Characteristics, Hospital Length of Stay, and Readmissions Among Individuals Undergoing Abdominal Ostomy Surgery: Review of a Large US Healthcare Database : Journal of Wound Ostomy & Continence Nursing

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Ostomy Care

Characteristics, Hospital Length of Stay, and Readmissions Among Individuals Undergoing Abdominal Ostomy Surgery

Review of a Large US Healthcare Database

Schott, Laura L.; Eaves, Deanna; Inglese, Gary; Sinha, Meenal

Author Information
Journal of Wound, Ostomy and Continence Nursing: November/December 2022 - Volume 49 - Issue 6 - p 529-539
doi: 10.1097/WON.0000000000000922
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Abstract

INTRODUCTION

Abdominal stoma surgeries are frequently performed for the management of various medical conditions.1,2 Clinical guidelines and recommendations for best practice, technical aspects, and patient assessment and education have been published.1,3–5 However, large-scale research summaries of patients undergoing ostomy surgery are lacking or limited in scope or generalizability.6–12

Complications following ostomy surgery are prevalent and negatively influence physical health and health-related quality of life.8,10,13–18 Factors that may contribute to complications include short length of stay (LOS), type of surgery, inadequate patient education, and lack of preoperative stoma site marking.3,13,14,18–21 Stoma and peristomal complications are also associated with increased morbidity, likelihood of hospital readmission, and health care utilization.10–13,22

Multiple factors, including hospital LOS, postsurgery LOS, and elective versus emergent procedure, influence patient education options. Recent research evaluating LOS and postsurgery LOS is limited.11,12,19,23–25 National guidelines for elective ostomy surgeries strongly support preoperative preparation (eg, patient education, stoma site selection) by an ostomy nurse specialist.1,4,5

Preoperative patient education and stoma site marking and postoperative ostomy nurse care may help improve patient satisfaction and operative outcomes, decrease LOS, and lessen stoma and peristomal complications.19–21,23,25–28 However, education and counseling must occur postoperatively among those undergoing emergent ostomy surgery.1,4 Additional research on the prevalence of elective surgeries, hospital LOS, and the proportion of patients receiving preoperative stoma site marking is needed.

We assert that a study that capitalizes on real-world data by using a large database of administrative records from hospitals across the United States is essential to characterize patients undergoing abdominal ostomy surgery and their hospital course. Research is also needed to evaluate the rates of hospital readmission and emergency department (ED) visits following ostomy surgery. Knowledge from this research has the potential to inform clinical guidelines for patients’ ostomy management and suggest strategies to improve outcomes in patients undergoing ostomy surgery. The aims of this study were to examine patient characteristics (including demographics, diagnoses, and surgery type), LOS (including LOS following surgery), hospital revisits (ie, hospital readmissions and subsequent ED visits), and stoma and peristomal complications of patients who underwent abdominal ostomy surgery.

METHODS

A retrospective cohort study examining characteristics of patients who underwent ostomy surgery was conducted using data from the PINC AI Healthcare Database (PHD; formerly, Premier Healthcare Database). The PHD is a geographically diverse, all-payer, hospital-based database containing administrative, billing, and service information from inpatient and hospital-based outpatient records from hospitals across the United States. The PHD captures approximately 25% of all US inpatient hospital discharges and includes more than 8 million inpatient and 70 million outpatient encounters across more than 800 providers per year. Patient data were tracked within a hospital system through a unique PHD patient key. The PHD has been certified as de-identified and is not considered human subjects research. Study data and recorded information could not be identified directly or through identifiers linked to individuals. No informed consent was pursued. All data were compliant with the Health Insurance Portability and Accountability Act (HIPAA). As a result of these factors and regulations in the US Title 45 Code of Federal Regulations, Part 46, institutional review board approval for this study was not required.

Data were drawn from all inpatient encounters between December 1, 2017, and November 30, 2018. Patients were 18 years or older and had an International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) code for colostomy, ileostomy, or urostomy creation at hospital discharge (Table 1). Three ostomy cohorts were created based on the type of surgery. Patient encounters were excluded if the patient died or if an ICD-10-PCS procedure code for more than 1 ostomy was identified during the index hospitalization. The index hospitalization was the visit in which an ostomy creation procedure occurred during the study time period.

