The dominant role of geriatrics vulnerabilities and comorbidities in readmissions after colorectal surgery: Shifting from "nonmodifiable" to "actionable" risk.

Abstract

Unplanned readmission within 30 days following colorectal surgery occurs in up to 20% of older patients (≥65 years), representing a significant clinical and economic burden. Designing effective interventions to reduce readmission depends on whether risk factors are modifiable or actionable. This study identified and categorized the drivers of readmission, with a specific focus on actionable factors. We analyzed data from 49,021 elective colectomy and proctectomy cases aged ≥65 years and discharged home in the National Surgical Quality Improvement Program from 2016 to 2020 using univariate and multivariable logistic regression. We categorized factors associated with readmission in 4 groups: (1) comorbidities, (2) preoperative clinical characteristics and geriatric vulnerabilities, (3) surgical stressors, and (4) postoperative complications before discharge. We restricted our analytic cohort to patients aged ≥65 years who were initially discharged to their home. The primary outcome was a composite of unplanned readmission or 30-day mortality. Unplanned readmission occurred in 4,569 (9.3%) of this sample; an additional 76 patients (0.2%) died within 30 days without a prior readmission, yielding a composite adverse outcome of 4,645 (9.5%). Among comorbidities, chronic heart failure (strongest predictor) (odds ratio, 1.96; 95% confidence interval, 1.49-2.53), insulin-dependent diabetes (odds ratio, 1.52; 95% confidence interval, 1.35-1.7), and chronic obstructive pulmonary disease (odds ratio, 1.38; 95% confidence interval, 1.23-1.55) were most strongly associated with readmission. Geriatric vulnerabilities included total functional dependence (strongest predictor) (odds ratio, 2.81; 95% confidence interval, 1.24-6.35) and preoperative hypoalbuminemia (<3.0 g/dL; odds ratio, 1.75; 95% confidence interval, 1.47-2.08). Surgical stressors-ostomy creation (odds ratio, 1.83; 95% confidence interval, 1.69-1.99), prolonged operations (>240 minutes; odds ratio, 1.87; 95% confidence interval, 1.71-2.05)-and complications (ileus: odds ratio, 5.56; 95% confidence interval, 5.16-5.98; and acute renal failure: odds ratio, 6.09; 95% confidence interval, 2.82-13.16) also increased risk. Readmissions in older adults reflect the interplay of medical, geriatric, and surgical risks, some of which are modifiable or actionable. A holistic approach that integrates perioperative optimization (eg, malnutrition), proactive comorbidity control (eg, diuretic and insulin management), and tailored postdischarge monitoring and support may mitigate readmission rates.