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Unplanned Hospital Visits after Cancer Surgery

Key findings

Approximately 12% to 40% of patients who undergo bladder, breast, colorectal, lung, prostate or thyroid surgery have an unplanned hospital visit following cancer surgery. Cancer Care Ontario is actively monitoring Ontario’s hospitals in an effort to improve surgery quality in Ontario.

Measure:  Percentage of patients with an unplanned hospital visit after lung surgery

 

Desired Direction:

 

An image of an arrow pointing downwards. This indicates that desired direction for this action is downwards.

 

As of this Report:

 

An image of a yellow box. This indicates that there is no time trend and this action is below but approaching target or has notable regional variation.

What is bladder, breast, colorectal, lung, prostate or thyroid cancer surgery?

  • Surgery is commonly used to help treat many types of cancer, including bladder, breast, colorectal, lung, prostate and thyroid cancers.
  • Bladder cancer can be treated using surgery, but the type of surgical procedure used is dependent on the tumour type and stage [1]. Three different types of surgery used to treat bladder cancer are as follows:
    • Transurethral resection (TUR) is often used to help diagnose and treat other bladder cancer tumours. This type of surgery involves the removal of tumours that are located exclusively on the bladder’s lining.
    • Partial cystectomy, also known as segmental cystectomy, is used to treat bladder cancer that is isolated to one area of the bladder. This means only a section of the bladder is removed along with the cancer.
    • Radical cystectomy removes the bladder, lymph nodes and any other surrounding organs that are affected. In some cases, this means reproductive organs are removed.
      • The data below include patients who had a cystectomy (partial or radical).

Measure:  Percentage of patients with an unplanned hospital visit after bladder, breast, colorectal, prostate or thyroid surgery

 

Desired Direction:

 

An image of an arrow pointing downwards. This indicates that desired direction for this action is downwards.

 

As of this Report:

 

An image of a yellow box. This indicates that there is no time trend and this action is below but approaching target or has notable regional variation.

  • Surgery is a common treatment option for patients with localized breast cancer. Some surgical treatment options for the removal of breast cancer include lumpectomy (removal of the cancer and a margin of breast tissue surrounding the affected area) and mastectomy (complete removal of the breast and nipple).
  • Following breast cancer surgery, some patients who have had a mastectomy may choose to have a breast reconstruction. Breast reconstruction may be performed at the same time as the breast cancer surgery (immediate reconstruction) or at a later date (delayed reconstruction). This depends on the medical condition of the patient and on personal preference for reconstruction.
  • The data below include patients who had a breast cancer surgery (lumpectomy, mastectomy, sentinel lymph node biopsies and axillary lymph node dissections), as well as patients who had immediate reconstruction following mastectomy.
  • The most common curative treatment method for localized colorectal cancer is surgery.
  • The goals of colorectal cancer surgery are to remove cancer completely, remove adjacent lymph nodes and rejoin the bowel to provide normal (or near normal) function, when possible.
  • Surgeries to remove colorectal cancer depend on a number of factors, such as tumour location and size, timing of surgery, cancer stage and patient status and preferences.

These surgeries can fall into the following categories [2] :

    • Partial colectomy (removal of part of the colon, such as a right or left hemicolectomy).
    • Abdominoperineal resection (removal of the sigmoid, rectum and anus).
    • Proctosigmoidectomy (removal of the diseased section of sigmoid colon and rectum).
    • Total abdominal colectomy (removal of the entire colon).
    • Total proctocolectomy (an extensive operation that involves removal of both the rectum and the colon).
      • The section below includes the following surgeries listed above.
    • Lung cancer surgery is a preferred treatment option for non-small cell lung cancer (NSCLC) [3]. However, surgery is not a typical treatment option for small cell lung cancer [4].
      • Surgeries (resections) to remove lung cancer can fall into the following categories [2, 5] :
        • Pneumonectomy (the removal of an entire lung).
        • Lobectomy (the removal of 1 lobe of the lung).
        • Bilobectomy (the removal of 2 lobes of the lung).
        • Segmentectomy (the removal of an anatomic division of a particular lobe of the lung).
        • Wedge resection (the removal of a small portion of a lobe of the lung that includes the tumour and a margin of surrounding normal tissue).
      • The data below specifically describe patients who have undergone a lobectomy or bilobectomy, since these are the most common procedures performed.
    • Prostate cancer surgery is a common treatment option for patients with localized prostate cancer [6].
      • Radical prostatectomy is the surgical procedure used to treat prostate cancer, and it involves removing the prostate gland and some of the tissue surrounding it [7].
      • The data for prostate surgery include patients who underwent a radical prostatectomy.
    • Surgery is the main treatment for thyroid cancer, except for certain anaplastic thyroid cancers.
      • The primary goal of thyroid cancer surgery is to remove the tumour and, if required, some surrounding healthy tissue.
      • The 2 main types of thyroid cancer surgery are:
        • Partial thyroidectomy (removal of a single lobe of the thyroid gland with or without removal of the thyroid isthmus and the medial portion of the contralateral lobe).
        • Total thyroidectomy (removal of the entire thyroid gland).
      • In conjunction with the thyroidectomy procedure, removal of adjacent lymph nodes (known as a lymphadenectomy or lymph node dissection) may be performed if there is the possibility that cancer has spread to the lymph nodes in the neck.
      • The data below include patients who had a partial or total thyroidectomy, with or without a lymph node dissection.

