j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e8
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Early discharge and readmission after colorectal resection Rebecca L. Hoffman, MD,a,* Edmund K. Bartlett, MD,a Clifford Ko, MD,b Najjia Mahmoud, MD,a Giorgos C. Karakousis, MD,a and Rachel R. Kelz, MD, MSCEa a b
Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, California
article info
abstract
Article history:
Background: Emphasis on the provision of high quality, cost-effective healthcare has meant
Received 4 January 2014
increasing efforts at reducing postoperative length of stay while reducing 30-d readmission
Received in revised form
rates. The aim of this study was to identify factors associated with early discharge (ED) and
31 January 2014
to evaluate the effectof ED on readmission after colorectal resection.
Accepted 11 February 2014
Materials and methods: We identified all inpatients aged 18 y who underwent a colorectal
Available online xxx
resection in the American College of Surgeons National Surgical Quality Improvement Program Participant Use File, 2011. ED was defined as a length of stay 25th percentile by
Keywords:
procedure (rectal resection, open colectomy, and laparoscopic colectomy). Multivariate
Early discharge
logistic regression was used to identify factors significantly associated with ED and read-
Readmission
mission. A subset analysis was performed by procedure type.
Colon
Results: Of 28,532 patients, 2171 (7%) underwent rectal resection, 14,976 (52%) underwent
Colorectal
open colectomy, and 11,385 (40%) underwent laparoscopic colectomy with an ED on or
Surgery
before postoperative days 5, 5, and 3, respectively. The overall cohort included patients
Laparoscopic
with a mean age of 61 y. A total of 52% were women and 37% were colorectal cancer pa-
ACS NSQIP
tients. Age >65 y, recent steroid use, simultaneous ostomy creation, nonelective surgery, need for reoperation, and a postoperative occurrence before discharge were significantly associated with a reduced likelihood of ED. The overall rate of readmission was 12%. Patients who were discharged early were significantly less likely to be readmitted (odds ratio, 0.77; 95% confidence interval, 0.70e0.84). Conclusions: In the appropriate patient population, ED after colorectal surgery may be implemented without any adverse effect on readmission rates. ª 2014 Elsevier Inc. All rights reserved.
1.
Introduction
A national emphasis on the provision of high quality, costeffective health care has meant increasing efforts at reducing postoperative length of stay (LOS) while simultaneously reducing 30-d readmission rates. Early research
suggested that early discharge (ED) was associated with increased rates of readmission. Therefore, concerns exist among surgeons that the inability to monitor patients’ clinical progress and detect complications would result in higher readmission rates and occurrences diagnosed after discharge [1e3].
* Corresponding author. Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, 4 Maloney, 3400 Spruce Street, Philadelphia, PA 19104. Tel.: þ1 267 275 3290; fax: þ1 215 662 7983. E-mail address: [email protected] (R.L. Hoffman). 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.02.006
2
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e8
Colorectal surgery provides a prime model for investigating the effects of ED on patient outcomes and readmission because of the frequency of procedures performed and the significant rates of postoperative occurrences (POs). Accordingly, recent data have been published regarding the relationship among LOS, ED, and readmissions after colorectal surgery. Single-institution experiences have demonstrated the benefits of early recovery pathways after colorectal surgery with little to no effect on readmission rates [4e7]. At the population level, however, LOS has decreased after colon surgery, whereas readmission rates have increased over the last two decades [8]. The recent addition of 30-d readmission information to the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) [9] provides a new opportunity to evaluate ED and readmission rates. In this study, we sought to identify factors associated with ED and evaluate the effect of ED on readmission after colorectal resection.
2.
