Analysis of Rates,Causes,and Risk Factors for 90-Day Readmission After Surgery for Large Hiatal Hernia: A Two-Center Study

Abstract

Background:

Hospital readmissions have become a more examined indicator of surgical care delivery and quality. There is scarcity of data in the literature on the rate, risk factors, and most common reasons of readmission following major hiatal hernia surgery. The primary endpoint was 90-day readmission after surgery for large hiatal hernia. Secondary endpoint was to examine which characteristics related with a higher risk of readmission.

Methods:

A retrospective review of two distinct institutional databases was performed for patients who had surgery for a large hiatal hernia between January 2012 and December 2019. Demographic, perioperative, and outpatient data were collected from the medical record.

Results:

A total of 71 patients met the inclusion criteria, most of them suffering from a type III hernia (66.2%). Mean operative time was 146 (±56.5) minutes and median length of stay (LOS) was 6 days (interquartile range = 3). The overall morbidity was 21.1% and the in-hospital mortality was 1.4%. The 30- and 90-day readmission rates were 7% and 8.5%, respectively. The mean time to readmission was 14.3 (±15.6) days. The reasons for 90-day hospital readmission were dysphagia (50%), pneumonia (16.7%), congestive heart failure (16.7%), and bowel obstruction (16.7%). Grade of esophagitis ≥2, presence of Barrett's esophagus, and LOS longer than 8 days were significant risk factors for unplanned readmission within 90 days.

Conclusion:

We observed that about 6 out of 71 patients who had surgery readmitted within 90 days (8.5%). Readmissions were most often linked to esophagitis ≥2, presence of Barrett's esophagus, and LOS longer than 8 days. These findings point to the necessity for focused treatments before, during, and after hospitalization to decrease morbidity and extra costs in this high-risk population.

Introduction

Patients undergoing surgery may develop complications during the postdischarge period, with some requiring readmission to the hospital. Furthermore, hospital readmission after surgery is used as a measure of hospital performance since it necessitates further postoperative care and a higher need for health care resources.^1,2,3

Readmission is related to higher mortality and morbidity, a lower quality of life. Furthermore, cancer patients showed a reduced 5-year overall survival according to several studies.^4–6 As a result, it has been acknowledged as a clinical and health care strategy to reduce the proportion of readmissions as a parameter for surgical treatment performance.⁷ For these reasons, The Medicare Hospital Readmissions Reduction Program was established by the Affordable Care Act in the United States (HRRP).⁸ Reduced readmission rates necessitate identifying readmission potential risks in specific patient groups and developing more focused therapies.

The majority of hiatal hernia surgery research has focused on outcomes like recurrence rates, patient satisfaction, and long-term quality-of-life evaluations.^9–11 There is scarcity of studies on the rates and factors related with 90-day readmissions after elective hiatal hernia surgery.^12,13 The objective of this study was to determine the 90-day readmission rate and causes after elective surgery for large hiatal hernia in two different tertiary institutions.

Methods

This is an observational, retrospective double-center cohort study on consecutive patients with grade III or grade IV hiatal hernia undergoing surgical repair between January 2012 and December 2019. Hiatal hernias were graded according to a comprehensive classification system.¹⁴ All surgical procedures were performed at two academic centers (Department of Surgery, Section of Chirurgia 1, Sant’ Anna University Hospital, Ferrara, Italy, and Unit of General Surgery, Parma University Hospital, Parma, Italy). Eligibility criterion for this study included patients undergoing elective surgery for large hiatal hernia (grade III or IV) ≥18 years of age. Exclusion criterion was patients who required emergency surgery—surgery for hiatal hernia grade 1 and 2.

Patient data collected from the medical records included patient demographics, smoking habits, and major comorbidities classified according to Charlson Comorbidity Index.¹⁵ Perioperative clinical symptoms, upper gastrointestinal endoscopies, were also recorded when available, along with characteristics of surgical procedure. Conversion to open procedure, length of stay (LOS), postoperative complications graded according to the Clavien-Dindo score,¹⁶ readmission, and recurrence were recorded as well.

Since patients did not routinely undergo scheduled radiologic or endoscopic procedures postoperatively after discharge, follow-up information was gathered from electronic charts review.

Surgical approach

With the patient in a standard position and five trocars, the laparoscopic surgical procedure begins with reduction of the viscera contained into the hiatal hernia. The hernia sac is then fully dissected from the mediastinum, avoiding, if possible, any injury to both vagus nerves. The esophagus is then mobilized with the aim of a tension-free repositioning of the esophagogastric junction in the subphrenic position. Based upon the surgeon's subjective feeling of weak crura, the hiatal defect is then repaired either just with nonabsorbable sutures placed on the crura posterior to the esophagus or with the addition of a prosthetic mesh. Several mesh types can be used: absorbable, nonabsorbable, and biosynthetic. The procedure is usually completed by the fashioning of an antireflux procedure to reduce the risk of postoperative reflux due to alteration of antireflux barrier function.