TABLE 1. - ICD-10-CM Diagnoses and ICD-10-PCS Procedures Used to Define Cohorts and Complications
Cohort/Condition ICD-10 Code
Colostomy creation/study inclusion Procedure 0D1K0Z4, 0D1K4Z4, 0D1L0Z4, 0D1L4Z4, 0D1N0Z4, 0D1N4Z4, 0D1H074, 0D1H0Z4, 0D1H4Z4, 0D1K074, 0D1L074, 0D1L0J4, 0D1L474, 0D1M074, 0D1M0J4, 0D1M0Z4, 0D1M474, 0D1M4Z4, 0D1M8Z4, 0D1N074, 0D1N0J4, 0D1N3J4, 0D1N474, 0D1N8Z4
Ileostomy creation/study inclusion Procedure 0D190Z4, 0D1A0J4, 0D1A0Z4, 0D1A3J4, 0D1A4J4, 0D1A4Z4, 0D1B074, 0D1B0J4, 0D1B0Z4, 0D1B3J4, 0D1B474, 0D1B4Z4, 0D1B8Z4
Urostomy creation/study inclusion Procedure 0T1607C, 0T160ZC, 0T1647C, 0T164ZC, 0T1707C, 0T170ZC, 0T1747C, 0T174ZC, 0T1807C, 0T180JC, 0T180ZC, 0T1847C, 0T184ZC, 0T160Z9, 0T160ZD, 0T163JD, 0T170ZD, 0T173JD, 0T174ZD, 0T18079, 0T1807D, 0T180Z9, 0T180ZD, 0T184Z9, 0T184ZD
Colostomy complications Diagnosis K94.00, K94.01, K94.02, K94.03, K94.09, Z43.3, Z93.3
Ileostomy complications Diagnosis K94.10, K94.11, K94.12, K94.13, K94.19, Z43.2, Z93.2
Urostomy complications Diagnosis N99.510, N99.511, N99.512, N99.518, N99.520, N99.521, N99.522, N99.523, N99.524, N99.528, N99.530, N99.531, N99.532, N99.533, N99.534, N99.538, Z43.6, Z93.6
General complications for use with all ostomies Diagnosis K43.3, K43.4, K43.5, E86.0, K31.5, K56.3, K68.11, N39.0, T81.40, T81.41, T81.42, T81.43, T81.44, T81.49
Other skin complications Diagnosis A49.01, A49.02, A49.1, A49.8, A49.9, B37.9, L08.0, L08.89, L08.9, L24.5, L24.9, L88, L92.8, L98.49
Colostomy reversal/repair Procedure 0DQE0ZZ, 0DQE3ZZ, 0DQE4ZZ, 0DQE7ZZ, 0DQE8ZZ, 0DQF0ZZ, 0DQF3ZZ, 0DQF4ZZ, 0DQF7ZZ, 0DQF8ZZ, 0DQG0ZZ, 0DQG3ZZ, 0DQG4ZZ, 0DQG7ZZ, 0DQG8ZZ, 0DQH0ZZ, 0DQH3ZZ, 0DQH4ZZ, 0DQH7ZZ, 0DQH8ZZ, 0DQK0ZZ, 0DQK3ZZ, 0DQK4ZZ, 0DQK7ZZ, 0DQK8ZZ, 0DQL0ZZ, 0DQL3ZZ, 0DQL4ZZ, 0DQL7ZZ, 0DQL8ZZ, 0DQM0ZZ, 0DQM3ZZ, 0DQM4ZZ, 0DQM7ZZ, 0DQM8ZZ, 0DQN0ZZ, 0DQN3ZZ, 0DQN4ZZ, 0DQN7ZZ, 0DQN8ZZ, 0DQP0ZZ, 0DQP3ZZ, 0DQP4ZZ, 0DQP7ZZ, 0DQP8ZZ
Ileostomy reversal/repair Procedure 0DQ80ZZ, 0DQ83ZZ, 0DQ84ZZ, 0DQ87ZZ, 0DQ88ZZ, 0DQ90ZZ, 0DQ93ZZ, 0DQ94ZZ, 0DQ97ZZ, 0DQ98ZZ, 0DQA0ZZ, 0DQA3ZZ, 0DQA4ZZ, 0DQA7ZZ, 0DQA8ZZ, 0DQB0ZZ, 0DQB3ZZ, 0DQB4ZZ, 0DQB7ZZ, 0DQB8ZZ
Urostomy reversal/repair Procedure 0TQ60ZZ, 0TQ63ZZ, 0TQ64ZZ, 0TQ67ZZ, 0TQ68ZZ, 0TQ70ZZ, 0TQ73ZZ, 0TQ74ZZ, 0TQ77ZZ, 0TQ78ZZ, 0TQB0ZZ, 0TQB3ZZ, 0TQB4ZZ, 0TQB7ZZ, 0TQB8ZZ, 0TQD0ZZ, 0TQD3ZZ, 0TQD4ZZ, 0TQD7ZZ, 0TQD8ZZ, 0TQDXZZ, 0WQFXZ2
Abbreviation: ICD-10, International Classification of Diseases, Tenth Revision.

Assessed Variables

Patient characteristics examined included age, sex, patients’ self-reported race (ie, Black, White, Other) and ethnicity (ie, Hispanic or Latino), primary insurance payer, and primary discharge diagnosis. Data were collected on multiple characteristics of the index hospital course (ie, hospital admission for ostomy surgery) including procedure type (ie, traditional open abdominal surgery “open” vs endoscopic), LOS, admission type (urgent vs planned), where patients were admitted from (ie, home, clinic, transfer from another hospital), and discharge status. Hospitals submitted these data according to criteria set by the Centers for Medicare & Medicaid Services (CMS). United States Census 2010 geographical region (ie, Midwest, Northeast, South, West) was used for hospital location. Postsurgery LOS was defined as the number of days between the ostomy surgery day and discharge day. Because ostomy hospitalizations are conventionally thought to be brief, short LOS was defined as total LOS of less than 3 days.

The Charlson Comorbidity Index (CCI) was assessed using a modified algorithm with primary or secondary International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes at discharge for the index hospitalization. The CCI is a well-established scale developed to predict 1-year mortality via weighted scores for specific comorbid conditions.29–31 For purposes of this study, the CCI was used to assess the prevalence of comorbid conditions such as myocardial infarction, heart failure, peripheral vascular disease, cerebrovascular disease, dementia, chronic pulmonary disease, rheumatic disease, peptic ulcer disease, diabetes mellitus, hemiplegia or paraplegia, moderate or severe renal disease, malignancies, liver diseases, metastatic solid tumors, and human immunodeficiency virus (HIV) disease. As a marker of severity of illness, CCI score was categorized as low (0-1), moderate (2), or severe (≥3). Total LOS and postsurgery LOS were reported by CCI score. Vitzthum and colleagues32 found the CCI to have an intraclass correlation of 0.74 (95% confidence interval, 0.58-0.87).

All-cause subsequent hospital-based encounters (ie, hospitalization, ED visit) were captured independently up to 120 days after discharge. Thus, patients could have 1 or more of both a hospital readmission and an ED visit following their index visit. Subsequent encounters were reported by cohort according to the top 10 primary diagnoses, LOS, and postsurgery LOS at index hospitalization. Encounters were characterized by subsequent location, primary ICD-10-CM diagnosis codes, and secondary stomal and peristomal complications, such as infection, hemorrhage, malfunction, ostomy status, and irritant contact dermatitis of the peristomal skin (Table 1). Frequency of reversal surgery within 120 days was also examined.

Data Analysis

All characteristics were evaluated using descriptive statistics. Data measured on a continuous scale were expressed as mean, standard deviation, median, and 25th/75th percentiles (or IQR, interquartile range). Categorical data were expressed as counts and percentages of patients in the categories. Proportions (percentages) and number of patients are listed in the various tables. All analyses were completed using SAS software version 9.4 (SAS Institute, Cary, North Carolina).

