Accepted Manuscript

Title: Hospital Charges and Length of Stay Following Radical Cystectomy in

the ERAS Era

Author: Alice Semerjian, Niv Milbar, Max Kates, Michael A. Gorin, Hiten D.
Patel, Heather J. Chalfin, Steven M. Frank, Christopher L. Wu, William W.
Yang, Deb Hobson, Lindsay Robertson, Elizabeth Wick, Mark P. Schoenberg,
Phillip M. Pierorazio, Michael H. Johnson, C.J. Stimson, Trinity J. Bivalacqua

PII: S0090-4295(17)30991-3
DOI: https://doi.org/doi:10.1016/j.urology.2017.09.010
Reference: URL 20668

To appear in: Urology

Received date: 11-4-2017

Accepted date: 8-9-2017

Please cite this article as: Alice Semerjian, Niv Milbar, Max Kates, Michael A. Gorin, Hiten D.
Patel, Heather J. Chalfin, Steven M. Frank, Christopher L. Wu, William W. Yang, Deb Hobson,
Lindsay Robertson, Elizabeth Wick, Mark P. Schoenberg, Phillip M. Pierorazio, Michael H.
Johnson, C.J. Stimson, Trinity J. Bivalacqua, Hospital Charges and Length of Stay Following
Radical Cystectomy in the ERAS Era, Urology (2017),
https://doi.org/doi:10.1016/j.urology.2017.09.010.

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Hospital Charges and Length of Stay Following Radical Cystectomy in the ERAS Era

Alice Semerjian1, Niv Milbar1, Max Kates1, Michael A. Gorin1, Hiten D. Patel1, Heather
J. Chalfin1, Steven M. Frank2, Christopher L. Wu2, William W. Yang2, Deb Hobson3,
Lindsay Robertson3, Elizabeth Wick4, Mark P. Schoenberg5, Phillip M. Pierorazio1,
Michael H Johnson1, C.J. Stimson1,Trinity J. Bivalacqua1

1 The James Buchanan Brady Urological Institute and Department of Urology, Johns
Hopkins University School of Medicine, Baltimore, MD
2 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins

University School of Medicine, Baltimore, MD

3 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore,

MD
4 Division of General Surgery, UCSF, San Francisco, CA
5Montefiore Medical Center and Albert Einstein College of Medicine, Department of

Urology, Bronx, NY

Corresponding Author:
Alice Semerjian MD
The James Buchanan Brady Urological Institute and Department of Urology
Johns Hopkins University School of Medicine
600 N. Wolfe Street, Marburg 134
Baltimore, MD 21287
Email: asemerj1@jhmi.edu
Phone: (202)270-5541
Fax: (410)502-7711

Abstract word count: 249

Manuscript word count: 2,853
Conflicts of Interest: None

Acknowledgements: No financial support or disclosures.

Keywords: cystectomy, enhanced recovery, clinical pathway, ERAS

Page 1 of 20
Abstract:

Objective: To report our center’s experience with Enhanced Recovery after

Surgery (ERAS) pathway for radical cystectomy (RC), specifically evaluating
complications, LOS, 30- and 90-day readmissions, and hospital charges.
Pathways of this type have been shown to decrease length of stay (LOS) and post-
operative ileus. However, concerns persist that ERAS is costly and increases
readmissions. To date, limited studies have evaluated these concerns.

Materials and Methods: Our ERAS protocol was implemented for RC in December
2015. Outcomes in ERAS patients were compared to those in RC patients from the
time period prior to ERAS. Patients were excluded if they underwent concomitant
nephroureterectomy.

Results: 56 consecutive ERAS patients were compared to 54 pre-ERAS patients.

Median charge for index hospitalization was $31,090 in the ERAS group and
$35,489 in the pre-ERAS group (p=0.036). Median LOS was 5.0 days in ERAS and
8.5 days in pre-ERAS (p=<0.001). The pre-ERAS group had a significantly increased
use of nasogastric tube (13.8% vs. 30.0%) and parenteral nutrition (6.9% vs.
20.4%). Overall complication rate (including infectious, renal, DVT/PE, MI/stroke,
respiratory and GI-related complications) was similar between both groups (51.7%
in ERAS and 62.0% in pre-ERAS, p=0.28). 30- and 90- day readmissions also
remained similar (19.0% vs. 14.8%, p=0.55 and 31.0% vs. 27.7%, p=0.64). The most
common readmission reason was infection, specifically UTI.

