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Readmission Following Radical Cystectomy: A Ray of Light in the “Black Box”?
EUF-285; No. of Pages 2 E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 17 ) X X X – X X X
available at www.sciencedirect.com journal homepage: www.europeanurology.com/eufocus
Editorial
Readmission Following Radical Cystectomy: A Ray of Light in the “Black Box”? John S. McGrath a,*, Siamak Daneshmand b a
Exeter Surgical Health Services Research Unit, Royal Devon and Exeter Hospital, Exeter, UK; b Keck School of Medicine, University of Southern California,
Los Angeles, CA, USA
In this issue of European Urology Focus, Krishnan and colleagues [1] from the University of Michigan present a novel insight into the “black box” of the readmission interval among patients undergoing radical cystectomy (RC). RC continues to be one of the most morbid operations performed in the modern era of cancer surgery. Despite improvements in perioperative care and an overall trend towards lower mortality [2], the 30-d complication rates reported are alarmingly high and readmission rates remain stubbornly in the region of 25–30%, even in high-volume centres of expertise [3]. The focus of existing research has often been on the surgical episode itself, with a relative paucity of published studies regarding the risk factors or patient-level characteristics that are associated with readmission. From a patient’s perspective, the ramifications of a readmission episode often extend well beyond the precipitating event itself. The vast majority of readmissions are unplanned, with complex and prolonged pathways for reentry into the health care system. Typically there are communication problems, which in themselves can result in loss of confidence in the patient’s care and further delay their recovery. They are also costly for health care providers and associated with higher overall mortality. Recent studies have demonstrated that the institution to which the patient is readmitted can affect overall survival and clinical outcomes, with a significant increase in mortality among patients admitted to centres other than the treating institution. Of course, not all complications are avoidable, but in certain instances readmission rates could be reduced,
particularly if a specialist at an earlier time point had offered the patient a senior review. So why do the authors refer to the problem as a “black box”? Black box theory is based on the explanatory principle that there may a causal link between an input (in this case, RC) and an output (readmission). The content of the box is by definition unknown or, perhaps more accurately in the setting of RC, not yet fully known. A commonly applied analogy is considering how a child understands that turning a door handle (input) will lead to the door opening (output) although they lack total understanding of what takes place within the handle mechanism. In performing RC (input), we find ourselves in a similar position to the child: we can be certain that at least one in four of our patients will be readmitted to hospital (output), but our understanding of why and in whom this occurs is an area has been poorly researched and hence poorly described. That said, experienced pelvic surgeons have alluded to the likely culprits for some time, borne out of the battle-hardened arena of managing complications in readmitted patients. The current paper begins to shed light on this black box and unravel some of these key aspects; it can perhaps provide preliminary guidance on how we predict and tackle this important clinical issue. The first interesting observation is that readmission following RC appears to be no respecter of patient demographics such as age, body mass index, American Society of Anesthesiologists classification, race, or gender. In other words, trying to preoperatively identify patients at “high risk” of readmission using conventional metrics may be unproductive. However, the authors have identified aspects
DOI of original article: http://dx.doi.org/10.1016/j.euf.2016.07.004. * Corresponding author. Exeter Surgical Health Services Research Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX8 5AB, UK. Tel.: +44 779 9628439. E-mail address: [email protected] (J.S. McGrath). http://dx.doi.org/10.1016/j.euf.2017.02.006 2405-4569/© 2017 Published by Elsevier B.V. on behalf of European Association of Urology.
