title: Causes, Timing, Hospital Costs and Perioperative Outcomes of Index vs Nonindex Hospital Readmissions after Radical Cystectomy: Implications for Regionalization of Care.
abstract: We compared the timing, causes, hospital costs and perioperative outcomes of index vs nonindex hospital readmissions after radical cystectomy.
  
  
  
  The 2013 Nationwide Readmissions Database was queried for patients with bladder cancer undergoing cystectomy. Sociodemographic characteristics, hospital costs and causes of readmission were compared among index and nonindex readmitted patients. Univariable and multivariable logistic regression models were used to identify predictors of nonindex readmissions, mortality during the first readmission and subsequent readmission.
  
  
  
  Among 4,991 patients identified 29% (1,447) and 11% (571) experienced an index and nonindex readmission, respectively. Compared to index readmissions, nonindex readmissions were more likely late readmissions (p <0.001) of older patients (p=0.047) who underwent cystectomy at higher volume hospitals (p=0.02) and were readmitted to hospitals located in less populated areas (p <0.001). Compared to index readmissions the percentage of nonindex readmissions for cardiovascular complications was higher (7.6% vs 2.9%, p=0.003), while the percentage of nonindex readmissions for gastrointestinal (6.0% vs 11.0%, p=0.04) and wound (5.3% vs 16.7%, p=0.0001) complications was lower. Predictors of nonindex readmission included longer length of stay (OR 1.02; 95% CI 1.001, 1.04), patient location in less populated areas, nonteaching hospital (OR 0.52; 95% CI 0.31, 0.86) and discharge to facility (OR 2.82; 95% CI 1.75, 4.55) or with home health (OR 1.49; 95% CI 1.05, 2.10). Nonindex readmissions had comparable mean readmission hospital costs ($14,147 vs $15,102, p=0.7), in-hospital mortality (OR 1.11; 95% CI 0.42, 2.87) and subsequent readmission (OR 1.32; 95% CI 0.87, 2.00) to index readmissions.
  
  
  
  This nationally representative study of patients undergoing radical cystectomy demonstrated comparable perioperative outcomes and hospital costs between index and nonindex readmitted patients, which supports the continued regionalization of cystectomy care.
authors.affiliation: James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address: mchappi1@jhmi.edu.
authors.forename: Meera R
authors.initials: MR
authors.lastname: Chappidi
authors.affiliation: James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Max
authors.initials: M
authors.lastname: Kates
authors.affiliation: James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: C J
authors.initials: CJ
authors.lastname: Stimson
authors.affiliation: James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Michael H
authors.initials: MH
authors.lastname: Johnson
authors.affiliation: James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Phillip M
authors.initials: PM
authors.lastname: Pierorazio
authors.affiliation: James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Trinity J
authors.initials: TJ
authors.lastname: Bivalacqua
mesh_terms: D000368:Aged; D015653:Cystectomy / Q000009:adverse effects / Q000191:economics / Q000706:statistics & numerical data*; D016208:Databases, Factual; D005260:Female; D017721:Hospital Costs / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission / Q000191:economics / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000453:epidemiology; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D001743:Urinary Bladder / Q000473:pathology / Q000528:radiation effects; D001749:Urinary Bladder Neoplasms / Q000601:surgery
keywords: continuity of patient care; cystectomy; patient readmission; postoperative care; urinary bladder neoplasms