Emergency Room Utilization Is High & Feeding Tube Problems Are The Biggest Culprit: Analysis Of Resource Utilization After Esophagectomy
Biniam Kidane1, Suha Kaaki1, Yu Shen2, Adam Bassili2, John Peel3, Frances Allison2, Thomas Waddell2, Gail Darling2
1University of Manitoba, Winnipeg, MB, Canada2University of Toronto, Toronto, ON, Canada3University of British Columbia, Vancouver, BC, Canada
OBJECTIVES: Esophagectomy is a complex operation with potential for significant morbidity and prolonged recovery. As part of a quality improvement initiative, the aim of this study was to evaluate health care resource utilization, specifically emergency department (ED) visits within 1 year of esophagectomy and to identify risk factors for ED visits as well as frequent ED use (FEDU).
METHODS: Retrospective cohort study was performed of consecutive esophagectomies at a tertiary Canadian centre (1999-2014). Fisher's exact, Mann-Whitney U, t-tests and multivariable logistic regression were used to identify factors associated with higher ED visits to the index hospital as well as FEDU (≥3 visits) within 1 year of esophagectomy. Demographic, socioeconomic, medical/surgical factors were assessed.
RESULTS: There were 520 esophagectomies with an in-hospital mortality of 6% (n=31). Of those surviving to discharge, 29.7% of patients (n=145) had ≥1 ED visit within 1 year of discharge. The most common causes were feeding tube problems (39.3%, n=57) and dysphagia/stricture (13.1%, n=19). Many of the feeding tube problems appear to be related to tube blockages or unsubstantiated concerns about infection. On multivariable analysis, higher income (adjusted odds ratio [aOR]=1.22 [1.04-1.42], p=0.01) and use of thoracoscopic-assisted esophagectomy (aOR=3.24 [1.71-6.11], p<0.0001) were independently associated with a higher risk of ED visits. Patients with thoracoscopic-assisted esophagectomy were discharged significantly earlier than others (p<0.0001).Living in a region further from the index hospital (aOR=0.39 [0.29-0.52], p<0.0001) and having surgery in the later years of the study period (aOR=0.91 [0.86-0.97], p=0.006) were both independently associated with lower risk of ED visits (aOR=0.39 [0.29-0.52], p<0.0001). Forty-three (8.8%) patients were frequent ED users, with the most common causes of repeat ED visits being feeding tube problems and dysphagia/stricture. On multivariable analysis, only the "region" predictor was independently associated with frequent ED visits. Living in a region further from the index hospital was associated with lower risk of frequent ED visits (aOR=0.25 [0.14-0.45], p<0.0001). Multivariable analyses including only the patients living in the regions within 1 hour of our hospital revealed the same finding. Resection type, specific in-hospital complications, use of chemotherapy or radiation therapy, age and comorbidity factors were not independently associated with higher ED utilization risk.
CONCLUSIONS: There is a high rate of ED utilization within 1 year of esophagectomy. Patients living further away from the index hospital had a lower rate of index hospital ED utilization; thus, the true rate of ED utilization is likely higher as these patients are likely utilizing their local hospitals. Some of our findings (higher risk with thoracoscopic-assisted esophagectomy & lower risk over time) likely reflect the effects of the learning curve of Minimally-Invasive Esophagectomy over time. Feeding tube problems are the most common causes of high ED utilization and are potentially modifiable with pre-emptive patient/caregiver education or arrangement of clinic visits in lieu of ED use. These interventions could represent significant cost savings & increased patient quality of life/satisfaction.
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