0.01, respectively) were more expensive. Nonindex hospital readmission predictors included minimally invasive radical prostatectomy (OR 1.28, 95% CI 1.03-1.58), radical prostatectomy done at a high volume institution (OR 2.02, 95% CI 1.41-2.89) and residence in a more rural location (less than 50,000 population OR 1.68, 95% CI 1.21-2.35).
In this nationally representative study nonindex hospital readmissions were associated with higher readmission costs, which were driven by differences in a small subset of readmissions. The benefits of undergoing radical prostatectomy at a high volume center should be carefully balanced with the increased odds of nonindex hospital readmissions and higher costs associated with such centers as regionalization continues.
实施基于疾病的支付模式需要深入了解患者术后 90 天内的整体医疗服务利用情况，包括目前接受根治性前列腺切除术治疗的患者不存在的非索引医院再入院情况。本研究比较了根治性前列腺切除术患者索引与非索引医院再入院的原因、费用和预测因素。
我们从 2010 年至 2014 年全美再入院数据库中确定了接受根治性前列腺切除术治疗的前列腺癌患者。比较索引与非索引医院再入院患者的社会人口统计学因素、医院费用和 90 天再入院原因。采用多变量回归模型确定索引与非索引再入院的几种原因中，非索引再入院的费用是否高于索引再入院，以及确定非索引再入院的预测因素。
在 214473 例接受根治性前列腺切除术治疗的患者中，有 12316 例（5.7%）发生了 90 天再入院，其中 4283 例（30.6%）发生了非索引再入院。心血管疾病相关的并发症（16.6%比 10.3%）和非根治性前列腺切除术相关的并发症（49.4%比 32.8%，均 p<0.01）更容易导致非索引再入院。多变量模型分析显示，非索引再入院的再入院费用明显高于索引再入院（$10751 比 $10113，p<0.01）。心血管和电解质相关的非索引再入院（$12995 比 $10108，p<0.001，和 $4962 比 $3179，p=0.01）的费用更高。非索引医院再入院的预测因素包括微创手术（OR 1.28，95%CI 1.03-1.58）、在高容量机构进行的根治性前列腺切除术（OR 2.02，95%CI 1.41-2.89）和居住在人口较少的农村地区（少于 50000 人 OR 1.68，95%CI 1.21-2.35）。
在这项具有全国代表性的研究中，非索引医院再入院与更高的再入院费用相关，而这些费用的差异主要由一小部分再入院原因造成。随着区域化的继续，在高容量中心进行根治性前列腺切除术的好处应该与非索引医院再入院的风险和与这些中心相关的更高费用仔细平衡。