RESULTS

Data from 27,658 patients undergoing ostomy surgery in 658 hospitals were analyzed; 56.1% underwent a colostomy procedure, 36.9% underwent an ileostomy procedure, and 7.0% had a urostomy procedure. Table 2 summarizes patient and hospital course characteristics; percentages and numbers of patients in each cohort are provided in the table, and the narrative reports percentages of selected cohorts only. The mean age of the entire sample was 62.5 years (SD = 15.1 years); this statistic varied based on type of ostomy created. The colostomy and ileostomy patient cohorts were almost evenly split based on sex, whereas the urostomy cohort was primarily male. Patients self-identified as primarily White, non-Hispanic, or Latino. Nearly half of patients were from hospitals in the Southern region of the United States (48.4%), followed by Midwest (21.5%), Northeast (18.5%), and West (11.7%). Medicare was the primary payer for half of the sample, nearly a third had commercial insurance, and approximately one-tenth had Medicaid. These distributions also varied based on type of ostomy.

TABLE 2. - Patient/Visit Characteristics
Overall (N = 27,658) Colostomy (N = 15,512) Ileostomy (N = 10,207) Urostomy (N = 1,939)
Age, n (%)
18-44 y 3,341 (12.1) 1,632 (10.5) 1,653 (16.2) 56 (2.9)
45-64 y 11,035 (39.9) 6,209 (40.0) 4,227 (41.4) 599 (30.9)
65-74 y 7,176 (26.0) 3,912 (25.2) 2,556 (25.0) 708 (36.5)
75-84 y 4,560 (16.5) 2,665 (17.2) 1,383 (13.6) 512 (26.4)
85+ y 1,546 (5.6) 1,094 (7.1) 388 (3.8) 64 (3.3)
Mean (SD) 62.5 (15.1) 63.5 (14.8) 59.9 (15.7) 68.0 (10.8)
Median (Q1, Q3) 64 (54, 73) 64 (54, 74) 62 (51, 71) 69 (62, 76)
Sex, n (%)
Male 14,117 (51.0) 7,505 (48.4) 5,187 (50.8) 1,425 (73.5)
Female 13,541 (49.0) 8,007 (51.6) 5,020 (49.2) 514 (26.5)
Race, n (%)
White 22,133 (80.0) 12,315 (79.4) 8,218 (80.5) 1,600 (82.5)
Black 2,665 (9.6) 1,654 (10.7) 892 (8.7) 119 (6.1)
Other/unknown 2,860 (10.3) 1,543 (9.9) 1,097 (10.7) 220 (11.3)
Ethnicity, n (%)
Hispanic or Latino 2,042 (7.4) 1,121 (7.2) 780 (7.6) 141 (7.3)
Non-Hispanic or Latino 20,080 (72.6) 11,272 (72.7) 7,411 (72.6) 1,397 (72.1)
Unknown 5,536 (20.0) 3,119 (20.1) 2,016 (19.8) 401 (20.7)
Primary payer type, n (%)
Medicare 14,438 (52.2) 8,414 (54.2) 4,749 (46.5) 1,275 (65.8)
Medicaid 3,243 (11.7) 1,867 (12.0) 1,235 (12.1) 141 (7.3)
Private/commercial insurance 8,623 (31.2) 4,342 (28.0) 3,812 (37.4) 469 (24.2)
Other/uninsured/unknown 1,354 (4.9) 889 (5.7) 411 (4.0) 54 (2.8)
Admission type, n (%)
Emergency, urgent, trauma 16,279 (58.9) 11,047 (71.2) 5,040 (49.4) 192 (9.9)
Elective (ie, planned) 10,981 (39.7) 4,215 (27.2) 5,026 (49.2) 1,740 (89.7)
Unknown/missing 398 (1.4) 250 (1.6) 141 (1.4) 7 (0.4)
Admission point of origin, n (%)
Non-healthcare facilitya 20,536 (74.3) 11,885 (76.6) 7,346 (72.0) 1,305 (67.3)
Clinic 4,593 (16.6) 2,029 (13.1) 1,971 (19.3) 593 (30.6)
Transfer from acute care 2,167 (7.8) 1,343 (8.7) 790 (7.7) 34 (1.7)
Transfer from SNF or hospice 283 (1.0) 204 (1.3) 76 (0.7) 3 (0.2)
Other 79 (0.3) 51 (0.3) 24 (0.2) 4 (0.2)
Procedure type, n (%)
Endoscopic 6,168 (22.3) 3,282 (21.2) 2,299 (22.5) 587 (30.3)
Open 21,434 (77.5) 12,201 (78.7) 7,883 (77.2) 1,350 (69.6)
Both endoscopic and openb 42 (0.2) 29 (0.2) 11 (0.1) 2 (0.1)
Unknown endoscopic or open 14 (0.1) 0 (0) 14 (0.1) 0 (0)
Short length of stay, n (%)
Yes (ie, <3 d) 852 (3.1) 475 (3.1) 371 (3.6) 6 (0.3)
No (ie, ≥3 d) 26,806 (96.9) 15,037 (96.9) 9,836 (96.4) 1,933 (99.7)
Discharge type, n (%)
Home/home with home healthcare 18,775 (67.9) 9,855 (63.5) 7,340 (71.9) 1,580 (81.5)
Transferred to acute care 357 (1.3) 217 (1.4) 135 (1.3) 5 (0.3)
SNF, rehab, ICF, or long-term care 8,182 (29.6) 5,224 (33.7) 2,621 (25.7) 337 (17.4)
Other 344 (1.2) 216 (1.4) 111 (1.1) 17 (0.9)
All-cause hospital readmission, n (%) 11,638 (42.1) 5,625 (36.3) 5,343 (52.3) 670 (34.6)
All-cause subsequent ED visit, n (%) 5,729 (20.7) 3,156 (20.3) 2,280 (22.3) 293 (15.1)
Abbreviations: ED, emergency department; ICD-10-PCS, International Classification of Diseases, Tenth Revision, Procedure Coding System; ICF, intermediate care facility; Q1, Q3, 25th, 75th percentiles; SD, standard deviation; SNF, skilled nursing facility.
aNon-healthcare facility indicates the patient was admitted from home or workplace.
bCategorization as “both endoscopic and open” indicated that more than 1 type of ICD-10-PCS code for the surgical procedure was specified for the surgery.

