Impact of index admission cholecystectomy vs interval cholecystectomy on readmission rate in acute cholangitis: National Readmission Database survey

Table 1 Baseline patient and hospital characteristics of patients admitted with gallstone-related acute cholangitis with same-admission and interval cholecystectomy

Patient characteristics	AC with same admission CCY			AC with interval CCY
	Index admission	30-d readmission	P value	Index admission	30-d readmission	P value
No. of patients (n)	18332	1019		106632	12265
Male, n (%)	9704 (52.94)	534 (52.37)	0.82	54937 (51.52)	6787 (55.34)	< 0.01
Mean age (yr)	66.9	68.28		69.89	69.08
Charlson Comorbidity Index			< 0.01			< 0.01
0	6205 (33.85%)	268 (26.33%)		22862 (21.44%)	1748 (14.25%)
1	3668 (20.01%)	124 (12.2%)		15003 (14.07%)	1326 (10.81%)
2	3487 (19.02%)	165 (16.23%)		19866 (18.63%)	2177 (17.75%)
3 or more	4968 (27.10%)	461 (45.22%)		48891 (45.85%)	7013 (57.18%)
Median income based on Zip codes			0.89			0.03
$1-$38999	4498 (24.54%)	252 (24.75%)		24078 (22.58%)	2807 (22.89%)
$39000-$47999	5316 (29%)	299 (29.38%)		29782 (27.93%)	3258 (26.56%)
$48000-$62999	4810 (26.24%)	277 (27.22%)		27575 (25.86%)	3097 (25.25%)
> $ 63000	3703 (20.2%)	190 (18.64%)		25186 (23.62%)	3101 (25.28%)
Primary payer, n (%)			0.05			0.12
Medicare	11831 (64.54)	727 (71.34)		73704 (69.12)	8372 (68.26)
Medicaid	1727 (9.42)	88 (8.68)		9458 (8.87)	1208 (9.85)
Private	4168 (22.74)	174 (17.03)		21316 (19.99)	2452 (19.99)
Others	601 (3.28)	30 (2.94)		2133 (2)	231 (1.88)
Comorbid conditions
Hypertension	7272 (39.67%)	461 (45.23%)	< 0.01	41640 (39.05%)	4706 (38.37%)	0.34
Diabetes mellitus	2576 (14.05%)	220 (21.62%)	< 0.01	15622 (14.65%)	1859 (15.16%)	0.36
End stage renal disease	295 (1.61%)	38 (3.69%)	< 0.01	2346 (2.2%)	438 (3.57%)	< 0.01
Chronic obstructive pulmonary disease	3269 (17.83%)	227 (22.31%)	< 0.01	19407 (18.2%)	2395 (19.53%)	0.03
Congestive heart failure	2444 (13.33%)	284 (27.84%)	< 0.01	18095 (16.97%)	2495 (20.34%)	< 0.01
Nicotine dependence	4739 (25.85%)	320 (31.38%)	< 0.01	28034 (26.29%)	3383 (27.58%)	0.04
Alcohol dependence	326 (1.78%)	11 (1.08%)	< 0.01	1749 (1.64%)	156 (1.27%)	0.04
Hospital characteristics
Hospital teaching status			< 0.01			0.10
Non-teaching	4148 (22.63%)	288 (28.31%)		17754 (16.65%)	2150 (17.53%)
Teaching	14181 (77.36%)	730 (71.68%)		88867 (83.34%)	10114 (82.46%)
Hospital bed size			0.34			0.04
Small	2656 (14.49%)	156 (15.37%)		13286 (12.46%)	1582 (12.9%)
Medium	4823 (26.31%)	235 (23.04%)		26072 (24.45%)	2806 (22.88%)
Large	10848 (59.18%)	628 (61.58%)		67263 (63.08%)	7874 (64.2%)
Hospital location			0.20			0.81
Rural	2561 (13.97%)	176 (17.28%)		11399 (10.69%)	1325 (10.80%)
Urban	15769 (86.02%)	843 (82.71%)		95222 (89.30%)	10939 (89.19%)

AC: Acute cholangitis; CCY: Cholecystectomy.

Table 2 Most common reasons for readmission in patients admitted with gallstones-related acute cholangitis with the same admission vs interval cholecystectomy

Acute cholangitis with same admission CCY	Acute cholangitis with interval CCY
Sepsis (A419)	Sepsis (A419)
Acute kidney failure (N179)	Other cholangitis (K8309)
Acute pancreatitis without necrosis or infection (K8590)	Malignant neoplasm of the head of the pancreas (C250)
Melena (K921)	Obstruction of the bile duct (K831)
Hypertensive heart and chronic kidney disease with heart failure (I130)	Sepsis due to Escherichia coli (A4151)

CCY: Cholecystectomy.

Table 3 Independent predictors of 30-d readmission for patients with gallstone-related acute cholangitis with same admission cholecystectomy