What is an unplanned visit after cancer surgery?

  • An unplanned visit occurs when a patient returns to the emergency department (ED) or is readmitted directly to the hospital within 30 days of a cancer surgery.

Figure 1. Percentage of patients who had lung surgery and an unplanned emergency department visit or were readmitted within 30 days after surgery, fiscal year 2015/2016 to fiscal year 2016/2017

More information regarding the methodology is available.

Report date: December 2017

Data source: CIHI-DAD, CIHI-NACRS

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note: Numbers shown are for Ontario. Groups are mutually exclusive. Dashed-line frame denotes data included in Figure 2.  † Values have been suppressed due to small cell counts.

 

Figure 2. Percentage of patients who had lung surgery and an unplanned emergency department visit or who were readmitted within 30 days after surgery (lobectomy or bilobectomy), fiscal year 2015/2016 to fiscal year 2016/2017, by designated centre of surgery

More information regarding the methodology is available.

Report date: December 2017

Data source: CIHI-DAD, CIHI-NACRS

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions
  2. † Values have been suppressed due to small cell counts

 

Figure 3. Percentage of patients who had bladder, breast, colorectal, prostate or thyroid surgery for cancer and an unplanned emergency department visit or who were readmitted within 30 days after surgery, fiscal year 2015/2016 to fiscal year 2016/2017

More information regarding the methodology is available. This figure used multiple methodologies including Methodology 2.2.b, Methodology 2.2.c, Methodology 2.2.d, Methodology 2.2.e and Methodology 2.2.f.

Report date: December 2017

Data source: CIHI-DAD, CIHI-NACRS

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note: 

  1. Numbers shown are for Ontario. Groups are mutually exclusive
  2. Due to rounding, percentages may not add up to 100%.

 

Figure 4. Percentage of patients who had bladder, breast, colorectal, prostate, thyroid surgery for cancer and an unplanned emergency department visit or who were readmitted within 30 days after surgery, fiscal year 2015/2016 to fiscal 2016/2017, by Local Health Integration Network (LHIN) of surgery

More information regarding the methodology is available. This figure used multiple methodologies including Methodology 2.2.b, Methodology 2.2.c, Methodology 2.2.d, Methodology 2.2.e and Methodology 2.2.f.

Report date: December 19, 2017

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

 

Figure 5. Number of patients who had an unplanned emergency department visit or who were readmitted within 30 days after surgery, by disease site

More information regarding the methodology is available. This figure used multiple methodologies including Methodology 2.2.b, Methodology 2.2.c, Methodology 2.2.d, Methodology 2.2.e and Methodology 2.2.f.

Report date: January 19, 2018

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

 

Data Table 2. Percentage of patients who had lung surgery and an unplanned emergency department visit or who were readmitted within 30 days after surgery (lobectomy or bilobectomy), fiscal year 2015/2016 to fiscal year 2016/2017, by designated centre of surgery