Admission type varied by ostomy type. Specifically, most patients who underwent a colostomy procedure were admitted emergently, urostomy procedures were primarily elective (planned), and ileostomies were evenly split between emergent and elective admissions. Across ostomy types, admission point of origin for patients was primarily from home, physician's office, or clinic. Less than 10% of patients were transferred from another hospital. Nearly three-fourths or more of ostomy surgeries were completed using an open approach. Most patients were discharged home (23.7%) or home with home healthcare (43.0%).

Within 120 days after index hospitalization, 42.1% of all patients had at least one all-cause hospital readmission and approximately 21% had at least one all-cause subsequent ED visit. There were 16,763 readmission visits and 8605 ED visits after hospital discharge; thus, some patients had multiple readmissions and/or ED visits. Subsequent encounters were evaluated independently, so a single patient may have had both a readmission and an ED visit during the follow-up period. Frequencies of subsequent encounters varied by ostomy cohort. Specifically, about one-third of patients in the colostomy or urostomy cohort had a subsequent hospitalization compared to half of patients in the ileostomy cohort. In contrast, subsequent ED visits were observed in approximately one-fifth of patients in the colostomy or ileostomy cohort compared to 15% of patients in the urostomy cohort.

Hospital and Postoperative LOS

The mean LOS and postsurgical LOS varied by ostomy, procedure, and admission type (Figure, panels A-C; Table 3). Total LOS for patients who underwent a colostomy or ileostomy procedure was 2 to 3 days longer than postsurgery LOS, whereas for patients who underwent a urostomy procedure, LOS and postsurgery LOS were similar and indicative of surgery on day of elective admission. Compared to emergency surgery, average LOS decreased by 3 to 7 days, and postsurgery LOS decreased by 1 to 3 days if the surgery was elective. Compared to open surgery, LOS and postsurgery LOS decreased by 1 to 4 days if the surgery was performed using an endoscopic approach (Figure, panel C). Seventy-three patients (0.3%) were discharged on day of surgery; they were not included in the analysis of postsurgery LOS results. The analysis also revealed a small percentage of all patients undergoing surgery (3.1%, n = 852) who had a particularly short LOS, defined as less than 3 days.

F1
Figure.:
Mean length of stay overall and by ostomy cohort. (A) Length of stay; (B) total LOS by admission type; (C) total LOS by procedure type; and (D) total LOS by CCI score. Error bars indicate standard deviation; LOS, length of stay; CCI, Charleston Comorbidity Index. CCI score was categorized as low (0-1), moderate (2), or severe (≥3).
TABLE 3. - Median Index Length of Stay and Postsurgery LOS Days by Ostomy Cohort and Characteristicsa
Overall (N = 27,658) Colostomy (N = 15,512) Ileostomy (N = 10,207) Urostomy (N = 1,939)
Overall
Total LOS, d 9 (6, 15) 10 (6, 15) 9 (5, 16) 7 (5, 9)
Postsurgery LOS, d 7 (5, 10) 7 (5, 12) 7 (5, 13) 7 (5, 9)
Emergent admission
Total LOS, d 12 (8, 18) 11 (7, 17) 13 (8, 21) 10 (6, 18)
Postsurgery LOS, d 8 (6, 13) 8 (6, 12) 9 (6, 16) 7 (6, 12)
Elective admission
Total LOS, d 6 (4, 9) 6 (4, 10) 6 (4, 10) 7 (5, 9)
Postsurgery LOS, d 6 (4, 9) 6 (4, 8) 6 (4, 9) 6 (5, 9)
Open surgery
Total LOS, d 10 (6, 16) 10 (7, 16) 10 (6, 18) 7 (6, 10)
Postsurgery LOS, d 8 (5, 13) 8 (5, 12) 8 (5, 14) 7 (5, 9)
Endoscopic procedure
Total LOS, d 7 (4, 12) 7 (4, 13) 6 (4, 10) 6 (5, 8)
Postsurgery LOS, d 5 (3, 8) 5 (3, 8) 5 (3, 8) 6 (5, 8)
Abbreviation: LOS, length of stay.
aValues are median (25th, 75th percentile); patients with more than 1 procedure or whose procedure type was unknown are excluded from open surgery and endoscopic procedure results.

Primary Diagnosis at Index Hospitalization

Table 4 summarizes the 10 most frequent diagnoses leading to colostomy surgery and the all-cause ED visits and admissions occurring within 120 days of the index hospital stay; the table provides number of patients and percentages, and the narrative provides most pertinent percentages alone. The most frequent primary diagnoses at the index hospitalization for patients who underwent a colostomy procedure were diverticulitis of large intestine (19.6%), malignant neoplasm (17.0%), and sepsis (15.8%). Hospital LOS and postsurgery LOS varied by procedure; they were longest for sepsis: mean = 16.1, SD = 14.0 days, and mean = 12.8, SD = 12.4 days, respectively. The hospital LOS and postsurgery LOS were shortest for index diagnosis of neoplasm of the rectum: mean = 7.3, SD = 6.2 days, and mean = 6.6, SD = 5.7 days, respectively. Subsequent encounters within 120 days of the index hospitalization varied across primary index diagnoses and ranged from 27.1% to 42.6% of patients, with a particular diagnosis being readmitted to a hospital and 16.9% to 24.7% having a subsequent ED visit. Hospital readmissions were least frequent for patients with a primary diagnosis of malignant neoplasm of the rectum and most frequent for patients with a diagnosis of diverticulitis of the large intestine. In contrast, ED visits within 120 days were least frequent for patients with a primary diagnosis at index hospitalization of malignant neoplasm of the rectosigmoid junction and most frequent for patients with a diagnosis of volvulus at the time of ostomy surgery. Approximately one-fifth of patients with an ED visit or hospital readmission had a diagnosis of diverticulitis of the large intestine with perforation at the index hospitalization. More than 40% of all patients who underwent a colostomy procedure had an index hospitalization diagnosis that was not listed in the top 10; this cohort accounted for over 40% of all hospital readmissions and subsequent ED visits.