Please cite this article in press as: McGrath JS, Daneshmand S. Readmission Following Radical Cystectomy: A Ray of Light in the “Black Box”? Eur Urol Focus (2017), http://dx.doi.org/10.1016/j.euf.2017.02.006
EUF-285; No. of Pages 2 2
E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 17 ) X X X – X X X
of patients’ postoperative recovery that are potential red flags and in some cases may prove indicative of subsequent readmission to hospital. Typical “at-risk” behaviour among readmitted patients is characterised by an individual who has struggled to maintain oral intake over a period of 2–3 d and made direct contact with the emergency department rather than seeking telephone- or clinic-based advice. This is perhaps unsurprising given that the majority of morbidity following RC is related to the return of normal gut function and resumption of oral intake. Greater precision in identifying patients at risk of readmission would allow improved counselling, focused patient information, and targeted interventions. For example, a simple composite daily score of the patient’s ability to eat, drink, and maintain bowel function may provide an early warning system that could trigger pre-emptive clinical review or a home-based intervention. In the future, we may see remote home monitoring systems performing this “early alert” function. Contemporary initiatives are emerging, such as home-based administration of enteral fluids, to pre-empt readmission to hospital (personal correspondence, S. Daneshmand). More diligent attention to the treatment of metabolic acidosis with sodium bicarbonate could potentially help to break the cycle of reduced appetite and dehydration. Likewise, a more personalised approach to antibiotic prophylaxis is needed, as unselected regimens will prove increasingly ineffective in the changing landscape of pathogen resistance.
If unplanned readmissions could be reduced, there would be benefits for both the patient and health care provider. A designated readmission pathway direct to the treating surgical team could reduce unnecessary delays and allow earlier intervention by those experienced in managing problems following major pelvic surgery. It seems logical to presume that a more targeted approach and more timely intervention would ultimately result in improved quality of care and overall clinical outcome following RC. Furthermore, a more planned approach to the management of surgical readmissions is highly likely to be associated with an overall reduction in health care costs and a concomitant improvement in patient-reported experience. Conflicts of interest: The authors have nothing to disclose.
References [1] Krishnan N, Li B, Jacobs BL, et al. The fate of radical cystectomy patients after hospital discharge: understanding the black box of the pre-readmission interval. Eur Urol Focus. In press. doi:10.1016/j. euf.2016.07.004. [2] Hounsome LS, Verne J, McGrath JS, Gillatt DA. Trends in operative caseload and mortality rates after radical cystectomy for bladder cancer in England for 1998–2010. Eur Urol 2015;67:1056–62. [3] Novara G, Catto JW, Wilson T, et al. Systematic review and cumulative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy. Eur Urol 2015;67:376–401.
Please cite this article in press as: McGrath JS, Daneshmand S. Readmission Following Radical Cystectomy: A Ray of Light in the “Black Box”? Eur Urol Focus (2017), http://dx.doi.org/10.1016/j.euf.2017.02.006
available at www.sciencedirect.com journal homepage: www.europeanurology.com/eufocus
Editorial
Readmission Following Radical Cystectomy: A Ray of Light in the “Black Box”? John S. McGrath a,*, Siamak Daneshmand b a
Exeter Surgical Health Services Research Unit, Royal Devon and Exeter Hospital, Exeter, UK; b Keck School of Medicine, University of Southern California,
Los Angeles, CA, USA
In this issue of European Urology Focus, Krishnan and colleagues [1] from the University of Michigan present a novel insight into the “black box” of the readmission interval among patients undergoing radical cystectomy (RC). RC continues to be one of the most morbid operations performed in the modern era of cancer surgery. Despite improvements in perioperative care and an overall trend towards lower mortality [2], the 30-d complication rates reported are alarmingly high and readmission rates remain stubbornly in the region of 25–30%, even in high-volume centres of expertise [3]. The focus of existing research has often been on the surgical episode itself, with a relative paucity of published studies regarding the risk factors or patient-level characteristics that are associated with readmission. From a patient’s perspective, the ramifications of a readmission episode often extend well beyond the precipitating event itself. The vast majority of readmissions are unplanned, with complex and prolonged pathways for reentry into the health care system. Typically there are communication problems, which in themselves can result in loss of confidence in the patient’s care and further delay their recovery. They are also costly for health care providers and associated with higher overall mortality. Recent studies have demonstrated that the institution to which the patient is readmitted can affect overall survival and clinical outcomes, with a significant increase in mortality among patients admitted to centres other than the treating institution. Of course, not all complications are avoidable, but in certain instances readmission rates could be reduced,