Definition of readmission

We used a 90-day readmission value defined as patients admitted to hospital within ≤90 days from discharge after the initial hospitalization.

Statistical analysis

The Shapiro-Wilk test was performed to determine if the continuous variables' distributions were normal. The variables were represented with mean and standard deviation in the presence of symmetry in the distributions, or the median value and interquartile range (IQR) in the case of non-normal distributions. Categorical values were presented as total numbers and percentages, and statistical comparisons were assessed using Pearson's 2 test or Fisher's exact test, depending on the minimal expected count in each crosstab. For continuous covariates, the Student's t test or Welch's t test for normally distributed variables and the Mann-Whitney U test for asymmetric variables were used when appropriate. Binary logistic regression was used to estimate their corresponding odds ratio (OR) values with their 95% confidence interval (95% CI).

Differences with P values of <.05 were determined statistically significant. Jamovi was used for all the analyses (The jamovi project. 2021. Jamovi: Version 1.6).

Ethical approval

All procedures used in studies involving human subjects complied with the institutional and/or national research committee's ethical requirements, as well as the 1964 Helsinki statement and its subsequent revisions or comparable ethical standards. The study protocol for this research was approved by the institutional review boards.

Results

Between January 2012 and December 2019, a total of 71 patients underwent surgical repair of type III or type IV hiatal hernia at our institutions. Demographic characteristics and preoperative data of patients who fulfilled inclusion criteria are summarized in Table 1. Most of the patients were female (56; 78.9%), median age was 68 (IQR = 18), and most of them suffered from a type III hernia (47; 66.2%). Following preoperative workup, 12 (21.8%) out of 55 patients had at least a grade 2 esophagitis according to Savary-Miller classification and 4 patients (7.4%) out of 54 had Barrett's esophagus. Sixty-three (88.7%) patients underwent laparoscopic hiatal hernia repair, 3 of them (4.2%) were converted to an open approach and 5 (7%) were subjected straight to laparotomic surgical procedure. Mean operative time was 146 (±56.5) minutes and median LOS was 6 days (IQR = 3).

Table 1.

Demographic and Preoperative Characteristics of Patient Population

	Total (n = 71)	90-Day readmission (n = 6)	P
Sex, female, n (%)	56 (78.9)	6 (10.7)	.331
Age, years, median (IQR)	68 (18)	65 (16)	.967
BMI^a, kg/m² (mean ± SD)	28.1 ± 4.89	27.5 ± 2.49	.796
ASA classification, n (%)			.692
1–2	41 (57.7)	3 (7.3)
3	30 (42.3)	3 (10.0)
4	0	0 (0.0)
Diabetes, n (%)	10 (14.1)	0 (0.0)	.585
Hypertension, n (%)	43 (60.6)	3 (7.0)	.674
COPD, n (%)	10 (14.1)	2 (20.0)	.197
Chronic renal failure, n (%)	7 (9.9)	0 (0.0)	1.000
Chronic steroid use, n (%)	5 (7.0)	2 (40.0)	.054
Smokers, n (%)	11 (15.5)	0 (0.0)	.581
Charlson comorbidity index, n (%)			.790
0	24 (33.8)	2 (8.3)
1–2	15 (21.1)	1 (6.7)
3–4	26 (36.6)	2 (7.7)
≥ 4	6 (8.5)	1 (16.7)
History of abdominal surgery, n (%)	47 (66.2)	4 (8.5)	1.000
History of cancer, n (%)	11 (15.5)	1 (9.1)	1.000
Symptoms, n (%)
Heartburn	35 (49.3)	2 (5.7)	.674
Dysphagia	22 (31)	2 (9.1)	1.000
Abdominal pain	33 (46.5)	4 (12.1)	.406
Chronic bleeding	17 (23.9)	1 (5.9)	1.000
Respiratory symptoms	25 (35.2)	2 (8.0)	1.000
Hearth symptoms	11 (15.5)	1 (9.1)	1.000
None	4 (5.6)	0 (0.0)	1.000
Hernia classification, n (%)			.399
Type III	47 (66.2)	3 (6.4)
Type IV	24 (33.8)	3 (12.5)
Grade of esophagitis^b,c, n (%)			.029^*
Grade 0–1	43 (78.2)	1 (2.3)
Grade ≥2	12 (21.8)	3 (25.0)
Barrett's esophagus^d, n (%)	4 (7.4)	2 (50.0)	.024^*
Gastric volvulus, n (%)	16 (22.5)	1 (6.3)	1.000

p < 0.05.

