Same-day discharge program shows promise in elective benign anterior bowel surgery

A prospective cohort study demonstrated that same-day home recovery (SHR) was feasible and safe for patients who underwent elective surgery for benign foregut.

Of the 1,248 patients participating in the Northern California Healthcare System’s SHR program, 11.5% were discharged on the same day of surgery prior to implementation in 2018, which increased to 26.9% after implementing the program in 2019, and then to 49.3% in 2020, and finally reached 72.6% in 2021, according to Swee H.

The researchers found that the program is feasible in all three types of benign surgical procedures for the foregut — fundoplication for gastroesophageal reflux disease, Heller myotomy for achalasia, and hiatal hernia repair. JAMA Surgery.

Importantly, there were no significant differences between patients in the SHR group and those who were not discharged on the same day for the 7-day rates of postoperative emergency department visits (11.8% vs 10%)s= 0.44), readmission to hospital (3.5% vs 4.5%, s= 0.51), restart (1.7% vs 3.5%, s= 0.15).

The same was true for 30 day rates:

  • Emergency department visits: 17% vs. 16.9% (s= 0.79)
  • Readmission: 4.5% vs 7.2% (s= 0.13)
  • Replay: 2.4% vs. 5% (s= 0.07)

As SHR has become the standard of care for many types of surgical procedures, it may have the potential to become standard practice for common foregut procedures as well, Teh’s group noted. Because of advances in modern medicine, SHR has become an option for a wide range of procedures, from minimally invasive surgeries to orthopedic procedures that previously only allowed inpatient care.

“The successful SHR program is built on patient education about surgical and anesthesia techniques, multimodal pain management, quality home support, anxiety management (both patient and surgeon), consistent expectations, and increased use of telehealth-based communications after surgery,” the authors wrote. .

They added, “An additional benefit of recovering at home is to reduce negative hospital-acquired effects, such as nosocomial infections and post-hospital syndromes, as well as reducing the use of limited hospital resources, especially during the COVID-19 pandemic.”

However, “while the program has been considered cost-effective within the Kaiser system, given the high rate of emergency department visits, readmissions, and restarts, the cost model needs to be closely examined outside of this health maintenance organization environment,” Marko noted. Patty, MD, and Fernando Herbella, MD, both from the University of Virginia in Charlottesville, in accompanying opening.

Furthermore, they wrote, “It is controversial whether patients are more comfortable or safer after being discharged from home a few hours after major surgery.” “While they are in the hospital, they can be monitored and given painkillers and antiemetics by professionals.”

For this study, Teh and colleagues examined the data of 1,248 patients who underwent benign foregut surgery across 19 NCKP centers from January 2017 to September 2021. Of these patients, 558 underwent surgery before the SHR was implemented and 690 underwent surgery after Program implementation.

A patient’s nomination for the program was based on care team evaluations including exercise outcomes, ability to take fluids without nausea or vomiting, and stable vital signs, among others. Patient characteristics were similar between groups. The average age was 60, 61% of women, 68% of whites, and 39% had a BMI greater than 30.

Of the 690 patients in the SHR program, only 288 patients were discharged on the same day of surgery and participated in telephone or video visits within 24 to 48 hours after discharge. The remaining 402 patients were significantly older (median age 61 vs 57) and the median duration of surgery was longer (3.02 vs 2.23 hours).

The 30-day mortality rate was 0.16%, with one death in each group.

Teh and his team acknowledged that the use of administrative data that relied on microsurgical reports was a limitation of their study. Furthermore, data on comorbidities and perioperative outcomes were not available.

  • Zaina Hamza He is a writer for MedPage Today, covering gastroenterology and infectious diseases. She resides in Chicago.

Disclosures

Teh and the co-authors reported being senior clinicians, contributors, and employees of Permanente Medical Group. No additional disclosures were reported.

Patty and Herbella reported no conflict of interest.