particularly if a specialist at an earlier time point had offered the patient a senior review. So why do the authors refer to the problem as a “black box”? Black box theory is based on the explanatory principle that there may a causal link between an input (in this case, RC) and an output (readmission). The content of the box is by definition unknown or, perhaps more accurately in the setting of RC, not yet fully known. A commonly applied analogy is considering how a child understands that turning a door handle (input) will lead to the door opening (output) although they lack total understanding of what takes place within the handle mechanism. In performing RC (input), we find ourselves in a similar position to the child: we can be certain that at least one in four of our patients will be readmitted to hospital (output), but our understanding of why and in whom this occurs is an area has been poorly researched and hence poorly described. That said, experienced pelvic surgeons have alluded to the likely culprits for some time, borne out of the battle-hardened arena of managing complications in readmitted patients. The current paper begins to shed light on this black box and unravel some of these key aspects; it can perhaps provide preliminary guidance on how we predict and tackle this important clinical issue. The first interesting observation is that readmission following RC appears to be no respecter of patient demographics such as age, body mass index, American Society of Anesthesiologists classification, race, or gender. In other words, trying to preoperatively identify patients at “high risk” of readmission using conventional metrics may be unproductive. However, the authors have identified aspects
DOI of original article: http://dx.doi.org/10.1016/j.euf.2016.07.004. * Corresponding author. Exeter Surgical Health Services Research Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX8 5AB, UK. Tel.: +44 779 9628439. E-mail address: [email protected] (J.S. McGrath). http://dx.doi.org/10.1016/j.euf.2017.02.006 2405-4569/© 2017 Published by Elsevier B.V. on behalf of European Association of Urology.
Please cite this article in press as: McGrath JS, Daneshmand S. Readmission Following Radical Cystectomy: A Ray of Light in the “Black Box”? Eur Urol Focus (2017), http://dx.doi.org/10.1016/j.euf.2017.02.006
EUF-285; No. of Pages 2 2
E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 17 ) X X X – X X X
of patients’ postoperative recovery that are potential red flags and in some cases may prove indicative of subsequent readmission to hospital. Typical “at-risk” behaviour among readmitted patients is characterised by an individual who has struggled to maintain oral intake over a period of 2–3 d and made direct contact with the emergency department rather than seeking telephone- or clinic-based advice. This is perhaps unsurprising given that the majority of morbidity following RC is related to the return of normal gut function and resumption of oral intake. Greater precision in identifying patients at risk of readmission would allow improved counselling, focused patient information, and targeted interventions. For example, a simple composite daily score of the patient’s ability to eat, drink, and maintain bowel function may provide an early warning system that could trigger pre-emptive clinical review or a home-based intervention. In the future, we may see remote home monitoring systems performing this “early alert” function. Contemporary initiatives are emerging, such as home-based administration of enteral fluids, to pre-empt readmission to hospital (personal correspondence, S. Daneshmand). More diligent attention to the treatment of metabolic acidosis with sodium bicarbonate could potentially help to break the cycle of reduced appetite and dehydration. Likewise, a more personalised approach to antibiotic prophylaxis is needed, as unselected regimens will prove increasingly ineffective in the changing landscape of pathogen resistance.
If unplanned readmissions could be reduced, there would be benefits for both the patient and health care provider. A designated readmission pathway direct to the treating surgical team could reduce unnecessary delays and allow earlier intervention by those experienced in managing problems following major pelvic surgery. It seems logical to presume that a more targeted approach and more timely intervention would ultimately result in improved quality of care and overall clinical outcome following RC. Furthermore, a more planned approach to the management of surgical readmissions is highly likely to be associated with an overall reduction in health care costs and a concomitant improvement in patient-reported experience. Conflicts of interest: The authors have nothing to disclose.
References [1] Krishnan N, Li B, Jacobs BL, et al. The fate of radical cystectomy patients after hospital discharge: understanding the black box of the pre-readmission interval. Eur Urol Focus. In press. doi:10.1016/j. euf.2016.07.004. [2] Hounsome LS, Verne J, McGrath JS, Gillatt DA. Trends in operative caseload and mortality rates after radical cystectomy for bladder cancer in England for 1998–2010. Eur Urol 2015;67:1056–62. [3] Novara G, Catto JW, Wilson T, et al. Systematic review and cumulative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy. Eur Urol 2015;67:376–401.
Please cite this article in press as: McGrath JS, Daneshmand S. Readmission Following Radical Cystectomy: A Ray of Light in the “Black Box”? Eur Urol Focus (2017), http://dx.doi.org/10.1016/j.euf.2017.02.006