Data were missing for 10 patients

Data were missing for 16 patients

According to Savary-Miller Endoscopic Classification

Data were missing for 17 patients.

ASA, American Society of Anesthesiologists; BMI, body mass index; IQR, interquartile range; SD, standard deviation.

The overall morbidity was 21.1% (15 cases), the in-hospital mortality was 1.4% (1 case), and the 30- and 90-day readmission rates were 7% and 8.5%, respectively (5 and 6 cases). The mean time to readmission was 14.3 (±15.6) days. With a median postoperative follow-up of 27 months (IQR = 54.5) hiatal stenosis was observed in 5 (7%) patients and recurrence occurred in 13 (18.3%) patients. For less than 24% of patients, body mass index, Savary-Miller classification of esophagitis, and presence of Barrett's esophagus data were missing. Surgical and postoperative characteristics are reported in Table 2.

Table 2.

Surgical and Postoperative Characteristics

	Total (n = 71)	90-Day readmission (n = 6)	P
Surgical approach, n (%)
Laparoscopy	63 (88.7)	5 (7.9)	.526
Conversion to open	3 (4.2)	0 (0.0)
Open	5 (7.0)	1 (20.0)
Operative time, minutes (mean ± SD)	146 ± 56.5	170 ± 90.1	.274
Postoperative ICU admission, n (%)	9 (12.7)	2 (22.2)	.164
Mesh reinforcement, n (%)	27 (38)	3 (11.1)	.667
Synthetic	4 (14.8)	0 (0.0)	1.000
Biosynthetic	23 (85.2)	3 (13.0)	1.000
Technique of fundoplication, n (%)			.365
Gastropexy	5 (7)	1 (20.0)
Nissen	54 (76.1)	4 (7.4)
Toupet	6 (8.5)	1 (16.7)
Dor	6 (8.5)	0 (0.0)
Blood transfusions, n (%)	4 (5.6)	0 (0.0)	1.000
LOS, days, median (IQR)	6 (3)	8 (10.3)	.039^*
Overall morbidity, n (%)	15 (21.1)	3 (20.0)	.104
Clavien-Dindo classification, n (%)			.040^*
0	56 (78.9)	3 (5.4)
I	2 (2.8)	1 (50.0)
II	7 (9.9)	1 (14.3)
III	4 (5.6)	0 (0.0)
IV	2 (2.8)	1 (50.0)
In-hospital mortality, n (%)	1 (1.4)	1 (100)	.085
Postoperative hiatal stenosis, n (%)	5 (7)	2 (40.0)	.054
Recurrence, n (%)	13 (18.3)	0 (0.0)	.584
Follow-up, months, median (IQR)	27 (54.5)	23.5 (71.3)	.728

p < 0.05.

ICU, intensive care unit; IQR, interquartile range; LOS, length of stay; SD, standard deviation.

Incidence of 90-day readmission

Six patients (8.5%) were readmitted within 90 days from hospital discharge. Three patients were readmitted for dysphagia (50%), of which 1 (16.7%) for abdominal pain with symptomatic reflux disease and 2 (33.2%) for early LES stenosis. Another patient (16.7%) was readmitted for pneumonia, 1 (16.7%) for congestive heart failure, and 1 (16.7%) for bowel obstruction. The two cases with LES stenosis were successfully treated with pneumatic dilation. All the other causes of readmission were treated with medical therapy. Twenty-five percent of them had a grade of esophagitis greater than 1 and only 2.3% had grade 1 or less (P = .029).

Fifty percent of patients having a preoperative diagnosis of Barrett's esophagus were also readmitted (P = .024). LOS was longer in 90-day readmitted patients (8 days, IQR = 10.3 versus 5 days, IQR = 3, P = .039). Taking into consideration Clavien-Dindo classification, the lowest incidence of 90-day readmission was found for CD class III (0%), the readmission rate was 5.3% (3 patients) for CD 0, 50% (1 patients) for CD I, 14.3% (1 patient) for CD II, and 50% (1 patients) for CD IV (P = .04).