Designated centre of surgery Percentage unplanned ED visits Unplanned ED visits lower confidence interval Unplanned ED visits upper confidence interval Percentage unplanned readmissions Readmissions lower confidence interval Readmissions upper confidence interval Percentage unplanned ED visits or readmissions Unplanned ED visits or readmissions lower confidence interval Unplanned ED visits or readmissions upper confidence interval
Province 17.0 15.6 18.4 6.1 5.2 7.0 23.1 21.5 24.6
WRH 11.5 2.7 20.3 6.6 0.0 13.6 18.0 7.6 28.5
LHSC 20.5 15.0 26.1 6.7 3.2 10.2 27.2 21.2 33.3
SMGH 22.4 15.6 29.3 8.3 3.7 13.0 30.8 23.2 38.3
STJOEHAM 9.9 7.1 12.6 8.2 5.7 10.8 18.1 14.6 21.6
OSLERHC 24.2 15.1 33.4 9.5 3.1 15.9 33.7 23.7 43.7
THP 9.8 4.1 15.5 4.1 0.2 8.0 13.9 7.4 20.5
STJOETOR 10.3 3.7 16.9 4.1 0.0 8.6 14.4 6.9 21.9
UHN 15.0 11.2 18.8 5.2 2.8 7.6 20.2 16.0 24.5
TEGH 12.4 8.1 16.6 5.2 2.2 8.1 17.5 12.6 22.4
SLRHC 17.4 9.9 25.0 7.3 2.0 12.7 24.8 16.2 33.3
LAKE 14.1 10.0 18.3 3.0 0.9 5.2 17.2 12.7 21.6
KGH/HDH 25.4 13.5 37.4 5.1 0.0 11.5 30.5 17.9 43.1
OTTAWA 25.0 20.0 30.0 6.3 3.4 9.1 31.3 25.9 36.6
HSN 23.4 15.5 31.2 6.5 1.7 11.2 29.8 21.4 38.3
TBH 37.3 23.0 51.5 3.9 0.0 10.2 41.2 26.7 55.7
NON-DC 45.2 26.0 64.3 3.2 0.0 11.1 48.4 29.2 67.6

Report date: December 2017

Data source: CIHI-DAD, CIHI-NACRS

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions
  2. † Values have been suppressed due to small cell counts

 

Data Table 4. Percentage of patients who had bladder, breast, colorectal, prostate, thyroid surgery for cancer and an unplanned emergency department visit or who were readmitted within 30 days after surgery, fiscal year 2015/2016 to fiscal 2016/2017, by Local Health Integration Network (LHIN) of surgery

LHIN Acronym Percentage total unplanned visits after bladder surgery Lower confidence interval after bladder surgery Upper confidence interval after bladder surgery Percentage total unplanned visits after breast surgery Lower confidence interval after breast surgery Upper confidence interval after breast surgery Percentage total unplanned visits after colorectal surgery Lower confidence interval after colorectal surgery Upper confidence interval after colorectal surgery Percentage total unplanned visits after prostate surgery Lower confidence interval after prostate surgery Upper confidence interval after prostate surgery Percentage total unplanned visits after thyroid surgery Lower confidence interval after thyroid surgery Upper confidence interval after thyroid surgery
Province ON 35.9 33.3 38.6 14.2 13.8 14.6 23.4 22.7 24.2 25.1 23.9 26.3 12.6 11.9 13.3
Erie St. Clair ESC 38.5 24.3 52.6 14.1 12.3 15.9 20.7 17.4 24.0 19.9 14.3 25.5 14.6 11.1 18.0
South West SW 37.8 30.1 45.5 16.6 15.1 18.1 28.9 26.3 31.5 32.6 28.4 36.8 17.1 13.8 20.3
Waterloo Wellington WW 47.4 30.2 64.6 13.1 11.4 14.9 21.8 18.6 25.0 28.8 16.4 41.2 14.4 10.3 18.4
Hmltn-Ngr-Hldmnd-Brnt HNHB 34.3 26.9 41.8 14.9 13.7 16.1 21.6 19.5 23.7 22.4 19.4 25.5 16.1 12.7 19.4
Central West CW 31.4 14.6 48.2 10.2 8.6 11.8 16.2 12.7 19.6 22.0 16.0 28.0 9.4 6.8 12.0
Mississauga Halton MH 23.6 11.5 35.8 14.7 13.3 16.0 18.8 16.2 21.4 24.7 18.8 30.5 7.6 5.6 9.6
Toronto Central TC 36.7 31.3 42.1 10.7 9.9 11.5 26.1 23.9 28.2 24.2 21.6 26.9 11.9 10.5 13.2
Central Cen 28.2 18.1 38.4 12.6 11.5 13.7 19.9 17.8 22.1 26.4 22.1 30.8 10.3 8.2 12.5
Central East CE 37.4 27.8 47.0 14.3 13.1 15.5 22.1 19.9 24.4 22.0 18.4 25.7 11.2 9.2 13.2
South East SE 32.4 16.0 48.9 18.9 16.7 21.2 23.9 20.1 27.7 24.8 16.4 33.2 14.4 7.7 21.2
Champlain Ch 44.3 35.4 53.2 16.5 15.2 17.8 23.4 21.1 25.8 25.2 21.4 29.1 17.7 14.3 21.1
North Simcoe Muskoka NSM 16.7 0.0 33.7 19.3 16.9 21.6 25.0 21.1 28.9 23.3 16.1 30.5 16.2 11.2 21.2
North East NE 46.0 28.5 63.4 16.4 14.4 18.4 30.0 26.4 33.6 29.6 21.7 37.4 13.5 9.3 17.6
North West NW 12.5 0.0 31.8 24.0 20.0 28.1 39.5 32.8 46.1 59.5 42.3 76.6 17.6 10.5 24.7

