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| Impact of pre- and peri-operative risk factors on length of stay and hospital readmission following minimally-invasive partial nephrectomy |
Vanessa A. Lukasa,Rahul Duttab,Ashok K. Hemalb,Matvey Tsivianb,Timothy E. Cravenb,Nicholas A. Deebelb,David D. Thielc,Ram Anil Pathakc,*( )
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aBrigham and Women's Hospital, Division of Urology, Department of Surgery, 75 Francis Street, Boston, MA, USA
bAtrium Health Wake Forest Baptist Medical Center, Department of Urology, 1 Medical Center Blvd, Winston-Salem, NC, USA
cMayo Clinic Florida, Department of Urology, 4500 San Pablo Road, Jacksonville, FL, USA |
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Abstract Objective: We conducted an analysis of the American College of Surgeons National Surgical Quality Improvement Program database for minimally-invasive partial nephrectomy cases reported with the goal to identify pre- and peri-operative variables associated with length of stay (LOS) greater than 3 days and readmission within 30 days. Methods: Records from 2008 to 2018 for “laparoscopy, surgical; partial nephrectomy” for prolonged LOS and readmission cohorts were compiled. Univariate analysis with Chi-square, t-tests, and multivariable logistic regression analysis with odds ratios (ORs), p-values, and 95% confidence intervals assessed statistical associations. Results: Totally, 20 306 records for LOS greater than 3 days and 15 854 for readmission within 30 days were available. Univariate and multivariable analysis exhibited similar results. For LOS greater than 3 days, undergoing non-elective surgery (OR=5.247), transfusion of greater than four units within 72 h prior to surgery (OR=5.072), pre-operative renal failure or dialysis (OR=2.941), and poor pre-operative functional status (OR=2.540) exhibited the strongest statistically significant associations. For hospital readmission within 30 days, loss in body weight greater than 10% in 6 months prior to surgery (OR=2.227) and bleeding disorders (OR=2.081) exhibited strongest statistically significant associations. Conclusion: Multiple pre- and peri-operative risk factors are independently associated with prolonged LOS and hospital readmission within 30 days of surgery using the American College of Surgeons National Surgical Quality Improvement Program data. Recognizing the risks factors that can potentially be improved prior to minimally-invasive partial nephrectomy is crucial to informing patient selection, optimization strategies, and patient education.
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Received: 20 October 2021
Available online: 20 January 2024
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Corresponding Authors:
*E-mail address: Pathak.Ram@mayo.edu (R.A. Pathak).
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| Factor | Overall (n=20 306) | Full dataset for LOS (n=20 306) | Full dataset for readmission (n=15 854) | | >3 days (n=3506) | ≤3 days (n=16 800) | p-Value | Readmitted <30 daysa (n=958) | Not readmitteda (n=14 896) | p-Value | | Ageb, year | 59±12 | 61±13 | 59±12 | <0.0001 | 61±13 | 59±12 | <0.0001 | | BMIb, kg/m2 | 30.9±6.7 | 31.2±7.1 | 30.8±6.6 | 0.006 | 31.3±6.9 | 30.8±6.7 | 0.031 | | Surgery yearc | | | | <0.0001 | | | <0.0001 | | 2008-2010 | 514 (3) | 146 (28) | 368 (72) | | NA | NA | | | 2011-2013 | 3915 (19) | 783 (20) | 3132 (80) | 175 (5) | 3650 (95) | | | 2014-2015 | 4800 (24) | 890 (19) | 3910 (81) | 245 (5) | 4516 (95) | | 2016-2018 | 11 077 (55) | 1687 (15) | 9390 (85) | 538 (7) | 6730 (93) |
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Descriptive statistics of pre-operative factors overall according to LOS >3 days versus LOS ≤3 days, and by readmission versus no readmission within 30 days.
