The primary months of the COVID pandemic had a profound effect on hospital discharge practices and use patterns for patients with colorectal disease, in line with findings presented on the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022. A study of greater than 100,000 surgical patients who underwent procedures for colorectal cancer found that they’d 40% lower odds of being discharged to post-hospital rehabilitation throughout the pandemic than before.

Despite this significantly lower rate, the hospital readmission rate didn’t change from pre-pandemic levels, said Marc Mankarious, MD, a surgical resident at Penn State Hershey Medical Center, Hershey, Pennsylvania.

We found that discharge to a rehabilitation facility pre-pandemic was 10%, which agreed with previous literature, but once the pandemic hit, the discharge-to-rehabilitation rate dropped to about 7%. We saw a drop of three percentage points, although we were doing more emergent operations and more open operations, that are typical risk aspects for requiring rehabilitation after surgery.”

Dr. Marc Mankarious, MD, Surgical Resident, Penn State Hershey Medical Center, Hershey, Pennsylvania

The authors hypothesized that anecdotally, fear of going into confined spaces, staff and provide shortages, and disease outbreaks contributed to changes in discharge practices.

Concerning the study

The retrospective cohort study used two databases from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®): the Participant Use File and Goal Colectomy databases. Researchers analyzed data on 116,677 patients: 90,250 from 2017 through 2019, and 26,427 from 2020. For comparison, the primary quarter was excluded from all years since the first COVID restrictions didn’t go into effect until March 2020. ACS NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the standard of surgical care in hospitals. It was created by surgeons to assist hospitals gauge the standard of their surgical programs and improve surgical outcomes by collecting robust, accurate, and precise clinical patient information.

Key findings

• In comparing the pre- and post-COVID-19 periods, the proportion of emergent cases and open operations-;versus minimally invasive procedures-;increased in 2020, from 13 to fifteen% (p<0.001) and 31 to 32% (p<0.001), respectively.

• A multivariable evaluation found that patients in 2020 had 40% lower odds of going to a post-discharge facility (odds ratio 0.62, p<0.001), even after the evaluation adjusted for reasons for having the operations and other medical conditions the patients had.

• The rates of patients going back to the hospital inside 30 days of discharge was 10% in each periods (p=0.4).

Surgeons’ observations

The soundness in hospital readmission rates was telling because that could be “one in every of the aspects that goes into deciding whether to supply a rehabilitation stay to a patient,” Dr. Mankarious said.

The study data didn’t include the reason why patients did or didn’t decide to go to post-discharge rehabilitation to get well; the authors hypothesized that aspects included limited availability of beds and patient concerns about visitor restrictions and contracting COVID-19 Dr. Mankarious said. However the pandemic saw a 63-fold increase in telehealth use in 2020 over 2019. “This case can have made patients and physicians more comfortable with the patient going home and following up with one another electronically,” he said.

The information included some information on medical reasons for going to rehabilitation. “We did find that patients that went to rehabilitation in 2020 were more functionally dependent or functionally impaired than patients that went to rehabilitation in previous years, so those aspects may additionally play an element in it.” Dr. Mankarious said.

The study grew out of what surgeons at Penn State Hershey were observing within the early days of the pandemic, said senior creator Audrey Kulayat, MD, assistant professor of colorectal surgery. “We wondered if those observations had an impact on a much bigger scale aside from just at our institution,” she said. “But then we desired to know, what is the downside? Was there a downside? Are patients getting readmitted more continuously consequently of going back to their home or whatever institution versus going to a spot with a better level of nursing care? We didn’t find that they were readmitted more often.”

Potential change in discharge practice

The study findings raise questions on the potential overuse of posthospital rehabilitation for colorectal patients, Dr. Mankarious said. “Medicare spends about $60 billion per yr on patients going to post-acute care facilities or rehab normally and any small reductions, even our 3% reduction, which was significant, could lead to considerable cost savings for the healthcare system.

“And it really helps us rethink who should go to post-surgery rehab, possibly raise our thresholds as we change into more comfortable sending patients home and have higher utilization of the brand new available modalities to assist us follow up with them without having to send them to rehab,” Dr. Mankarious added.

Source:

American College of Surgeons