Methods
We performed a retrospective study of prospectively collected data from the ACS NSQIP Participant Use File (PUF) data set from 2011. The ACS NSQIP PUF contains data on 442,149 cases collected from 315 academic and community-based hospitals located around the United States. A trained Surgical Clinical Reviewer captures data on 252 variables, including preoperative risk factors, intraoperative variables, and 30d postoperative morbidity and mortality outcomes. Patients aged 18 y undergoing major surgical procedures (both inpatient and outpatient) are included using an 8-d cycle sampling procedure. All variables collected in the ACS NSQIP are predefined in the NSQIP PUF 2011 user guide [10]. We identified all inpatients aged 18 y who underwent colorectal resection in the 2011 ACS NSQIP PUF. Colorectal resection was defined using Common Procedural Terminology codes for both open and laparoscopic procedures, including 44140e44147, 44150, 44151, 44155e44158, 44160, 44204e44208, 44210e44212, 45110e45114, 45116, 45119e45123, 45126, 45135, 45136, 45395, and 45397. Patients missing information on LOS and those with a LOS recorded as 0 d were excluded from the analysis. In addition, patients who were listed as still in the hospital and those who died during the initial inpatient hospitalization were excluded (Fig. 1). Patient demographic characteristics including age, sex, and race were abstracted from the NSQIP database, as was information regarding preoperative comorbidities and whether the procedure was performed electively or emergently. Heart disease was assigned for all patients with a recorded history of congestive heart failure, myocardial infarction, percutaneous coronary intervention or stenting, and/or angina. A history of colorectal cancer was defined using a postoperative International Classification of Diseases, Ninth Edition (ICD-9) diagnosis code of 153, 153.0, 154, 154.0, or 197.7. The simultaneous creation of an ostomy was determined using the Common Procedural Technology codes 44141, 44143, 44144, 44146, 44188, 44206, 44208, 44320, 44322, 44340, 44345, 44346, 45110, 45395, 44150, 44151, 44156, 44157, 44158, 44211, and 44187.
Fig. 1 e Selection of the study cohort.
To examine the effects of patient complications on the likelihood of ED and that of readmission, patients were classified by the presence or absence of any PO. Information regarding POs, including cardiac, respiratory, infectious, renal and neurologic events, and an unplanned return to the operating room was noted. More specifically, POs categorized as wound complication (superficial skin infection, deep surgical site infection, or fascial dehiscence), organ space infection, sepsis (sepsis or septic shock), renal (progressive renal failure or acute renal failure requiring dialysis), venous thromboembolism (deep vein thrombosis or pulmonary embolism), respiratory (pneumonia, intubation for greater than 48 h, or reintubation), bleeding (hemorrhage requiring transfusion of at least 4 U of blood), neurologic (stroke or coma), urinary tract infection, or cardiac (myocardial infarction or arrest requiring resuscitation) were abstracted directly from the ACS NSQIP PUF, and patients were classified by occurrence status: no occurrence, any occurrence before hospital discharge, and any occurrence after hospital discharge. The primary outcome variable was procedure-specific ED. The secondary outcome of interest was 30-d readmission. LOS was defined as the number of days from the index operation to hospital discharge (to home or any facility). Because it is commonly acknowledged that differences in LOS exist by procedure, procedure-specific ED was defined as an LOS 25th percentile for rectal resection, open colectomy, and laparoscopic colectomy, respectively [11,12]. ED was reported as a binary outcome. Readmission refers to an admission to any hospital within 30 d of the principal surgical procedure, as defined within the NSQIP PUF. Descriptive statistics were performed. Patient and procedure characteristics were examined by ED status using the Student t and chi-square tests, as appropriate. Multivariate logistic regression was used to identify factors significantly associated with ED. The association between ED and
3
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e8
readmission was investigated using univariate and multivariate logistic regression to adjust for potential confounders. Independent logistic regression models were developed to examine the association between ED and readmission for each of the procedure groups with adjustment for potential confounders. All statistical analyses were performed using STATA, version 12.1 (STATA Corp, College Station, TX). This study was reviewed by the Institutional Review Board of the University of Pennsylvania and deemed exempt from continuing review (IRB#818956).
3.