	Bivariate logistic regression			Multivariate logistic regression
	Adjusted HR	95%CI	P value	Adjusted HR	95%CI	P value
Female	1.01	0.82-1.25	0.88	-	-	-
Age (mean)	1.01	0.99-1.01	0.14	0.99	0.98-1.00	0.34
Charlson comorbidity index
1			Reference
2	1.47	1.06-2.04	< 0.01	1.48	0.94-2.33	0.08
3 or more	2.49	1.89-3.27	< 0.01	1.75	1.04-2.94	0.03
Median income based on the zip code
$1-$38999			Reference
$39000-$47999	0.98	0.74-1.30	0.92	-	-	-
$48000-$62999	0.96	0.72-1.29	0.83	-	-	-
> $63000	0.89	0.65-1.21	0.47	-	-	-
Primary payer
Medicare			Reference
Medicaid	0.76	0.52-1.12	0.17	0.85	0.50-1.46	0.57
Private	0.68	0.52-0.90	< 0.01	0.73	0.48-1.10	0.14
Others	0.51	0.26-1.12	0.05	0.69	0.30-1.60	0.39
Comorbidities
Diabetes mellitus	1.45	1.11-1.91	< 0.01	1.07	0.74-1.55	0.69
Hypertension	1.24	1.01-1.52	0.03	1.2	0.88-1.64	0.24
Chronic kidney disease	1.1	1.04-1.16	< 0.01	0.98	0.90-1.07	0.8
End stage renal disease	3.31	2.03-5.39	< 0.01	2.18	1.25-3.81	< 0.01
Congestive heart failure	2.37	1.85-3.02	< 0.01	1.87	1.31-2.66	< 0.01
Chronic pulmonary obstructive disease	1.5	1.18-1.91	< 0.01	1.09	0.79-1.52	0.57
Hospital teaching status
Non-teaching			Reference
Teaching	0.81	0.65-1.01	0.05	1.11	0.69-1.77	0.65
Hospital bed size
Small			Reference
Medium	0.94	0.66- 1.33	0.72	0.64	0.42-0.99	0.04
Large	1.19	0.87-1.63	0.25	0.92	0.64-1.31	0.64
Hospital location
Rural			Reference
Urban	0.76	0.58-0.99	0.04	0.61	0.37-1.02	0.06
Outcomes
Intensive care unit	1.98	1.38-2.83	< 0.01	1.29	0.56-2.96	0.54
Acute respiratory failure	2.45	1.46-4.11	< 0.01	1.51	0.85-2.7	0.15
Septic shock	1.23	0.49-3.09	< 0.64	-	-	-

CI: Confidence interval; HR: Hazard ratio.

Table 4 Independent predictors of 30-d readmission for patients with gallstone-related acute cholangitis with interval cholecystectomy

	Bivariate logistic regression			Multivariate logistic regression
	Adjusted HR	95%CI	P value	Adjusted HR	95%CI	P value
Female	1.01	0.82-1.25	0.88	0.87	0.80-0.94	< 0.01
Age (mean)	1.01	0.99-1.01	< 0.14	0.99	0.98-0.99	< 0.01
Charlson comorbidity index
1			Reference
2	1.47	1.06-2.04	0.12	-	-	-
3 or more	2.49	1.89-3.27	< 0.01	1.27	1.22-1.32	< 0.01
Median income based on the zip code
$1-$38999			Reference
$39000-$47999	0.98	0.74-1.30	0.92	-	-	-
$48000-$62999	0.96	0.72-1.29	0.83	-	-	-
> $63000	0.89	0.65-1.21	0.47	-	-	-
Primary payer
Medicare			Reference
Medicaid	0.76	0.52-1.12	0.17	1.06	0.92-1.22	0.38
Private	0.68	0.52-0.90	< 0.01	0.97	0.87-1.09	0.69
Others	0.51	0.26-1.12	0.05	0.91	0.67-1.24	0.57
Comorbidities
Diabetes mellitus	1.45	1.11-1.91	< 0.01	0.93	0.85-1.03	0.2
Hypertension	1.24	1.01-1.52	0.03	1.00	0.92-1.09	0.88
Chronic kidney disease	1.1	1.04-1.16	< 0.01	0.99	0.97-1.02	0.71
End stage renal disease	3.31	2.03-5.39	< 0.01	1.41	1.15-1.73	< 0.01
Congestive heart failure	2.37	1.85-3.02	< 0.01	1.06	0.96-1.18	0.19
Chronic obstructive pulmonary disease	1.5	1.18-1.91	< 0.01	0.95	0.85-1.05	0.32
Hospital teaching status
Non-teaching			Reference
Teaching	1.11	1.03-1.20	< 0.01	0.98	0.84-1.15	0.85
Hospital bed size
Small			Reference
Medium	1.08	0.98-1.21	0.11	1.02	0.90-1.17	0.66
Large	1.23	1.12-1.35	< 0.01	1.12	1.01-1.26	0.03
Hospital location
Rural			Reference
Urban	1.13	1.03-1.25	< 0.01	1.06	0.89-1.27	0.49
Complications
Intensive care unit	1.98	1.38-2.83	< 0.01	1.01	0.79-1.29	0.74
Acute respiratory failure	2.45	1.46-4.11	< 0.01	1.13	0.85-1.49	0.38
Septic shock	1.23	0.49-3.09	< 0.64	1.29	0.93-1.80	0.12

CI: Confidence interval; HR: Hazard ratio.

Table 5 Primary and secondary outcomes in patients admitted with gallstone-related acute cholangitis on the same admission vs interval cholecystectomy for index and 30-d readmissions

Outcomes	Index hospitalizations			30-d readmissions
	Same admission CCY	Interval CCY	P value	Same admission CCY	Interval CCY	P value
Mortality, n (%)	216 (1.18)	3380 (3.17)	< 0.01	25 (2.53%)	554 (4.52%)	< 0.01
Intensive care utilization	827 (4.51%)	7454 (6.99%)	< 0.01	34 (3.36%)	464 (3.78%)	< 0.01
Acute respiratory failure	330 (1.86%)	2282 (2.14%)	< 0.01	21 (2.1%)	172 (1.4%)	< 0.01
Septic shock	165 (0.9%)	1482 (1.39%)	< 0.01	15 (1.51%)	229 (1.87%)	< 0.01
Mean length of stay (d)	7.39	6.51	< 0.01	5.3	5.7	< 0.01
Mean hospitalization cost	$29522	$24014	< 0.01	$14166	$17672	< 0.01

CCY: Cholecystectomy.