Predictive factors for 90-day readmission

Variables tested in univariate analysis for potential effect on 90-day readmission are summarized in Table 3. Among the factors tested, only grade of esophagitis ≥2, presence of Barrett's esophagus, and LOS showed a significant influence with OR of 14.0 (95% CI: 1.300–151.000, P = .029), 24.0 (95% CI: 2.140–269.000, P = .024), 1.148 (95% CI: 1.022–1.290, P = .020), and 1.789 (95% CI: 1.053–3.038, P = .031), respectively. The influence of mesh reinforcement on the incidence of 90-day readmission could not be assessed in this study. There were 3 readmitted patients after mesh reinforcement versus 3 with cruroplasty only (11.1% versus 6.8%, respectively; P = .667). Also, the difference in incidence of 90-day readmission after fundoplication (n = 5) compared with no fundoplication (n = 1) showed no significance (7.6% versus 20%, respectively; P = .366).

Table 3.

Possible Predictive Factors Entered in the Univariate Analysis

Variables	OR	95% CI	P
Age	1.004	0.943–1.070	.881
Sex (female)	3.99	0.213–74.900	.331
BMI	0.971	0.782–1.210	.792
ASA classification ≥3	1.41	0.264–7.510	.692
Chronic steroid use	10.3	1.320–80.700	.054
Charlson comorbidity index ≥3	1.24	0.233–6.620	1.000
Type IV hernia	2.10	0.389–11.300	.399
Grade of esophagitis^a ≥2	14.0	1.300–151.000	.029^*
Barrett's esophagus	24.0	2.14–269.000	.024^*
Laparoscopic approach	0.328	0.030–3.520	.366
Operative time	1.008	0.993–1.023	.275
Postoperative ICU admission	4.14	0.639–26.900	.164
LOS	1.148	1.022–1.290	.020^*
Mesh reinforcement	1.710	0.319–9.150	.667
Fundoplication	0.328	0.030–3.520	.366
Overall morbidity	4.420	0.792–24.600	.104
Clavien Dindo classification	1.591	0.867–2.923	.134
Postoperative hiatal stenosis	10.300	1.320–80.700	.054
Recurrence	0.299	0.015–5.650	.584

p < 0.05.

according su Salivary-Miller Endoscopic Classification.

ASA, American Society of Anesthesiologists; BMI, body mass index; CI, confidence interval; ICU, intensive care unit; OR, odds ratio.

Discussion

The main objective of health care workers is clearly to offer the best possible treatment to each patient. Many payers are increasingly offering financial incentives to organizations that excel. However, there is no straightforward definition of “excellent quality” treatment. Readmission is becoming a serious concern for hospitals, doctors, and policy makers as a quality and cost-containment indicator. Because readmissions are typically an unfavorable event for the patient, they have evolved into a key indicator for evaluating hospital performance. Therefore, options and solutions to minimize readmission rates, and a procedure-specific examination of the incidence of, reasons for, and risk factors for readmission are necessary.^7,17

Several studies have underlined the impact of readmissions terms of treatment quality and related costs. Han et al. investigated variations in postoperative 30-day readmissions in the Veterans Health Administration (VA) population during a 10-year period.¹⁸ General surgery, urology, neurology, orthopedics, otolaryngology, plastic surgery, thoracic surgery, peripheral vascular surgery, and cardiac surgery were all included. Over a 10-year period, readmission rates ranged from 9% (urology) to 16.6% (cardiac), with the overall 30-day readmission rate decreasing from 12.9% to 12.2%. Postoperative infection, urinary tract infection, and digestive system issues were the most prevalent indications for readmission.

Furthermore, in 2009, the 30-day readmission rate among Medicare users was reported to be 21% following discharge for a medical condition and 15.6% after surgical operations.¹⁹ Another study used data from the National Surgical Quality Improvement Program to look at 30-day readmissions by surgical specialization to develop a readmission prediction system.²⁰ Overall, 7.8% of patients were readmitted, ranging from 5% (general surgery) to 15.8% (cardiac surgery). The authors indicate that risk classification and early patient intervention could be aided by scoring based on American Society of Anesthesiologists class and LOS. The goal of this study was to measure the incidence of readmission, the risk factors associated with it, and the causes for it in patients who had surgery for large hiatal hernia. Few studies in Literature evaluated readmission after surgery for hiatal hernia.

