By David Wild

Originally published by our sister publication, Clinical Oncology News.

Researchers at several centers across the country are raising doubts about rates of 30-day readmission after liver surgery for hepatocellular carcinoma as a quality metric.

In one study’s retrospective review of more than 16,000 patients who underwent liver transplantation or liver resection during a nearly 20-year period (Am Surg 2022;88[1]:83-92), researchers found 30-day readmissions were not associated with 30-day mortality.

“We demonstrate 30-day readmission to show no increase in 30-day mortality, but rather higher 90-day mortality,” wrote the researchers, led by Sidrah Khan, MD, a general surgery resident at the University of Pittsburgh.

According to the investigators, “hospital readmission rates are rapidly becoming an important quality-of-care metric. Therefore, it is very important to understand the effect of 30-day readmission on mortality and the factors associated with increased 30- and 90-day mortality rates.”

With that aim, Dr. Khan and her co-investigators at three universities in the United States retrospectively examined data from the National Cancer Database, including 8,023 HCC patients who underwent liver transplantation and 8,635 HCC patients who underwent liver resection between 2003 and 2011.

They found that among patients who had liver transplantation, 30-day readmission was associated with a 65% lower risk for 30-day mortality (odds ratio [OR], 0.347; 95% CI, 0.152-0.791; P=0.012). They found a nonsignificant trend toward higher 90-day mortality among patients who were readmitted within 30 days.

Among patients who underwent liver resection for HCC and were readmitted to hospital within 30 days, there was a 48% lower risk for 30-day mortality (OR, 0.552; 95% CI, 0.344-0.887; P=0.014) but a significantly higher risk for 90-day mortality, compared with those who had not been readmitted within 30 days of surgery (OR, 2.186; 95% CI, 1.580-3.026; P≤0.001).

“Higher 90-day mortality after lower 30-day mortalities associated with readmission suggests that patient salvage was attempted, but it was not successful in the long run,” the authors wrote, noting that patients readmitted within 30 days tended to be sicker, as indicated by their higher Charlson-Deyo Comorbidity Index scores at baseline and longer initial hospital stays.

In a multivariate analysis, the authors found higher 30-day mortality among liver transplant patients was associated with Medicaid or Medicare insurance or stage IV cancer, while stage II cancer and longer postoperative inpatient hospital stays were associated with significantly lower 30-day mortality.

The investigators also found that among liver resection patients, older age, advanced tumor stage, increased Charlson-Deyo Comorbidity Index scores and uninsured status were associated with a higher risk for 30-day mortality, while higher income, treatment at an academic center, and care-transitioning factors were associated with lower 30-day mortality rates.

The study “raises the question [of] whether assessing 30-day mortality after 30-day readmission is prudent and subsequently raises serious caution against the use of this in penalizing health care systems,” noted the investigators, who called for further study on “the effect of 30-day readmission on longer-term mortality as well as the culture to shift toward the use of 90-day mortality rates to better assess outcomes.”