Results
Of 31,267 colorectal procedures included in the data set, 28,532 (91%) patients were included in the study. Patient characteristics can be viewed in Table 1. In the overall cohort, the median LOS was 6 d (range, 1e130). A total of 7% (n ¼ 2171) of patients underwent rectal resection, 52% (n ¼ 14,976) underwent an open colectomy, and 40% (n ¼ 11,385) underwent a laparoscopic colectomy. Within these three groups, the median surgical LOSs were 7 d for rectal resections and open colectomies, and 4 d for laparoscopic colectomies. Procedurespecific ED, defined as an LOS 25th percentile, corresponded to a day of discharge on or before postoperative day 5 for patients undergoing a rectal resection, day 5 for patients undergoing an open colon resection, and day 3 for patients undergoing a laparoscopic colectomy (see Fig. 2). Of all patients, 30% (n ¼ 8641) were discharged early. The overall readmission rate was 12% (n ¼ 3325) with 17% (n ¼ 346) of rectal resection patients, 15% (n ¼ 2027) of open colectomy patients, and 10% (n ¼ 1048) of patients undergoing a laparoscopic colon resection requiring a readmission. There were 8280 (29%) patients who experienced a PO. Complete information regarding the timing of the PO was available for 7008 patients, and 4755 (68%) experienced the event before discharge. Despite having a PO diagnosed before discharge, 26% of the patients were discharged early. In a multivariate analysis of the overall cohort done to identify factors associated with ED, ages 65e79 y (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.64e0.87) and >80 y (OR, 0.50; 95% CI, 0.41e0.60), chronic obstructive pulmonary disease (COPD; OR, 0.60; 95% CI, 0.49e0.75), history of cerebrovascular accident (OR, 0.63; 95% CI, 0.42e0.94), recent steroid use (OR, 0.80; 95% CI, 0.68e0.95), nonelective surgery (OR, 0.58; 95% CI, 0.50e0.68), simultaneous ostomy creation (OR, 0.65; 95% CI, 0.58e0.72), need for reoperation (OR, 0.57; 95% CI, 0.44e0.73), and a PO before discharge (OR, 0.13; 95% CI, 0.11e0.16) were significantly associated with a reduced likelihood of ED. Simultaneous ostomy creation and a PO before discharge were the only covariates that remained significantly associated with a reduced likelihood of ED in the three models developed for the subset analysis by procedure type. In the two independent models developed for open and laparoscopic colectomy, age >80 y, a history of COPD, a procedure classified as emergent, and the need for reoperation were also significantly associated with a reduced likelihood of ED. Recent steroid use was significantly associated with a reduced likelihood of ED in only the laparoscopic colectomy model (see models in Appendix A).
Table 1 e Patient characteristics for the overall cohort and by discharge status. Patient characteristics
Overall cohort, n (%)
Early discharge
N 28,532 8641 (30) Age (y, mean SD) 61.1 15.6 58.4 14.8 Sex Female 14,912 (52) 4537 (53) Male 13,557 (48) 4090 (47) Race Caucasian 22,459 (79) 7066 (82) Black 2525 (9) 633 (7) Asian 723 (3) 243 (3) Other 2825 (10) 699 (8) Ethnicity-hispanic 1396 (5) 439 (5) Comorbidities Smoke 5139 (18) 1512 (18) Diabetes 4187 (15) 1045 (12) Hypertension 13,958 (49) 3756 (43) COPD 1595 (6) 294 (3) Ascites 320 (1) 38 (0.4) BMI 30 8621 (31) 2546 (30) Heart disease 1329 (5) 274 (3) Acute renal 153 (0.5) 9 (0.1) failure Dialysis 241 (0.8) 36 (0.4) Cerebrovascular 654 (2) 126 (1) disease Steroid use 2147 (8) 508 (6) Bleeding 1357 (5) 215 (2) disorder Colorectal 10,624 (37) 3243 (38) cancer Intraoperative factors Ostomy 6983 (24) 1345 (16) Emergent 3976 (14) 625 (7) surgery Complications Return to OR 1501 (5) 195 (2) No complication 19,875 (74) 7357 (88) PO before 4755 (18) 273 (3) discharge PO after 2253 (8) 778 (9) discharge Readmission 3325 (12) 839 (10)
Not P discharged value early 19,891 (70) 62.3 15.8 10,375 (52) 9467 (48)
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Early discharge and readmission after colorectal resection Rebecca L. Hoffman, MD,a,* Edmund K. Bartlett, MD,a Clifford Ko, MD,b Najjia Mahmoud, MD,a Giorgos C. Karakousis, MD,a and Rachel R. Kelz, MD, MSCEa a b
Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, California
article info
abstract
Article history:
Background: Emphasis on the provision of high quality, cost-effective healthcare has meant
Received 4 January 2014
increasing efforts at reducing postoperative length of stay while reducing 30-d readmission
Received in revised form
rates. The aim of this study was to identify factors associated with early discharge (ED) and
31 January 2014
to evaluate the effectof ED on readmission after colorectal resection.