Conclusions: Implementation of the ERAS pathway at our center resulted in

significantly reduced LOS and total hospital charge, with comparable rates of
complication and readmission, highlighting the need for ERAS pathways in patients
undergoing RC.

Introduction:

Radical cystectomy is among the most complex and high-risk procedures

performed by urologists.1,2,3 Major or minor complications are reported in

approximately 60% to 80% of patients in most series.1,2 In a National Surgical

Quality Improvement Program analysis, length of hospital stay (LOS) was

Page 2 of 20
reported to be 10.75 days.3 A significant contributor to LOS is slowed return of

bowel function and early gastrointestinal complications in addition to infection,

specifically of the urinary tract.4

Enhanced recovery after surgery (ERAS) protocols were originally

developed by colorectal surgeons and have been shown to decrease both GI

related complications and LOS.5,6 Similar evidence-based protocols have been

developed in the radical cystectomy (RC) population to accelerate recovery and

improve quality.7,8 Several centers have adapted ERAS protocols and have seen
1,9,10,11,12
a decreased LOS without increased complications. Although both a

clinical and cost benefit has been clearly demonstrated in the colorectal

population, there is a paucity of information about cost-effectiveness with

implementation of ERAS in urologic patients. 7,13, 14

The ERAS protocol at our institution was developed to mirror the protocols

demonstrating success at other centers. We report our preliminary experience,

specifically 30- and 90- day complication rates, readmission rates, and

comparative hospital charge data. With the implementation of ERAS protocol in

our RC population, we found a significant decrease in LOS by 3.5(p<0.0001)

days and decrease hospital charges by an average $4,399(p=0.036), while

readmission rates and complication rates remained similar between the two

cohorts.

Materials and Methods:

Page 3 of 20
Study Population:

IRB approval was obtained for our evaluation of our ERAS protocol in the

RC population. All consecutive patients diagnosed with urothelial carcinoma and

underwent RC (both open and robotic) from December 2015 to May 2016 were

included in our prospective study. In the ERAS cohort, 14% of RC was

performed robotically versus 4% in the pre-ERAS cohort (p=0.054); all urinary

diversions were performed extracorporeally. The same ERAS pathway was

applied regardless of approach or diversion type. Patients were excluded if they

underwent additional procedures such as nephroureterectomy. Characteristics

and outcomes of the ERAS group were compared to a historical cohort of

consecutive patients who underwent RC prior to the initiation of ERAS from

February 2014 to July 2014. Four urologists specializing in bladder cancer (TB,

PP, MS and MJ) performed all cystectomies.

ERAS Pre-operative Protocol:

Patients were given information packets outlining specific instructions and

expectations for their hospitalization and discharge. No pre-operative bowel prep

was administered; patients were instructed to continue a regular diet the day

prior to cystectomy and encouraged to carbohydrate load by drinking Gatorade

(16 oz.) up to two hours prior to surgery.15 All patients were given alvimopan

within one hour of surgery, a standardized multimodal analgesic/antiemetic

prophylactic regimen (acetaminophen, gabapentin, transdermal scopolamine),

and a thoracic epidural placement pre-operatively unless specifically

Page 4 of 20
contraindicated. Intravenous antibiotics were initiated prior to cystectomy and re-

dosed for the first 24 hours.

ERAS Intra-operative Protocol:

For open surgical procedures, a standardized intraoperative anesthetic

using epidural anesthesia with local anesthetics and total intravenous anesthesia

with propofol was administered with the goal of minimizing intraoperative opioids

and preserving perioperative immune function. For robotic cases, an

intraoperative infusion of intravenous lidocaine and postoperative transversus

abdominis plane block was used in place of the epidural. The intraoperative goal

for fluid management was euvolemia, which was achieved with an initial Lactate

Ringer’s (LR) carrier at 125-200 ml/hr, with hypotension due to hypovolemia

treated with phenylephrine, additional boluses of 250-500ml LR or albumin to

replace fluid losses/boluses. In addition, a lung-protective ventilation strategy

(tidal volume = 6-8 ml/kg of predicted body weight, PEEP 2-5) was utilized.