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| Dichotomous factor | Overalla (n=20 306) | Full dataset for LOS >3 days (n=20 306) | Full dataset for readmission (n=15 854) | | Factor+a | Factor?a | p-Value | Readmitted (factor+)a | Readmitted (factor?)a | p-Value | | BMI ≥30 kg/m2 | 10 112 (49) | 1778/10 112 (18) | 1728/10 194 (17) | 0.23 | 514/7836 (7) | 444/8018 (6) | 0.007 | | Hispanic ethnicity (vs. non-Hispanic) | 1302 (6) | 189/1302 (15) | 3317/19 004 (17) | 0.007 | 70/985 (7) | 888/14 869 (6) | 0.15 | | Race | | Caucasian (vs. others) | 15 066 (74) | 2377/15 066 (16) | 1129/5240 (22) | <0.0001 | 700/11 851 (6) | 258/4003 (6) | 0.22 | | African-American (vs. others) | 1964 (10) | 368/1964 (19) | 3138/18 342 (17) | 0.070 | 103/1475 (7) | 855/14 379 (6) | 0.11 | | Asian (vs. others) | 610 (3) | 91/610 (15) | 3415/19 696 (17) | 0.119 | 21/471 (4) | 937/15 383 (6) | 0.14 | | Other or unknown (vs. others) | 2666 (13) | 670/2666 (25) | 2836/17 640 (16) | <0.0001 | 134/2057 (7) | 824/13 797 (6) | 0.34 | | Diabetes mellitus (on medications) | 3992 (20) | 852/3992 (21) | 2654/16 314 (16) | <0.0001 | 261/3097 (8) | 697/12 757 (5) | <0.0001 | | Current smoker within 1 year | 3764 (19) | 653/3764 (17) | 2853/16 542 (17) | 0.88 | 186/3010 (6) | 772/12 844 (6) | 0.73 | | Dyspnea | 1063 (5) | 279/1063 (26) | 2853/19 243 (15) | <0.0001 | 79/870 (9) | 879/14 984 (6) | 0.0001 | | History of severe COPD | 698 (3) | 202/698 (29) | 3304/19 608 (17) | <0.0001 | 56/561 (10) | 902/15 293 (6) | <0.0001 | | History of CHF within 30 days | 66 (<1) | 22/66 (33) | 3484/20 240 (17) | 0.0005 | 8/53 (15) | 950/15 801 (6) | 0.014b | | Hypertension requiring medication | 11 784 (58) | 2298/11 784 (20) | 1208/8522 (14) | <0.0001 | 605/9193 (7) | 353/6661 (5) | 0.0008 | | Steroid use for chronic condition | 520 (3) | 109/520 (21) | 3397/19 786 (17) | 0.024 | 40/413 (10) | 918/15 441 (6) | 0.002 | | Bleeding disorder | 363 (2) | 112/363 (31) | 3394/19 943 (17) | <0.0001 | 42/304 (14) | 916/15 550 (6) | <0.0001 | | Open wound or wound infection | 66 (<1) | 17/66 (26) | 3489/20 240 (17) | 0.068 | 5/51 (10) | 953/15 803 (6) | 0.24b | | More than 10% loss of body weight last 6 months | 146 (1) | 44/146 (30) | 3462/20 160 (17) | <0.0001 | 16/119 (13) | 942/15 735 (6) | 0.0007 | | Emergency case | 32 (<1) | 13/32 (41) | 3493/20 274 (17) | 0.0005 | 5/28 (18) | 953/15 826 (6) | 0.025b | | Transfusion of greater than four units within 72 h prior to surgery | 20 (<1) | 14/20 (70) | 3492/20 286 (17) | <0.0001c | 1/17 (6) | 957/15 837 (6) | 1.00b | | Non-elective case of surgery | 306 (2) | 167/306 (55) | 3339/20 000 (17) | <0.0001 | 28/264 (11) | 930/15 590 (6) | 0.002 | | Renal failure or dialysis | 70 (<1) | 34/70 (49) | 3472/20 236 (17) | <0.0001 | 6/42 (14) | 952/15 812 (6) | 0.039b | | Systemic sepsis | 60 (<1) | 19/60 (32) | 3487/20 246 (17) | 0.003 | 3/44 (7) | 955/15 810 (6) | 0.75b | | Partially/totally dependent functional status | 116 (1) | 46/116 (40) | 3460/20 190 (17) | <0.0001 | 11/86 (13) | 947/15 768 (6) | 0.009 | | ASA classification: severe disturbancec | 10 525 (52) | 2029/10 525 (19) | 1476/9779 (15) | <0.0001 | 577/8163 (7) | 381/7690 (5) | <0.0001 | | Contaminated wound | 109 (1) | 28/109 (26) | 3478/20 197 (17) | 0.020 | 8/82 (10) | 950/15 772 (6) | 0.16b |
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Descriptive statistics of ACS-NSQIP specific pre-operative characteristics for patients categorized by LOS >3 days versus LOS ≤3 days, and by readmission versus no readmission within 30 days.