TABLE 4. - Colostomy Top 10 Most Frequent Primary Diagnosis Categories on Index and All-Cause Subsequent Encounters Within 120 Days
Index Visit Hospital Readmission Subsequent ED Visit
ICD-10-CM Diagnosis Description [Code #] N % of Index Total LOSa Postsurgery LOSa N % of Readmission Total % of Patients With Diagnosis N % of ED Visit Total % of Patients With Diagnosis
1 Diverticulitis of large intestine with perforation and abscess without bleeding [K57.20] 2,755 17.8% 9 (7, 13) 7 (6, 10) 1,144 20.3% 41.5% 570 18.1% 20.7%
2 Sepsis, unspecified organism [A41.9] 2,448 15.8% 13 (9, 19) 10 (7, 15) 933 16.6% 38.1% 507 16.1% 20.7%
3 Malignant neoplasm of rectum [C20] 1,449 9.4% 6 (4, 9) 5 (4, 7) 392 7.0% 27.1% 262 8.3% 18.1%
4 Malignant neoplasm of sigmoid colon [C18.7] 723 4.7% 9 (6, 13) 7 (5, 10) 208 3.7% 28.8% 140 4.4% 19.4%
5 Malignant neoplasm rectosigmoid junction [C19] 455 2.9% 8 (6, 13) 6 (4, 9) 143 2.5% 31.4% 77 2.4% 16.9%
6 Per other diseases of intestine, perforation intestine (nontraumatic) [K63.1] 305 2.0% 10 (7, 15) 9 (6, 14) 121 2.2% 39.7% 58 1.8% 19.0%
7 Diverticulitis of large intestine without perforation and abscess without bleeding [K57.32] 284 1.8% 9 (6, 14) 7 (4, 10) 121 2.15% 42.6% 63 2.0% 22.2%
8 Volvulus [K56.2] 271 1.8% 9 (6, 15) 7 (5, 12) 100 1.8% 36.9% 67 2.1% 24.7%
9 Fistula of vagina to large intestine [N82.3] 220 1.4% 6 (4, 10) 5 (3, 7) 61 1.1% 27.7% 51 1.6% 23.2%
10 Pressure ulcer sacral region stage 4 [L89.154] 198 1.3% 11 (6, 18) 7 (4, 13) 75 1.3% 37.9% 48 1.5% 24.2%
All other diagnoses 6,360 41.1% 10 (6, 17) 7 (5, 12) 2,327 41.4% 36.6% 1,313 41.6% 20.6%
Total N 15,468 5,625 3,156
Abbreviations: ED, emergency department; ICD-10-CM, International Classification of Diseases, Tenth Revision, Clinical Modification; LOS, length of stay; % of patients with diagnosis, the percentage of patients with that diagnosis at index visit who had a subsequent encounter (ie, readmission or ED visit).
aValues are median (25th, 75th percentile).

Table 5 summarizes the 10 most frequent diagnoses leading to ileostomy surgery and the all-cause ED visits and admissions occurring within 120 days of the index hospital stay; the table provides number of patients and percentages, and the narrative provides most pertinent percentages alone. The most frequent primary diagnoses of patients with an ileostomy were malignant neoplasm (22.5%), sepsis (9.8%), and diverticulitis of the large intestine (8.4%). More than half of all patients managed with an ileostomy had an index hospitalization diagnosis that was not listed in the top 10. In addition, 2.4% of patients who underwent an ileostomy procedure had a primary diagnosis of “attention to colostomy,” suggesting a sequela or complication related to their original ostomy type (colostomy) created prior to ileostomy surgery. Hospital LOS and postsurgery LOS varied by index diagnosis; they were longest for sepsis: mean = 20.1, SD = 22.6 days, and mean = 6.6, SD = 5.7 days, respectively. The hospital LOS and postsurgery LOS were shortest for the index diagnosis of rectal neoplasm; mean = 6.4, SD = 5.6 days, and mean = 6.2, SD = 5.4 days, respectively. Hospital readmission rates among patients with an ileostomy were most frequent for patients with a diverticulitis of the large bowel at the index, whereas subsequent ED visits were most frequent in patients with an index diagnosis of other postprocedural complications and disorders of digestive system. Hospital readmissions and subsequent ED visits were least frequent for patients with a primary diagnosis of a malignant neoplasm at their index hospitalization. Among patients with a subsequent encounter, approximately one-fifth had a malignancy diagnosis at the index hospitalization and approximately half had an unlisted/other diagnosis at index.

TABLE 5. - Ileostomy Top 10 Most Frequent Primary Diagnosis Categories on Index and All-Cause Subsequent Encounters Within 120 Days
Index Visit Hospital Readmission Subsequent ED Visit
ICD-10-CM Diagnosis Description [Code #] N % of Index Total LOSa Postsurgery LOSa N % of Readmission Total % of Patients With Diagnosis N % of ED Visit Total % of Patients With Diagnosis
1 Malignant neoplasm of rectum [C20] 1,528 15.0% 5 (3, 7) 5 (3, 7) 763 14.3% 49.9% 290 12.7% 19.0%
2 Sepsis, unspecified organism [A41.9] 995 9.8% 16 (10, 24) 12 (8, 19) 528 9.9% 53.1% 257 11.3% 25.8%
3 Diverticulitis of large intestine with perforation and abscess without bleeding [K57.20] 650 6.4% 9 (5, 13) 7 (5, 10) 475 8.9% 73.1% 137 6.0% 21.1%
4 Malignant neoplasm of rectosigmoid junction [C19] 368 3.6% 6 (4, 9) 5 (4, 8) 176 3.3% 47.8% 67 2.9% 18.2%
5 Encounter for attention to colostomy [Z43.3] 242 2.4% 6 (4, 10) 6 (4, 9) 167 3.1% 69.0% 50 2.2% 20.7%
6 Malignant neoplasm of sigmoid colon [C18.7] 237 2.3% 9 (6, 16) 7 (5, 12) 123 2.3% 51.9% 53 2.3% 22.4%
7 Ulcerative colitis, unspecified, without complication [K51.90] 215 2.1% 5 (3, 9) 5 (3, 8) 116 2.2% 54.0% 46 2.0% 21.4%
8 Diverticulitis of large intestine without perforation and abscess without bleeding [K57.32] 202 2.0% 7 (4, 11) 6 (4, 8) 158 3.0% 78.2% 50 2.2% 24.8%
9 Other postprocedure complication and disorder of digestive system [K91.89] 200 2.0% 10 (7, 16) 9 (6, 14) 109 2.0% 54.5% 52 2.3% 26.0%
10 Malignant neoplasm of ascending colon [C18.2] 165 1.6% 11 (7, 18) 8 (5, 12) 78 1.5% 47.3% 32 1.4% 19.4%
All other diagnoses 5,390 52.9% 11 (6, 19) 8 (5, 14) 2,650 49.6% 49.2% 1,246 54.7% 23.1%
Total N 10,192 5,343 2,280
Abbreviations: ED, emergency department; ICD-10-CM, International Classification of Diseases, Tenth Revision, Clinical Modification; LOS, length of stay; % of patients with diagnosis, the percentage of patients with that diagnosis at index visit who had a subsequent encounter (ie, readmission or ED visit).
aValues are median (25th, 75th percentile).