Routine placement of OG and NG tube during surgery was not performed.

At the conclusion of the case, we used an incisional wound VAC closure

device (KCI Medical, San Antonio, TX) for all incisions in patients of one surgeon

(TB). 82% of patients in the ERAS cohort received a VAC at the conclusion of

their cystectomy. The midline fascia was closed with interrupted 1-0 PDS suture

and subcutaneous tissue closed with running 3-0 Vicryl suture. The wound was

thoroughly irrigated and coated with Betadine scrub. 3-0 Vicryl subdermal

sutures were used to re-approximate the skin edges. Restore contact layer

Page 5 of 20
(Hollister Woundcare, Libertyville, IL) was applied to the length of the incision,

covered with a black sponge and sealed with VAC dressing. A VAC device was

applied and placed to low continuous suction. The VAC was left in place

throughout the duration of the hospitalization, changed every three days, and

replaced with steri-strips placed at discharge. See Figure 1.

ERAS Post-Operative Protocol:

Alvimopan was continued post-operatively until the patient had a bowel

movement. A multimodal analgesic regimen maximizing non-opioid analgesics

was utilized, including continuation of epidural with a local anesthetic only (no

opioid) in conjunction with scheduled doses of acetaminophen, gabapentin,

transdermal lidocaine unless contraindicated. Ketorolac was also started on

POD#1 if the patient’s renal function allowed. For breakthrough pain, tramadol

was available on an as needed (PRN) basis. No standing or patient controlled

demand opioid medications were ordered; opioids were reserved for

breakthrough pain not controlled with the above regimen. An NGT was only

inserted if indicated for nausea, vomiting or signs of ileus. A clear liquid diet was

initiated immediately post-operatively and full liquid diet was started on POD#2,

then advanced to regular diet as tolerated. Patients received prophylaxis with a

proton pump inhibitor. Patients started ambulation on the night of surgery.

ERAS Post-Discharge Protocol:

Page 6 of 20
 Patients were considered ready for discharge when they had adequate

pain control, had received satisfactory instruction on the use of stoma supplies

and urinary collection devices or were comfortable managing and irrigating their

own neobladder, were able to tolerate adequate diet, and had a bowel

movement.

Routine use of epidural anesthesia, fluid restriction, alvimopan, high dose

non-opioid pain medication, carbohydrate loading, and lack of bowel prep were

not done prior to initiation of ERAS.

Data Collection and Analysis:

Data collection was performed in a prospective fashion to include details

on patient characteristics, disease specific characteristics, hospital course,

complications, hospital charges, and charge breakdown. Data regarding

readmissions for both cohorts was reviewed up to 90 days in a retrospective

fashion. A historical cohort of pre-ERAS patients was compared to the ERAS

cohort. Data was analyzed using STATA.. Continuous variables were compared

with Mann-Whitney (Wilcoxin Rank-Sum) test and categorical variables were

compared with Pearson’s chi-squared tests. P < 0.05 defined significance.

Results:

Page 7 of 20
 At our institution, 56 consecutive patients underwent RC with urinary

diversion between December 2015 (initiation of ERAS protocol) and May 2016

and met all criteria for inclusion. 54 consecutive patients were included in the

historical pre-ERAS cohort. There was no significant difference between the two

groups in terms of age, gender, BMI, Charlson Comorbidity Index, neoadjuvant

chemotherapy use, pathologic T stage, nodal mets, diversion type, or approach

(open vs. robotic). (Table 1).

Median estimated blood loss (EBL) was similar in the ERAS group as the

pre-ERAS group (650cc vs. 725cc, p=0.15). The proportion of ERAS patients

receiving at least one unit of blood was not significantly decreased from the pre-

ERAS patients (32.7% vs. 44.4% respectively, p=0.21). There was lower median

pre-operative hemoglobin in the ERAS group (10.7 mg/dL vs. 11.6 mg/dL,

p=0.04). 9 out of 56 patients in the ERAS group spent at least 1 day in the ICU

compared to 24 out of 54 in the pre-ERAS group (16% vs. 44%, p=0.001). ICU

admission from the operating room was more common in the pre-ERAS group

because intermediate care units and monitored beds on the wards were

introduced and used with frequency by the time ERAS was started. To account

for this system change between the pre-ERAS and ERAS area, we did a

subanalysis to look at differential costs of patients who had no ICU stay. When

excluding patients from both cohorts with any ICU stay, we found that although

slightly more modest, there was still a statistically significant increased charge

associated with room and board in the pre-ERAS group. ($12,172 vs. $9,524,

Page 8 of 20
p<0.05). Surgery time (time from incision to extubation) was similar in the two

groups, (median 263 vs. 261 minutes, p=0.90).

