Small Variation in Risk-Adjusted Hospital Readmission After Colorectal Cancer Surgery


Key Points

  • Raw readmission rates ranged from 0% to 41.2%.
  • Estimated risk-adjusted readmission rates ranged from 11.3% to 13.2%.

In a study reported in JAMA Surgery, Lucas et al found wide variation in raw hospital readmission rates after colorectal cancer surgery but little variation in readmission in risk-adjusted analysis. Thirty-day readmission rates have been reported at 10% to 14% in this setting.

Study Details

The study involved data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database on 44,822 patients who underwent colorectal resection for colorectal cancer at 1,401 U.S. hospitals between January 1997 and December 2002. Hierarchical multivariable logistic regression analysis was performed to determine variation in risk-adjusted 30-day readmission among hospitals. The median age of study patients was 78 years (interquartile range [IQR] = 72–83 years).

The overall 30-day readmission rate was 12.3% (n = 5,502). A total of 872 hospitals had fewer than five cases annually, with these hospitals accounting for 10.2% of the total number of operations. Among hospitals with at least five operations annually, readmission rates ranged from 0% to 41.2% (IQR = 9.5%–14.8%).

Risk Factors

On multivariate analysis, factors associated with significantly increased risk of readmission were (P < .05): increasing age; black vs white race; total colectomy, other colectomy, and abdominoperineal resection vs right colectomy; and history of myocardial infarction, congestive heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, peptic ulcer disease, diabetes, and paralysis. Factors associated with significantly reduced risk of readmission (< .05) were female sex and sigmoid colectomy vs right colectomy.

Risk-Adjusted Analysis

After adjustment for patient characteristics, comorbidities, and operation types in a hierarchical model, no hospital, including those with fewer than five cases per year, had a readmission odds ratio (OR) that differed significantly from the overall mean. When the adjusted odds ratios were applied to the group mean (12.3%), the resultant estimated readmission rates for hospitals with at least five cases per year fell in a narrower distribution of 11.3% to 13.2% (IQR = 12.1%–12.4%).

When hospital annual case volume quartiles were added to the hierarchical model, the first quartile (lowest case volume) was associated with significantly increased risk of readmission compared with the fourth quartile (OR  = 1.16, P < .001). The second quartile (OR = 1.00, P = .84) and third quartile (OR = 1.00, P = .89) were not associated with increased risk vs the fourth quartile.

The investigators concluded: “Little risk-adjusted variation exists in hospital readmission rates after colorectal surgery. The use of readmission rates as a high-stakes quality measure for payment adjustment or public reporting across surgical specialties should proceed cautiously and must include appropriate risk adjustment.”

Timothy M. Pawlik, MD, MPH, PhD, of Johns Hopkins University School of Medicine, is the corresponding author for the JAMA Surgery article.

The authors reported no potential conflicts of interest.

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