332. Postoperative Day One Discharge Following Anatomic Lung Resection: An STS Database Analysis of Safety, Factors Predicting Readmission, and Center Variability
*Philip A. Linden1, Amelia Wallace2, Yaron Perry1, Stephanie Worrell1, Luis Argote-Greene1, Vanessa P. Ho3, Christopher W. Towe1
1University Hospitals Cleveland Medical Center, Cleveland, OH;2Duke Clinical Research Unit, Durham, NC;3Metrohealth Medical Center, Cleveland, OH
Invited Discussant: *Benjamin D. Kozower
Objective: Although median length of stay (LOS) following lobectomy is 4 days, some centers discharge patients as early as one day following surgery. While factors associated with prolonged hospitalization are known, factors associated with postoperative day 1 (POD1) discharge are unknown. We sought to examine the incidence, safety and interhospital variation in POD1 discharge, as well as factors associated with readmission.
Methods: A retrospective review of the STS General Thoracic Surgery Database from 2012-2017 was performed. Adult lung cancer patients receiving lobectomy or segmentectomy were included. Patients missing key study variables or who died during their hospitalization were excluded. The longest 10% of hospital LOS outliers were excluded. A multivariable logistic regression model incorporating preoperative and intraoperative variables was developed to assess factors associated with POD1 discharge, as well as compare postoperative complications between the POD1 and later discharge group. Factors associated with readmission among early discharge were analyzed using the Wilcoxon rank sum test and Chi-square test.
Results: Among 51,078 patients available for analysis, 1,821 (3.6%) were discharged on POD1. 46,325 (90.7%) were discharged by POD9. In multivariable analysis, factors associated with POD1 discharge included younger age, zubrod score, BMI>25, higher FEV1, middle or upper lobectomy, VATS procedure, and shorter procedure time. Vascular disease, diabetes, ASA, and race were not associated. (Table 1)
Among POD1 patients, any complication and major complications occurred less frequently (11.9% vs 32.3% p<0.001, and 1.3% vs 4.2% p<0.001 respectively). POD1 discharge patients were less likely to be readmitted (6.3% vs 7.8%, p<0.001), and there was no increase in post-discharge 30-day mortality (0.3% vs 0.4%, p=0.472). Readmission following POD1 discharge was associated with male gender (57.9% vs. 41.4%, p = 0.0006), coronary artery disease (28.1% vs. 15.1%, p = 0.0003), COPD (44.7% vs. 28.9%, p = 0.0004), and longer procedure time (median 209 vs. 192 min, p = 0.0330).
The rate of early discharge from 2012-2016 was 3.4-4.0% but increased to 5.5% in 2017. There was substantial variation in the rates of early discharge, with eleven centers (11/278 4.0%) discharging more than 20% of their patients on POD1, while 102/278 (36.7%) had no POD1 discharges.
Conclusions: In the STS database, just 3.6% of patients are discharged on POD1 following anatomic lung resection, although the rate is increasing. POD1 discharge can be done safely. These patients were less likely to be readmitted than those discharged after POD1 and the 30 day mortality rate was not increased. Significant variation in POD1 discharge patterns suggest that POD1 discharge may be underutilized.