Table 6 summarizes the 10 most frequent diagnoses leading to urostomy surgery and the all-cause ED visits and admissions occurring within 120 days of the index hospital stay; the table provides number of patients and percentages, and the narrative provides most pertinent percentages alone. The most common diagnosis at index hospital admission for patients with a urostomy was malignant neoplasm of the bladder (78.1%). Hospital LOS and postoperative LOS were similar across specific malignancy diagnoses recorded. Because analyses in this study were based on ICD-10-CM administrative codes, diagnoses codes indicate the main location of the cancer; these diagnoses do not identify the stage or grade of the malignancy. Within 120 days of index hospitalization, hospital readmission rates were 34.0% and subsequent ED visits rates were 15.4% for patients with a primary diagnosis of malignancy. Hospital readmissions were most frequent for patients with a diagnosis of neurogenic lower urinary tract dysfunction (neurogenic bladder) at the index hospitalization, whereas subsequent ED visits were most frequent for patients with a diagnosis of malignant neoplasm. Less than 18% of all patients who underwent a urostomy procedure had an index diagnosis that was not listed in the top 10, but more than a third of these patients were readmitted. The ICD-10-CM diagnoses at the index hospitalization was missing for 0.3% (n = 59) of the overall sample.

TABLE 6. - Urostomy Top 10 Most Frequent Primary Diagnosis Categories on Index and All-Cause Subsequent Encounters Within 120 Days
Index Visit Hospital Readmission Subsequent ED Visit
ICD-10-CM Diagnosis Description [Code #] N % of Index Total LOSa Postsurgery LOSa N % of Readmission Total % of Patients With Diagnosis N % of ED Visit Total % of Patients With Diagnosis
1 Malignant neoplasm bladder, unspecified [C67.9] 902 46.5% 7 (5, 9) 6 (5, 8) 310 46.3% 34.4% 137 46.8% 15.2%
2 Malignant neoplasm of overlapping sites of bladder [C67.8] 223 11.5% 6 (5, 9) 6 (5, 8) 73 10.9% 32.7% 23 7.9% 10.3%
3 Malignant neoplasm lateral wall of bladder [C67.2] 137 7.1% 6 (5, 9) 6 (5, 9) 43 6.4% 31.4% 24 8.2% 17.5%
4 Malignant neoplasm posterior wall of bladder [C67.4] 74 3.8% 7 (5, 10) 7 (5, 10) 23 3.4% 31.1% 16 5.5% 21.6%
5 Malignant neoplasm trigone of bladder [C67.0] 58 3.0% 6.5 (5, 10) 6.5 (5, 10) 23 3.4% 39.7% 6 2.1% 10.3%
6 Malignant neoplasm dome of bladder [C67.1] 43 2.2% 6 (5, 10) 6 (5, 10) 16 2.4% 37.2% 8 2.7% 18.6%
7 Neuromuscular dysfunction, bladder, unspecified [N31.9]b 40 2.1% 6.5 (5.5, 8.5) 6 (5, 8) 20 3.0% 50.0% 8 2.7% 20.0%
8 Malignant neoplasm anterior wall of bladder [C67.3] 39 2.0% 6 (5, 10) 6 (5, 9) 15 2.2% 38.5% 6 2.1% 15.4%
9 Carcinoma in situ of bladder [D09.0] 39 2.0% 7 (5, 10) 7 (5, 10) 18 2.7% 46.2% 5 1.7% 12.8%
10 Malignant neoplasm of bladder neck [C67.5] 38 2.0% 7 (5, 8) 7 (5, 8) 12 1.8% 31.6% 5 1.7% 13.2%
All other diagnoses 346 17.8% 7 (5, 12) 7 (5, 10) 117 17.5% 33.8% 55 18.8% 15.9%
Total N 1,939 670 293
Abbreviations: ED, emergency department; ICD-10-CM, International Classification of Diseases, Tenth Revision, Clinical Modification; LOS, length of stay, % of patients with diagnosis, the percentage of patients with that diagnosis at index visit who had a subsequent encounter (ie, readmission or ED visit).
aValues are median (25th, 75th percentile).
bNeurogenic lower urinary tract dysfunction (neurogenic bladder).

Comorbid Conditions at Index Admission Identified by the Charlson Comorbidity Index

The most common conditions identified via the CCI were any malignancy, including leukemia and lymphoma, chronic pulmonary disease, diabetes mellitus without chronic complications, metastatic solid tumor, and renal disease (Table 7). Total scores varied based on type of ostomy. Among patients who underwent a colostomy or ileostomy procedure, 36.2% to 40.1% had a severe CCI score and 41.4% to 41.9% had a low CCI score. In contrast, among patients undergoing a urostomy procedure, 60.0% had a severe CCI score and 6.9% had a low CCI score. Across ostomy cohorts, total LOS and postsurgery LOS were about 1 day longer for patients with a severe CCI scores as compared to those with a low or moderate score (Figure, panel D). The biggest difference appeared to be among patients who underwent an ileostomy procedure; their mean hospital LOS was 2 to 4 days longer for patients with a severe CCI score compared to patients with a low or moderate score. The frequency of hospital readmissions and subsequent ED visits overall and by ostomy type varied little based on CCI score.