Median LOS was 5.0 days for the ERAS group and 8.5 days for the pre-

ERAS group (p<0.001). The ERAS group had a significantly decreased use of

nasogastric tube (NGT) (13.8% vs. 30.0%, p<0.05) and parenteral nutrition (6.9%

vs. 20.4%, p<0.05). Overall readmission rates were similar. There was a trend

towards higher rate of readmission for GI related complications in the ERAS

group (7% vs. 1.8%, p=0.18), although overall readmission rates were similar

between the two groups. Overall complication rate across all Clavien

classifications was comparable in the ERAS and pre-ERAS groups (51.7% vs.

62.0%, p=0.28).

30- and 90-day readmissions rates were comparable between ERAS and

pre-ERAS (19.0% vs. 14.8%, p=0.55 and 31.0% vs. 27.7% p=0.64). Median LOS

on readmission was 2 (range 1-10) days in the ERAS group and 3 (range 1-36)

days in the pre-ERAS group. The most frequent complication and reason for

readmission was fever secondary to urinary source in both groups (14% in ERAS

and 25.6% in pre-ERAS, p=0.14). Surgical site infections were not significantly

more frequent in the ERAS group (1.8%) compared to the pre-ERAS group

(7.0%, p=0.11), however there was a trend of fewer surgical site infections in the

ERAS group. Other complication rates were similar between ERAS and pre-

ERAS cohorts including MI/stroke (0 vs. 1.8%, p=0.31), respiratory (0 vs. 0),

DVT/PE (1.8% vs. 0, p=0.34), and renal failure (5.2% vs. 3.7%, p=0.81). Social

Page 9 of 20
and other (dehydration, failure to thrive) readmission rates were also similar

(7.1% vs. 7.4%, p=0.93). (Table 2).

Total charge and type of charge data was acquired and compared

between the two cohorts. An overall charge reduction of $4,399 was observed

per patient in the ERAS cohort compared to the pre-ERAS cohort (median

$31,090 vs. $35,489, p=0.036). Figure 2 demonstrates how each charge

component contributes to the total charge per patient. The difference is

accounted for by a significant reduction of room and board associated charges

(median $10,117 vs. $16,122, p<0.001) and charges associated with longer LOS

(radiology, lab). There was a significant increased charge in the ERAS cohort

were pharmacologic ($3,190 vs. $1,014, p<0.001) and supply charges ($5,211

vs. $2,760, p<0.001), from the administration of alvimopan in the pre and post-op

period and placement of incisional wound VAC device. OR charges,

encompassing charges associated with use of the robot were not significantly

increased in either group ($8,849 vs. $9,339, p=0.138), despite increased use of

the robot in the ERAS era. Likely, no significant difference is seen because the

absolute numbers of robotic cases are low in both cohorts, however on sub-

analysis of the ERAS group, we saw that the median OR charge for a robotic

cystectomy was approximately $4,000 more than median charge for open

cystectomy in the same cohort.

Discussion:

10

Page 10 of 20
 Implementation of ERAS protocols has been widely adapted in multiple

surgical specialties with goals to improve or maintain perioperative outcomes

while driving down spending.6,13,16, 17 In the urologic oncology literature, several

1,9-12, 14
reports have demonstrated similar successes. When applied to RC

patients at our institution, the ERAS protocol significantly decreased the LOS by

3.5 days (p<0.001) and overall cost by $4,399 (p=0.036) without adversely

affecting early and late complication or readmission rates.

Our ERAS protocol employs several evidence-based interventions to

decrease time to return of bowel function and gastrointestinal complications in a

multimodal fashion. These include early resumption of oral diet, limited opioids

for pain control, use of epidural anesthesia, no routine use of NGT, elimination of

pre-operative bowel prep, and use of alvimopan. The most common GI

complication following radical cystectomy is post-operative ileus (POI), an entity

1,2,18,19,20
also responsible for prolonged hospitalization following bowel surgery.