Report date: December 19, 2017

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

 

Data Table 5. Number of patients who had an unplanned emergency department visit or who were readmitted within 30 days after surgery, by disease site

Province Bladder Breast Colorectal Prostate Thyroid
ON 459 4,765 3,031 1,231 1,061

Report date: January 19, 2018

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

 

Figure 1. Percentage of patients who had lung surgery and an unplanned emergency department visit or were readmitted within 30 days after surgery, fiscal year 2015/2016 to fiscal year 2016/2017

The figure is a flow chart with 19 labeled boxes linked by lines.

Here the flow chart is presented as lists in which the connections are listed beneath each box label. Each box label includes the relevant number and percentage of cancer patients who had a lung resection.

  1. Patients who had lung surgery for cancer treatment: N=5515
    1. Connects to Pneumonectomy: N=223 (4%)
      1. Connects to ED visit only: N=41 (18%)
      2. Connects to No ED/Admission visit: N=156 (70%)
      3. Readmitted: N=26 (12%)
      4. Connects to Via ED: N=†
      5. Connects to Direct readmission: †
    2. Connects to Lobectomy/Bilobectomy: N=2833 (51%)
      1. Connects to ED visit only: N=481 (17%)
      2. Connects to No ED/Admission visit: N=2180 (77%)
      3. Readmitted: N=172 (6%)
      4. Connects to Via ED: N=147 (5%)
      5. Connects to Direct readmission: N=25 (1%)
    3. Connects to Segmentectomy/Wedge resection: N=2459 (45%)
      1. Connects to ED visit only: N=410 (17%)
      2. Connects to No ED/Admission visit: N=1900 (78%)
      3. Readmitted: N=149 (6%)
      4. Connects to Via ED: N=116 (5%)
      5. Connects to Direct readmission: N=33 (1%)

Figure 3. Percentage of patients who had bladder, breast, colorectal, prostate or thyroid surgery for cancer and an unplanned emergency department visit or who were readmitted within 30 days after surgery, fiscal year 2015/2016 to fiscal year 2016/2017

The figure is a flow chart with 6 labeled boxes linked by lines.

Here the flow chart is presented as lists in which the connections are listed beneath each box label. Each box label includes the relevant number and percentage of cancer patients who had a breast, bladder, colorectal, prostate or thyroid resection.

  1. Patients who had cancer surgery:
    • Bladder N= 1,277
    • Breast N=33,527
    • Colorectal N=12,941
    • Prostate N=4,909
    • Thyroid N=8,436
      1. Connects to ED visit only:
        • Bladder N=235 (18%)
        • Breast N=3,535 (10%)
        • Colorectal N=1,813 (14%)
        • Prostate N=1,078 (22%)
        • Thyroid N=855 (10%)
      2. Connects to Readmitted:
        • Bladder N=224 (17%)
        • Breast N=1,230 (4%)
        • Colorectal N=1,218 (9%)
        • Prostate N=153 (3%)
        • Thyroid N=206 (2%)
          1. Connects to Via ED
            • Bladder N=162 (13%)
            • Breast N=294 (1%)
            • Colorectal N=944 (7%)
            • Prostate N=129 (3%)
            • Thyroid N=95 (1%)
          2. Connects to Direct readmission
            • Bladder N=62 (5%)
            • Breast N=936 (3%)
            • Colorectal N=274 (2%)
            • Prostate N=24 (1%)
            • Thyroid N=111(1%)
      3. Connects to No ED/Admission visit:
        • Bladder N=818 (64%)
        • Breast N=28,762 (86%)
        • Colorectal N=9,910 (77%)
        • Prostate N=3,678 (75%)
        • Thyroid N=7,375 (87%)

What do the results show?

Among patients who underwent lung surgery for a lobectomy or bilobectomy, 23% had an unplanned emergency department visit or were readmitted to hospital within 30 days following surgery (Figures 1 and 2).