TABLE 7. - Frequency of Charlson Comorbidity Index Diagnoses by Ostomy Cohort
Comorbid Condition, n (%)
Overall (N = 27,599) Colostomy (N = 15,468) Ileostomy (N = 10,192) Urostomy (N = 1,939)
Myocardial infarction 1,774 (6.4) 1,024 (6.6) 617 (6.0) 133 (6.9)
Congestive heart failure 2,712 (9.8) 1,718 (11.1) 879 (8.6) 115 (5.9)
Peripheral vascular disease 1,308 (4.7) 786 (5.1) 429 (4.2) 93 (4.8)
Cerebrovascular disease 870 (3.2) 534 (3.4) 298 (2.9) 38 (2.0)
Dementia 1,012 (3.7) 714 (4.6) 272 (2.7) 26 (1.3)
Chronic pulmonary disease 5,212 (18.9) 3,018 (19.5) 1,825 (17.9) 369 (19.0)
Rheumatologic disease 695 (2.5) 431 (2.8) 236 (2.3) 28 (1.4)
Peptic ulcer disease 493 (1.8) 210 (1.4) 268 (2.6) 15 (0.8)
Mild liver disease 366 (1.3) 198 (1.3) 160 (1.6) 8 (0.4)
Diabetes without chronic complication 4,669 (16.9) 2,680 (17.3) 1,649 (16.2) 340 (17.5)
Diabetes with chronic complications 2,551 (9.2) 1,542 (9.9) 803 (7.9) 206 (10.6)
Hemiplegia or paraplegia 579 (2.1) 470 (3.0) 77 (0.8) 32 (1.7)
Renal disease (moderate or severe) 3,724 (13.5) 2,126 (13.7) 1,156 (11.3) 442 (22.8)
Any malignancy, including leukemia and lymphoma 11,101 (40.2) 5,331 (34.4) 4,078 (40.0) 1,692 (87.3)
Moderate or severe liver disease 191 (0.7) 118 (0.8) 73 (0.7) 0 (0)
Metastatic solid tumor 4,247 (15.4) 2,522 (16.3) 1,414 (13.9) 311 (16.0)
HIV disease 73 (0.3) 48 (0.3) 23 (0.2) 2 (0.1)
Calculated CCI score
Low (0-1) 10,818 (39.2) 6,409 (41.4) 4,275 (41.9) 134 (6.9)
Moderate (2) 5,728 (20.8) 2,859 (18.5) 2,227 (21.9) 642 (33.1)
Severe (≥3) 11,053 (40.0) 6,200 (40.1) 3,690 (36.2) 1,163 (60.0)
Abbreviations: CCI, Charlson Comorbidity Index; HIV, human immunodeficiency virus.

Diagnosis at Subsequent Encounters

Among patients who were readmitted to a hospital, the most common primary diagnoses at subsequent hospitalization were attention to colostomy/ileostomy (30.8%), sepsis (10.4%), acute kidney failure (8.1%), and infection following a procedure (5.3%). The most common primary diagnoses at subsequent ED visit were unspecified or general abdominal pain (9.1%) and colostomy/enterostomy complications such as infection, hemorrhage, or unspecified (8.0%). Other common primary diagnoses (3%-4%) at a subsequent encounter included other complications of colostomy/enterostomy (ie, K94.09), other and unspecified intestinal obstruction, and urinary tract infection. The frequency and type of primary diagnosis also varied somewhat based on ostomy procedure.

Patients with a subsequent encounter could have no or multiple secondary diagnoses. Across ostomy types, common secondary diagnoses or complications at a subsequent encounter included colostomy/ileostomy/other artificial opening of gastrointestinal tract status (47.1% hospitalizations, 31.3% ED visits), dehydration (21.4% hospitalizations, 6.5% ED visits), and urinary tract infections (14.8% hospitalizations, 4.7% ED visits). One or more stoma or peristomal complications (listed in Table 1) were reported in 62.4% of patients requiring hospital readmission (66.5% for colostomy, 57.2% for ileostomy, and 69.1% for urostomy) and 39.7% of patients with a subsequent ED visit (44.4% for colostomy, 34.7% for ileostomy, and 27.5% for urostomy). Most were coded as ostomy-related conditions (ie, ICD-10-CM Z93.2, Z93.3, Z93.6). Peristomal skin complications during subsequent encounters (<2%) were not well captured in our administrative database. In the short follow-up period, 636 surgeries were reversed/repaired within 120 days of the index hospitalization; they comprised 2.1% of colostomy (n = 320), 3.0% of ileostomy (n = 304), and 0.6% of urostomy (n = 12) procedures.

Among patients undergoing ostomy reversal procedure within 120 days, the median LOS of the index visit was 4 to 8 days longer and median postsurgery LOS was 3 to 6 days longer than patients who did not return for a reversal procedure. Reasons for the longer LOS at index were not explored, and the small number of urostomy reversals/repairs suggests that these results should be interpreted with caution.

DISCUSSION

We conducted a retrospective study of real-world data to better understand certain characteristics among individuals undergoing creation of an abdominal stoma. The median LOS was 9 days overall and longer for patients with an emergency admission, open surgical procedure, and certain diagnoses. During the 120 days following surgery, the frequency of hospital readmission and subsequent ED visit was high and often involved an ostomy-related complication.

Hospital LOS is a standard indicator of efficiency of facility management and quality of care. Nonetheless, few recent studies on ostomy surgery outcomes capture and report LOS. In the United States, 2 regional studies described LOS by ostomy type and reported mean LOS for colostomy and urostomy similar to our sample, although results varied by peristomal skin complications.11,12 For ileostomy, they reported mean LOS was 3 to 10 days longer than we found. However, our LOS was similar to a study of 120 patients who underwent an ileostomy procedure in the United Kingdom, where mean LOS was 8 days (IQR = 14) after implementation of an enhanced recovery program.23 Additionally, our overall median LOS of 9 days (IQR = 9) was similar to a large retrospective regional US study (N = 4250 patients across 34 hospitals).10 Our median postsurgery LOS of 7 days was within the range of 5 to 13 days reported in 3 European studies examining postoperative LOS as part of surgery enhancement programs.10,19,24 However, our median postsurgery LOS for the ileostomy cohort with elective admission (6 days) was longer than that reported in a recent study (range, 3-5 days by group) evaluating patient engagement technology (ie, smartphone app).33 Advances in surgical techniques (including greater use of endoscopic procedures) and use of ERAS (Enhanced Recovery After Surgery) and other programs may influence the variability in LOS reported across studies.