Accepted 11 February 2014
Materials and methods: We identified all inpatients aged 18 y who underwent a colorectal
Available online xxx
resection in the American College of Surgeons National Surgical Quality Improvement Program Participant Use File, 2011. ED was defined as a length of stay 25th percentile by
Keywords:
procedure (rectal resection, open colectomy, and laparoscopic colectomy). Multivariate
Early discharge
logistic regression was used to identify factors significantly associated with ED and read-
Readmission
mission. A subset analysis was performed by procedure type.
Colon
Results: Of 28,532 patients, 2171 (7%) underwent rectal resection, 14,976 (52%) underwent
Colorectal
open colectomy, and 11,385 (40%) underwent laparoscopic colectomy with an ED on or
Surgery
before postoperative days 5, 5, and 3, respectively. The overall cohort included patients
Laparoscopic
with a mean age of 61 y. A total of 52% were women and 37% were colorectal cancer pa-
ACS NSQIP
tients. Age >65 y, recent steroid use, simultaneous ostomy creation, nonelective surgery, need for reoperation, and a postoperative occurrence before discharge were significantly associated with a reduced likelihood of ED. The overall rate of readmission was 12%. Patients who were discharged early were significantly less likely to be readmitted (odds ratio, 0.77; 95% confidence interval, 0.70e0.84). Conclusions: In the appropriate patient population, ED after colorectal surgery may be implemented without any adverse effect on readmission rates. ª 2014 Elsevier Inc. All rights reserved.
1.
Introduction
A national emphasis on the provision of high quality, costeffective health care has meant increasing efforts at reducing postoperative length of stay (LOS) while simultaneously reducing 30-d readmission rates. Early research
suggested that early discharge (ED) was associated with increased rates of readmission. Therefore, concerns exist among surgeons that the inability to monitor patients’ clinical progress and detect complications would result in higher readmission rates and occurrences diagnosed after discharge [1e3].
* Corresponding author. Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, 4 Maloney, 3400 Spruce Street, Philadelphia, PA 19104. Tel.: þ1 267 275 3290; fax: þ1 215 662 7983. E-mail address: [email protected] (R.L. Hoffman). 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.02.006
2
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e8
Colorectal surgery provides a prime model for investigating the effects of ED on patient outcomes and readmission because of the frequency of procedures performed and the significant rates of postoperative occurrences (POs). Accordingly, recent data have been published regarding the relationship among LOS, ED, and readmissions after colorectal surgery. Single-institution experiences have demonstrated the benefits of early recovery pathways after colorectal surgery with little to no effect on readmission rates [4e7]. At the population level, however, LOS has decreased after colon surgery, whereas readmission rates have increased over the last two decades [8]. The recent addition of 30-d readmission information to the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) [9] provides a new opportunity to evaluate ED and readmission rates. In this study, we sought to identify factors associated with ED and evaluate the effect of ED on readmission after colorectal resection.
2.