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| Factor | LOS >3 days | Readmission <30 days | | OR | 95% CI | p-Value | OR | 95% CI | p-Value | | Calendar year of surgical procedure | | | <0.0001 | | | <0.0001 | | 2008-2010 vs. 2016-2018 | 2.338 | 1.908-2.866 | | N/A | | | | 2011-2013 vs. 2016-2018 | 1.427 | 1.295-1.572 | 0.601 | 0.504-0.718 | | 2014-2015 vs. 2016-2018 | 1.277 | 1.165-1.400 | 0.678 | 0.579-0.793 | | Age of patient | 1.184 | 1.134-1.236 | <0.0001 | 1.099 | 1.017-1.188 | 0.017 | | BMI≥30 kg/m2 | 1.029 | 0.950-1.114 | 0.490 | 1.091 | 0.947-1.257 | 0.230 | | Hispanic ethnicity | 0.763 | 0.646-0.901 | 0.0014 | 1.186 | 0.916-1.537 | 0.200 | | Patient race | | | <0.0001 | | | 0.250 | | African-American vs. Caucasian | 1.179 | 1.039-1.337 | | 1.143 | 0.918-1.423 | | | Asian vs. Caucasian | 1.036 | 0.821-1.308 | 0.802 | 0.511-1.257 | | Other or unknown race vs. Caucasian | 2.021 | 1.825-2.239 | 1.142 | 0.939-1.388 | | Diabetes mellitus with oral agents or insulin | 1.204 | 1.096-1.323 | 0.0001 | 1.373 | 1.170-1.611 | 0.0001 | | Current smoker within 1 year | 1.014 | 0.917-1.121 | 0.780 | 1.040 | 0.874-1.238 | 0.660 | | Dyspnea | 1.289 | 1.103-1.507 | 0.0014 | 1.285 | 0.992-1.666 | 0.058 | | History of severe COPD | 1.571 | 1.306-1.890 | <0.0001 | 1.431 | 1.053-1.945 | 0.022 | | Congestive heart failure within 30 days | 1.544 | 0.890-2.676 | 0.120 | 2.004 | 0.924-4.347 | 0.079 | | Hypertension requiring medication | 1.191 | 1.090-1.301 | 0.0001 | 0.971 | 0.830-1.136 | 0.710 | | Steroid use for chronic condition | 1.098 | 0.878-1.375 | 0.410 | 1.426 | 1.014-2.006 | 0.042 | | Bleeding disorder | 1.695 | 1.336-2.150 | <0.0001 | 2.081 | 1.475-2.935 | <0.0001 | | Open wound or wound infection | 1.210 | 0.673-2.177 | 0.520 | 1.386 | 0.542-3.546 | 0.500 | | More than 10% loss body weight in last 6 months | 1.617 | 1.108-2.360 | 0.013 | 2.227 | 1.290-3.845 | 0.004 | | Emergency case | 1.149 | 0.495-2.667 | 0.750 | 2.823 | 0.986-8.086 | 0.053 | | Transfusion >4 units PRBCs within 72 h | 5.072 | 1.760-14.617 | 0.003 | 0.314 | 0.037-2.687 | 0.290 | | Non-elective surgery | 5.247 | 4.123-6.677 | <0.0001 | 1.615 | 1.060-2.461 | 0.026 | | Pre-operative renal failure or dialysis | 2.941 | 1.763-4.906 | <0.0001 | 1.485 | 0.590-3.736 | 0.400 | | Systemic sepsis (SIRS or sepsis) | 1.415 | 0.766-2.615 | 0.270 | 0.753 | 0.224-2.531 | 0.650 | | Functional status dependent vs. independent or unknown | 2.540 | 1.713-3.767 | <0.0001 | 1.801 | 0.928-3.494 | 0.082 | | ASA class (1 or 2 vs. greater than 3) | 1.145 | 1.055-1.242 | 0.0011 | 1.218 | 1.053-1.408 | 0.008 | | Contaminated or dirty wound | 1.531 | 0.974-2.406 | 0.065 | 1.647 | 0.779-3.484 | 0.190 |
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Results of multivariable logistic regression model for LOS more than 3 days and readmission within 30 days after surgery including pre-operative factors only as predictors (n=20 306, 3505 [17.3%] with LOS>3 days, 958 [4.7%] readmitted <30 days).
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