Readmission rates, which are reported within variable follow-up periods and differing samples, are harder to compare across studies. We found that 42% of patients were readmitted during the 120 days following stoma surgery, which is comparable to frequencies reported by Taneja and colleaues12 using the same time frame. Studies examining 30-day readmission report frequencies ranging from 16% to 25%.9,19,22,33 We found that 21% of patients had a subsequent ED visit within 120 days, which is similar to the 30-day frequencies ranging from 17% to 25% found in a study using survey data and another evaluating ERAS.9,19 However, a recent study reported that only 2.3% of patients overall had a subsequent ED visit within 30 days of discharge.33 Since we did not examine a shorter time span, the proportion of patients in our study that fell into the 30-day follow-up is not known. Additionally, we found that 62% of all readmissions and 40% of subsequent ED visits involved ostomy-related complications. Reduction in hospital readmissions may be achieved by decreasing preventable adverse events, increasing patient education, implementing early clinical follow-up, and application of quality improvement program incentives.9,22,24

We evaluated multiple aspects of ostomy surgery, such as elective versus emergent and endoscopic versus open surgical approach, that influenced clinically relevant patient outcomes. Few studies have reported rates of elective versus emergent surgery, and patient education programs often target elective surgeries.19,24,25,33 We reported that 71% of colostomy and 49% of ileostomy surgeries were emergent admissions, which are higher rates than the 37.2% reported in a large regional retrospective 5-year study.10 Sheetz and colleagues10 also reported higher 30-day morbidity and mortality rates for emergent versus elective procedures. Furthermore, they reported that 9% of surgeries were laparoscopic, which is lower than the 22% reported in our study. However, in that study, patients were identified via Current Procedural Terminology (CPT) codes that included repair, resection, and partial ostomy procedures. A small Swedish study (N = 207) reported 74% of ostomy surgeries were elective and 7.7% were endoscopic, which might reflect temporal and regional differences.13

Given the high proportion of emergent and open procedures in this large cohort, ostomy education for many patients must occur postoperatively when they have recovered enough to fully comprehend information. Discharge status is also pertinent when considering stoma and peristomal complications; we found that the vast majority of patients are discharged home and thus reliant on self-management and lay caregivers, with or without home healthcare services. Encouragingly, a recent US study found involvement in a postdischarge support program was associated with a lower likelihood of readmissions and ED visits.9 Furthermore, a Danish study reported that the cost related to establishing a patient education program showed no significant increase in the overall average costs and may result in a significant reduction in costs related to unplanned readmissions visits.24 Results of a randomized controlled trial found that postoperative telephone calls from an enterostomal (WOC) nurse were associated with better patient adjustment and fewer stoma complications.26 Furthermore, a prospective study in Sweden suggested that their low prevalence of peristomal skin complications was likely influenced by regular follow-up care for 1 year by a WOC nurse.13 In recent studies, use of technology, where the resource can be taken home and viewed as needed following hospital discharge, has been found to be beneficial for patients undergoing ostomy surgery.28,33 Three months after discharge, scores on the Ostomy Adjustment Inventory-23 were better for patients who initially viewed a multimedia educational program during hospitalization when compared to the control and traditional education groups in a randomized controlled trial, where intervention patients were regularly contacted via phone after hospitalization and encouraged to apply educational content.28

LIMITATIONS

Limitations of this study include those inherent to use of any administrative database, such as reliance upon accurate and complete diagnoses, procedure coding, and similar practices between hospitals. Lack of specificity in ICD-10 (International Classification of Diseases, Tenth Revision) coding (eg, attention to ostomy, other complications) may not fully capture more specific underlying reason for hospital readmissions and ED visits. Additionally, the data were limited to certain elements, so we may have been unable to fully assess the extent of burden of all patient and surgical characteristics. Events, readmissions, or subsequent encounters that occurred outside of a hospital system or the PHD were not captured. This study is descriptive in nature; thus, statistical inferences regarding the data cannot be made.

CONCLUSIONS

Individuals undergoing abdominal surgery for creation of an ostomy demonstrate a high level of acuity as evidenced by their LOS, frequency of readmission and subsequent ED visits, and complications requiring follow-up care. Emergent surgeries are common and associated with longer hospital LOS. Postsurgical hospital LOS remains consistent at a median of 7 to 8 days, although this time span was attenuated in our analyses when surgery was planned or completed via an endoscopic approach. As constraints on hospital budgets continue to escalate, greater attention to the needs of this population may be required to ensure optimal outcomes are not adversely affected by pressures to reduce hospital LOS. Two-thirds of patients are discharged home, some with home healthcare services, and thus reliant on care that may not include a WOC or ostomy nurse specialist. To address these issues, clinicians and hospital management should ensure patients receive the services of a WOC or ostomy nurse specialist, preoperative stoma marking, and postdischarge support programs needed to promote self-management skills and adjustment to life with an ostomy. Timely clinical follow-up after discharge may contribute to early identification and management of modifiable factors increasing risk for stomal or peristomal complications and thereby may decrease readmissions and subsequent ED visits. Finally, we recommend greater attention to reducing the frequency of unplanned ostomy creation, providing presurgical education to all patients undergoing an ostomy, and using appropriate stoma site marking.

ACKNOWLEDGMENT

This study was funded by Hollister Inc. Cate Polacek, senior medical writer employed by PINC AI Applied Sciences, Premier Inc, provided literature review, manuscript editing, and publication support.

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Keywords:

Colostomy; Emergency department admissions; Hospital readmissions; Ileostomy; Ostomy; Patient readmissions; Stoma; Urostomy

© 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Wound, Ostomy, and Continence Nurses Society