Methods
We performed a retrospective study of prospectively collected data from the ACS NSQIP Participant Use File (PUF) data set from 2011. The ACS NSQIP PUF contains data on 442,149 cases collected from 315 academic and community-based hospitals located around the United States. A trained Surgical Clinical Reviewer captures data on 252 variables, including preoperative risk factors, intraoperative variables, and 30d postoperative morbidity and mortality outcomes. Patients aged 18 y undergoing major surgical procedures (both inpatient and outpatient) are included using an 8-d cycle sampling procedure. All variables collected in the ACS NSQIP are predefined in the NSQIP PUF 2011 user guide [10]. We identified all inpatients aged 18 y who underwent colorectal resection in the 2011 ACS NSQIP PUF. Colorectal resection was defined using Common Procedural Terminology codes for both open and laparoscopic procedures, including 44140e44147, 44150, 44151, 44155e44158, 44160, 44204e44208, 44210e44212, 45110e45114, 45116, 45119e45123, 45126, 45135, 45136, 45395, and 45397. Patients missing information on LOS and those with a LOS recorded as 0 d were excluded from the analysis. In addition, patients who were listed as still in the hospital and those who died during the initial inpatient hospitalization were excluded (Fig. 1). Patient demographic characteristics including age, sex, and race were abstracted from the NSQIP database, as was information regarding preoperative comorbidities and whether the procedure was performed electively or emergently. Heart disease was assigned for all patients with a recorded history of congestive heart failure, myocardial infarction, percutaneous coronary intervention or stenting, and/or angina. A history of colorectal cancer was defined using a postoperative International Classification of Diseases, Ninth Edition (ICD-9) diagnosis code of 153, 153.0, 154, 154.0, or 197.7. The simultaneous creation of an ostomy was determined using the Common Procedural Technology codes 44141, 44143, 44144, 44146, 44188, 44206, 44208, 44320, 44322, 44340, 44345, 44346, 45110, 45395, 44150, 44151, 44156, 44157, 44158, 44211, and 44187.
Fig. 1 e Selection of the study cohort.
To examine the effects of patient complications on the likelihood of ED and that of readmission, patients were classified by the presence or absence of any PO. Information regarding POs, including cardiac, respiratory, infectious, renal and neurologic events, and an unplanned return to the operating room was noted. More specifically, POs categorized as wound complication (superficial skin infection, deep surgical site infection, or fascial dehiscence), organ space infection, sepsis (sepsis or septic shock), renal (progressive renal failure or acute renal failure requiring dialysis), venous thromboembolism (deep vein thrombosis or pulmonary embolism), respiratory (pneumonia, intubation for greater than 48 h, or reintubation), bleeding (hemorrhage requiring transfusion of at least 4 U of blood), neurologic (stroke or coma), urinary tract infection, or cardiac (myocardial infarction or arrest requiring resuscitation) were abstracted directly from the ACS NSQIP PUF, and patients were classified by occurrence status: no occurrence, any occurrence before hospital discharge, and any occurrence after hospital discharge. The primary outcome variable was procedure-specific ED. The secondary outcome of interest was 30-d readmission. LOS was defined as the number of days from the index operation to hospital discharge (to home or any facility). Because it is commonly acknowledged that differences in LOS exist by procedure, procedure-specific ED was defined as an LOS 25th percentile for rectal resection, open colectomy, and laparoscopic colectomy, respectively [11,12]. ED was reported as a binary outcome. Readmission refers to an admission to any hospital within 30 d of the principal surgical procedure, as defined within the NSQIP PUF. Descriptive statistics were performed. Patient and procedure characteristics were examined by ED status using the Student t and chi-square tests, as appropriate. Multivariate logistic regression was used to identify factors significantly associated with ED. The association between ED and
3
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e8
readmission was investigated using univariate and multivariate logistic regression to adjust for potential confounders. Independent logistic regression models were developed to examine the association between ED and readmission for each of the procedure groups with adjustment for potential confounders. All statistical analyses were performed using STATA, version 12.1 (STATA Corp, College Station, TX). This study was reviewed by the Institutional Review Board of the University of Pennsylvania and deemed exempt from continuing review (IRB#818956).
3.