Directing efforts at minimizing POI significantly reduces LOS.21 Early oral

feeding and lack of NGT is well tolerated, not associated with increased GI

complications, and results in more rapid progression to meet discharge criteria.

10,17
We saw an NGT insertion rate reduction from 30% to 13% in our series after

initiation of ERAS as a surrogate for POI, without any change in our indications

for NGT placement. This was similar to other series that reported reduction from

31% to 10% and as low as 5% after ERAS.1,22 The colorectal literature has failed

to show an advantage to using pre-operative bowel prep and hence has been

eliminated by many urologists prior to RC.23

11

Page 11 of 20
 Another mainstay of ERAS is limitation of opioid pain medications. We

routinely used epidural anesthesia in all patients until discharge, in addition to

scheduled doses ketorolac, acetaminophen, gabapentin and transdermal

lidocaine. Addition of these medications has been shown to decrease demand of

opioid pain medications for post-operative pain.24 Published series report a

similar pain regiment significantly reduces daily dose of opioids (4.9mg vs.

20.67mg) and POI (7.3% vs. 22.2%) leading to a reduced LOS (4 vs. 8 days).25

While the ERAS protocol is multi-modal, some of the decline of POI is

attributable to epidural anesthesia and lower opioid doses, as a dose-dependent

relationship between opioid use and POI has been demonstrated.26 In addition,

the sympathectomy from epidural blockade acts to enhance gastrointestinal

motility.

In our ERAS group, every patient received alvimopan unless specifically

contraindicated. This μ-opioid receptor antagonist significantly reduces POI and

LOS in radical cystectomy patients.27 Moreover, hospital costs are moderately

reduced with alvimopan use, related to POI treatment and LOS, which offsets the

cost of the medication.28 In the colorectal population, a meta-analysis of RCT’s

shows that ERAS has been associated with a mean cost reduction of about
13
$2000 per patient. The urologic literature lacks this kind of analysis as there

are no RCT’s evaluating ERAS and minimal cost data in existing series. Our

series demonstrated a charge reduction of $4,399 in the ERAS cohort ($31,090

vs. $35,489, p=0.036), mostly accounted for by reduced room and board charges

($10,117 vs. $16,122, p<0.001); this was due to both longer LOS and increased

12

Page 12 of 20
rate of ICU admission in pre-ERAS. The only charges that were significantly

increased in the ERAS cohort was pharmacologic charges ($3,190 vs. $1,014,

p<0.001) and supply charges ($5,211 vs. $2,760, p<0.001) associated with the

use of alvimopan and incisional VAC closure device. Other savings offset this

modest increase in pharmacologic charge in the ERAS group. Nabhani et al.

recently compared their ERAS cohort to historical controls, with an average cost

reduction of $4488 per patient ($31,139 vs. $26,650) and showed similar areas

of cost increases and reductions.14 Our data clearly shows that ERAS protocols

contribute to a significant increase in healthcare savings for the RC patient

without sacrificing quality and safety measures.

A significant reduction in LOS was seen in our ERAS group by a median

of 3.5 days (5.0 vs. 8.5 days). Similar decrease in LOS has been established in

other US and European series.1,10,11,12,18,21,22 Criticism of ERAS focuses on the

premise that complications and readmission will increase, however, in our

series, 30- and 90-day readmissions (19% vs. 14.8% and 31% vs. 27.7%) and

overall number of complications (51.7% vs. 62%) were unchanged. Similar 30-

and 90- day readmission rates were observed in other series, with the most

common reason for early readmission being UTI or ileus.2,19, 29

Although the data for the ERAS group was collected in a prospective

manner, our study is limited by the small sample size of the groups and

comparison to retrospective historical controls. In addition, follow-up data for

both groups was collected retrospectively. With increased experience over time

and growing knowledge of the importance and improvement of certain quality

13

Page 13 of 20
metrics, comparison to a historical cohort may bias in favor of ERAS. The

unmeasured “Hawthorne effect” remains a limitation of our study design. The

best method for study would be a prospective, multi-center randomized control

trial, however, we argue that this is not feasible or ethical with the improved

outcomes already seen in multiple series. Another limitation is post-operative

care fragmentation. As a high-volume academic tertiary care center, it is

expected that some patients may present and be readmitted closer to their home.