  • Patients described in these figures include those who had lobectomies or bilobectomies.
  • Among the patients who underwent lung surgery for lobectomies or bilobectomies from fiscal year 2015/2016 to fiscal year 2016/2017, 23% had an unplanned hospital visit, with 6% of patients being readmitted to the hospital and 17% having an ED visit only.
  • ED visits for lobectomy or bilobectomy patients varied significantly between designated thoracic surgery centres, with St. Joseph’s Hamilton, Trillium Health Partners and St. Joseph’s Toronto having the lowest rates of unplanned hospital visits (10%). Thunder Bay Regional Health Sciences Centre had the highest rate (37%).
  • Readmission rates ranged from 3% at Lakeridge Health Corporation to 9% at William Osler Health Centre.
  • The unplanned hospital visit rate in non-designated thoracic centres is 48%. It is important to note, however, that the volumes are very low because the vast majority of thoracic resections in Ontario (99%) are performed at one of 15 designated thoracic surgery centres.

The percentage of patients who visited the emergency department or were readmitted to hospital within 30 days following cancer surgery varied by disease site (Figures 3 and 4).

  • The provincial average of patients who visited the hospital within 30 days after cancer surgery from fiscal year 2015/2016 to fiscal year 2016/2017 was 36% for bladder cancer, 14% for breast cancer, 23% for colorectal cancer, 25% for prostate cancer and 13% for thyroid cancer.
  • Prostate cancer patients had the highest rate of ED visits of the 5 disease sites (22%). Bladder patients had the highest readmission rate of the 5 disease sites (17%).
  • There was some regional variation for unplanned hospital visits across all 5 disease sites. For instance, about 13% of patients from North West LHIN who had bladder cancer surgery had an unplanned hospital visit. The rate was 47% in Waterloo Wellington LHIN.
  • Central West LHIN had the lowest reported rate of unplanned hospital visits within 30 days following breast (10%) and colorectal surgery (16%). The LHIN with the lowest rate of unplanned hospital visits within 30 days for prostate cancer was Erie St. Clair (20%). Mississauga Halton had the lowest rate for thyroid cancer (8%).
  • North West LHIN had the highest percentage of reported unplanned visits across the remaining 4 disease sites with breast (24%), colorectal (39%), prostate (59%) and thyroid (18%). Champlain LHIN also had an unplanned visits rate of 18% for thyroid cancer.
  • Unplanned hospital visits also are reported for patients undergoing chemotherapy treatment

The number of patients who visited the emergency department or who were readmitted to hospital within 30 days following cancer surgery by number of cases (Figure 5).

  • The total number of unplanned hospital visits within Ontario from fiscal year 2015/2016 to fiscal year 2016/2017 was lowest for bladder cancer (459 visits). Breast cancer was the highest with 4,765 visits.
  • Additionally, there were a total of 3,031 unplanned visits for colorectal cancer, 1,231 for prostate cancer and 1,061 for thyroid cancer within 30 days following cancer surgery.

Why is this important to patient care?

  • Looking at unplanned visits after bladder, breast, colorectal, lung and thyroid cancer surgery allows us to monitor the complications and adverse events following cancer surgeries.
  • There may be some complications after cancer surgery that require the patient to return to the hospital, but others may be appropriately managed in different ways. Common problems include bleeding, infection, pain and slow recovery of other body functions [1].

Find out more:

Notes

  1. A Guide to Cancer Surgery [Internet]. American Cancer Society; c2018 [cited 2018 Jan 24]. Available from here.
  2. Colorectal Cancer Surgery [Internet]. WebMD: c2005–2018 [cited 2018 Mar 6]. Available from here.
  3. Park BJ, Altorki NK. Diagnosis and management of early lung cancer. Surg Clin N Am. 2002;82(3):457–76.
  4. Darling G, Nenshi R, Schultz SE, Gunraj N, Wilton AS, Simunovic M, et al. Surgery for lung cancer. In: Urbach DR, Simunovic M, Schultz SE, editors. Cancer surgery in Ontario: ICES atlas. Toronto: Institute for Clinical Evaluation Sciences; 2008.
  5. Nakamura H, Kazuyuki S, Kawasaki N, Taguchi M, Kato H. History of limited resection for non-small cell lung cancer. Ann Thor Card Surg. 2005;11(6):356–62.
  6. Klein EA. Radical prostatectomy for localized prostate cancer. In: Post T, editor. UpToDate. Waltham (Mass): UpToDate; 2016.
  7. Schaeffer EM, Partin AW, Lepor H, Wash PC. Radical retropubic and perineal prostatectomy. In Campbell MF, Kavoussi LR, Wein AJ, editors. Campbell-Walsh Urology, 10th ed. Volume 3. Philadelphia: Saunders; 2012. p. 2801–2829.