Results
Of 31,267 colorectal procedures included in the data set, 28,532 (91%) patients were included in the study. Patient characteristics can be viewed in Table 1. In the overall cohort, the median LOS was 6 d (range, 1e130). A total of 7% (n ¼ 2171) of patients underwent rectal resection, 52% (n ¼ 14,976) underwent an open colectomy, and 40% (n ¼ 11,385) underwent a laparoscopic colectomy. Within these three groups, the median surgical LOSs were 7 d for rectal resections and open colectomies, and 4 d for laparoscopic colectomies. Procedurespecific ED, defined as an LOS 25th percentile, corresponded to a day of discharge on or before postoperative day 5 for patients undergoing a rectal resection, day 5 for patients undergoing an open colon resection, and day 3 for patients undergoing a laparoscopic colectomy (see Fig. 2). Of all patients, 30% (n ¼ 8641) were discharged early. The overall readmission rate was 12% (n ¼ 3325) with 17% (n ¼ 346) of rectal resection patients, 15% (n ¼ 2027) of open colectomy patients, and 10% (n ¼ 1048) of patients undergoing a laparoscopic colon resection requiring a readmission. There were 8280 (29%) patients who experienced a PO. Complete information regarding the timing of the PO was available for 7008 patients, and 4755 (68%) experienced the event before discharge. Despite having a PO diagnosed before discharge, 26% of the patients were discharged early. In a multivariate analysis of the overall cohort done to identify factors associated with ED, ages 65e79 y (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.64e0.87) and >80 y (OR, 0.50; 95% CI, 0.41e0.60), chronic obstructive pulmonary disease (COPD; OR, 0.60; 95% CI, 0.49e0.75), history of cerebrovascular accident (OR, 0.63; 95% CI, 0.42e0.94), recent steroid use (OR, 0.80; 95% CI, 0.68e0.95), nonelective surgery (OR, 0.58; 95% CI, 0.50e0.68), simultaneous ostomy creation (OR, 0.65; 95% CI, 0.58e0.72), need for reoperation (OR, 0.57; 95% CI, 0.44e0.73), and a PO before discharge (OR, 0.13; 95% CI, 0.11e0.16) were significantly associated with a reduced likelihood of ED. Simultaneous ostomy creation and a PO before discharge were the only covariates that remained significantly associated with a reduced likelihood of ED in the three models developed for the subset analysis by procedure type. In the two independent models developed for open and laparoscopic colectomy, age >80 y, a history of COPD, a procedure classified as emergent, and the need for reoperation were also significantly associated with a reduced likelihood of ED. Recent steroid use was significantly associated with a reduced likelihood of ED in only the laparoscopic colectomy model (see models in Appendix A).
Table 1 e Patient characteristics for the overall cohort and by discharge status. Patient characteristics
Overall cohort, n (%)
Early discharge
N 28,532 8641 (30) Age (y, mean SD) 61.1 15.6 58.4 14.8 Sex Female 14,912 (52) 4537 (53) Male 13,557 (48) 4090 (47) Race Caucasian 22,459 (79) 7066 (82) Black 2525 (9) 633 (7) Asian 723 (3) 243 (3) Other 2825 (10) 699 (8) Ethnicity-hispanic 1396 (5) 439 (5) Comorbidities Smoke 5139 (18) 1512 (18) Diabetes 4187 (15) 1045 (12) Hypertension 13,958 (49) 3756 (43) COPD 1595 (6) 294 (3) Ascites 320 (1) 38 (0.4) BMI 30 8621 (31) 2546 (30) Heart disease 1329 (5) 274 (3) Acute renal 153 (0.5) 9 (0.1) failure Dialysis 241 (0.8) 36 (0.4) Cerebrovascular 654 (2) 126 (1) disease Steroid use 2147 (8) 508 (6) Bleeding 1357 (5) 215 (2) disorder Colorectal 10,624 (37) 3243 (38) cancer Intraoperative factors Ostomy 6983 (24) 1345 (16) Emergent 3976 (14) 625 (7) surgery Complications Return to OR 1501 (5) 195 (2) No complication 19,875 (74) 7357 (88) PO before 4755 (18) 273 (3) discharge PO after 2253 (8) 778 (9) discharge Readmission 3325 (12) 839 (10)
Not P discharged value early 19,891 (70) 62.3 15.8 10,375 (52) 9467 (48)
