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National recurrence of pancreatitis and readmissions after biliary pancreatitis
Arturo J Rios-Diaz1, Ryan Lamm2, David Metcalfe3
1Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut Street, Philadelphia, PA, 19107, USA. Arturo.RiosDiaz@jefferson.edu.
Insights
Early cholecystectomy after mild gallstone pancreatitis (GP) is recommended but underutilized. Non-operative management (NOM) leads to higher recurrence, readmissions, and costs compared to same-day surgery.
Area of Science:
- Gastroenterology
- Surgical Outcomes
- Health Economics
Background:
- National and international guidelines advocate for early cholecystectomy following mild gallstone pancreatitis (GP).
- Recent studies indicate a potential gap in adherence to these guidelines.
- This study investigates the national utilization of cholecystectomy versus non-operative management (NOM) for mild GP.
Purpose of the Study:
- To quantify the national utilization of same-hospitalization cholecystectomy versus NOM for mild GP.
- To assess the association between these management strategies and pancreatitis recurrence, readmissions, and healthcare costs.
- To evaluate mortality rates, length of stay, and total costs associated with each approach.
Main Methods:
- Analysis of adult patients admitted with mild GP from the Nationwide Readmission Database (2010-2015).
- Comparison of outcomes including same-admission cholecystectomy rates, pancreatitis recurrence, and readmissions at 30 and 180 days.
- Statistical modeling (Cox regression, generalized linear models) to control for patient and hospital confounders, analyzing mortality, length of stay, and total costs.
Main Results:
- Only 30% of 65,067 identified patients underwent cholecystectomy during their index admission.
- NOM was associated with significantly higher rates of pancreatitis recurrence and unplanned readmissions at 30 and 180 days.
- NOM also correlated with increased mortality during readmission, longer hospital stays, and higher total healthcare costs.
Conclusions:
- Most mild gallstone pancreatitis patients in the USA do not receive same-hospitalization cholecystectomy.
- Non-operative management is linked to increased recurrent pancreatitis, mortality during readmission, and substantial nationwide hospital costs.
- Same-hospitalization cholecystectomy should be considered the gold standard for managing mild gallstone pancreatitis.
Background:
National and international guidelines support early cholecystectomy after mild gallstone pancreatitis but a recent nationwide study suggested these recommendations are not universally followed. Our study sought to quantify the national utilization of same hospitalization cholecystectomy versus non-operative management (NOM) and its association with pancreatitis recurrence, readmissions, and costs after mild gallstone pancreatitis (GP).
Methods:
Adult patients admitted with mild GP were identified from the Nationwide Readmission Database 2010-2015. Primary outcomes included the rate of cholecystectomy during the index admission as well as pancreatitis recurrence and readmission at 30 and 180 days (30d, 180d) comparing NOM to same hospitalization cholecystectomy. Mortality upon readmission, total length of stay (LOS), and total costs (combined index-readmission hospital costs) were also explored. Cox proportional hazards regression and generalized linear models controlled for patient/hospital confounders.
Results:
Among the 65,067 patients identified, 30% underwent cholecystectomy. The NOM cohort was older (58 vs. 50 years), had more comorbidities (Charlson index > 2, 23.5% vs. 11.5%), fewer female patients (56.7% vs. 67%) and less discharge-to-home (84.9% vs. 94.4%) (all p < 0.001). NOM was associated with increase in recurrence and unplanned readmissions at 30d [Hazard Ratio 3.53 (95% CI 2.92-4.27), 2.41 (2.11-2.74), respectively], and 180d [4.27 (3.65-4.98), 2.78 (2.54-3.04), respectively], as well as increased mortality during 180d readmission 1.88 (1.06-3.35). This approach was also associated with significant increase in LOS [predicted mean difference 2.79 days (95% CI 2.46-3.12)] and total costs [$2507.89 ($1714.4-$3301.4)].
Conclusions:
In the USA, most patients presenting with mild GP do not undergo same hospitalization cholecystectomy. This strategy results in higher recurrent pancreatitis, mortality during readmission, and an additional $4.85 M/year in hospital costs nationwide. These data support same hospitalization cholecystectomy as the gold standard for mild GP.
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