Poupore et al.¹² evaluated the incidence and risk factors for 30-day readmission following surgery for benign distal esophageal diseases. They observed a 5.5% readmission rate. Hospital readmission was most significantly related to an open surgical approach, prolonged steroid use, emergency admission, and a predischarge complication. In another study, Skancke et al.¹³ analyzed the effect of mesh and time of surgery on postoperative morbidity. They found an incidence of 30-day readmission of 5.45% in the no mesh group and 6.19% of cases with mesh utilization. Another research examined 128 people who had surgery for all types of hiatal hernias (I–IV), and found that the laparoscopic group had a 30-day readmission rate of 8.3%, while the robotic group had a rate of 4.6%.²¹

However, as value-based compensation concepts have expanded, the focus has shifted to 90 days after hospital discharge. For this reason, this study focused on 90-day readmissions and the results showed an overall readmission rate of 8.5%. Therefore, to reduce readmissions after large hiatal hernia procedures and hence enhance patient care, it is important to analyze why patients return to the hospital. The following are the reasons for readmission, according to our research: dysphagia (50%) caused either by early LES stenosis (33.2%) or symptomatic reflux disease (16.7%), respiratory complications (16.7%), cardiovascular complications (16.7%), and bowel obstruction (16.7%). Dysphagia is one of the most troublesome complication after antireflux surgery affecting 5%–10% of patients.²²

There is limited evidence that alternative therapies, apart from a loose wrap and a nonobstructing hiatal closure, can minimize the prevalence of transient dysphagia. Randomized studies comparing total and partial fundoplication show that a posterior wrap reduces early dysphagia without affecting late dysphagia.²³

In our series, the readmissions for early dysphagia were mainly related to surgical aspects: in fact, the majority of these issues are anatomical, such as a too tight fundoplication, paraesophageal herniation, or hiatal stenosis.^24,25 Since most episodes of postfundoplication dysphagia are unpreventable, despite cautious patient selection and adequate surgical techniques, it is critical that a safe and effective therapy for this disease be provided. In fact, GERD or a functional blockage of the wrap might create peristaltic issues after surgery. In the instance of postfundoplication dysphagia, pneumatic dilation appears to be a rather safe and successful treatment modality.²⁶

In this retrospective study of patients from two centers specialized for hiatal hernia treatment in Italy, we showed that the need for readmission was mainly related to grade of esophagitis ≥2, presence of Barrett's esophagus, and LOS. Previous research has shown that the duration of hospital stay is an important factor in determining the total cost and quality of elective surgical treatments.²⁷ Furthermore, increased LOS is also associated with increased unfavorable outcomes such as hospital-acquired infection and venous thromboembolic events.^28,29 Our study found an elevated risk of readmission in patients with prolonged hospital stay: in fact, patients requiring readmission had a median hospital stay of 8 (IQR: 10.3) days compared to no-readmitted patients showing a median hospital stay of 5 (IQR: 3) days.

Previous studies have shown that increased hospital stay is a risk factor for both 30- and 90-day readmissions.^30,31 Therefore, our findings should drive clinicians to improve follow-up care visits with patients who have an elevated LOS because these patients also have higher readmission rates. Another strategy is to implement standardized perioperative interventions comparable to Enhanced Recovery programs. After Enhanced Recovery after Surgery (ERAS), which has been demonstrated to reduce LOS and postoperative complications in colorectal operations,³² and, more recently, esophageal and bariatric operations, many avoidable readmissions would likely be avoided.^33,34 However, only few studies have shown that high ERAS adherence leads to lower readmission rates., and further randomized control trials are required.³⁵

Furthermore, relatively closer follow-ups should be carried out for these inpatients with a postoperative course characterized by longer LOS than the usual schedule. Some readmissions may have been avoided if postoperative problems were identified early and treated in the postoperative or outpatient setting, as proven by Antonoff et al. after lung resections and Hornick et al. following vascular surgery.^36,37

This study has several limitations, one of which was that it was a two-center retrospective analysis, which means that the findings cannot be easily applied to other institutions.

Our institutions' use for a readmission study, on the other hand, is a strength: in fact, the majority of patients undergoing surgery is readmitted to our centers or followed up at the institution's outpatient clinic in the first 90 days. This enables for reliable reporting of readmission rates after 90 days. The low volume of surgeries in this study compared to other studies investigating readmission is the study's second limitation. Another limitation is the lack of analysis of socioeconomic factors that could affect surgical outcomes. Finally, during the study period, there was no standardization in patient treatment since individual surgeons were in charge of perioperative treatment, which could have resulted in different outcomes for different patients.

Conclusions

In summary, this retrospective study from two centers has shown that the 90-day readmission rate following surgery for large hiatal hernia is 8.5%. There are a variety of reasons for readmission following surgery. Prolonged LOS seems to be the most significant risk factor for readmission. As a result, effective discharge plans and close follow-ups for these high-risk patients should be developed to significantly improve their treatment quality. Our results highlight the need for future studies to continue to enhance surgical quality.

Footnotes

Authors' Contributions

Design of the work: N.T., G.D., F.M., and G.A. Drafting the work and revising it critically: F.P., M.V., and M.F. Final approval: G.V., G.R., and G.C. All authors agree on all aspects of the work.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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