Chappidi et al. reported on fragmentation of medical care for urologic oncology

patients. 30- and 90-day readmission rates for cystectomy were underestimated

by 18.5% and 23.0% respectively due to nonindex hospital readmissions.30 This

consideration is certainly not unique to our institution, and we have no reason to

suspect that this underestimation would be different for our pre-ERAS and ERAS

cohorts.

ERAS aims to reduce complications and readmissions and thus decrease

associated charges. Much work still needs to be done to study what specific

changes would decrease complications and readmissions in this particularly at-

risk radical cystectomy population. As these practices are developed, they

should be added to existing pathways and studied in a systematic fashion.

Conclusions:

The ERAS protocol implemented at JHH is a multimodal approach to pre-

operative, intraoperative, and post-operative management of the radical

14

Page 14 of 20
cystectomy patient. Elements of the protocol are evidence-based and have been

utilized in other ERAS protocols. Application of ERAS protocol at our institution

resulted in a significant reduction in hospital length of stay and POI without

adversely affected early or late readmission rates or overall complication rates.

As a result of decreased LOS, total hospital charges were also decreased.

Figure 1. a) Fascia is closed with interrupted 1-0 PDS suture. b) Subcutaneous AUTHOR: Please check if
tissue is closed with a running 3-0 Vicryl suture. c) Interrupted 3-0 Vicryl the Figure 1-2 captions used is correct.
subdermal sutures are used to re-approximate the skin edge. d) VAC device (KCI
Medical, San Antonio, TX) is placed over entire midline incision and placed to low
continuous suction until just prior to discharge.

Figure 2. ERAS and pre-ERAS cost by type of charge.

$35,000

$30,000

$25,000

$20,000

$15,000

$10,000

$5,000

$0
ERAS pre-ERAS
Charge (median, IQR) ERAS Pre-ERAS p-value
Total Charge $31,090 (9,912) $35,489 (21,069) 0.036
Room & Board $10,117 (3,842) $16,122 (10,462) <0.001
OR $8,849 (3,210) $9,339 (3,373) 0.138
Pharmacy $3,190 (812) $1,014 (1128) <0.001
Radiology $0 (485) $334 (1,893) 0.038
Laboratory $1434 (1,032) $2,646 (2,021) <0.001
Supply $5,211 (2,194) $2,760 (1,497) <0.001
Therapy $247 (613) $286 (1,204) 0.197

15

Page 15 of 20
Other $0 (106) $91 (379) 0.001

16

Page 16 of 20
Table 1. Characteristics of Patients in ERAS and pre-ERAS cohorts.
Variable ERAS Pre-ERAS p-
value
No. of Patients n=56 n=54
Median Age (IQR) 68.6 (12.7) 69.5 (9.0) 0.47
Sex
Male (%) 48 (86%) 47 (87%) 0.84
Female (%) 8 (14%) 7 (13%)
Median BMI (kg/m^2) (IQR) 27.1 (4.4) 27.3 (7.4) 0.46
Median Charlson Comorbidity 3 3 0.77
Points
NAC (%) 36 (64%) 34 (63%) 0.89
Pathologic Tumor Stage
pT0 12 (21%) 12 (22%) 0.73
pTis, pTa or pT1 17 (30%) 15 (28%)
pT2 13 (23%) 9 (17%)
pT3 or pT4 14 (25%) 18 (33%)
Nodal Mets (%) 11 (20%) 7 (13%) 0.34
Diversion Type
Orthotopic Neobladder 3 (5%) 3 (6%) 0.96
Continent Cutaneous 0 (0%) 0 (0%)
Diversion
Ileal Conduit 53 (95%) 51 (94%)
Modality of Treatment
Open 48 (86%) 52 (96%)
Robotic 8 (14%) 2 (4%) 0.05
Median First Hb (range) 10.75 (6.5- 11.65 (7.7- 0.043
17) 15.1)

17

Page 17 of 20
Table 2. Percentage of Complications by Type for ERAS and pre-ERAS groups.
Outcome ERAS pre-ERAS p-value
Infection 14.0% 25.6% 0.64
SSI 1.8% 7.4% 0.11
DVT/PE 1.8% 0% 0.34
Renal 5.3% 3.7% 0.81
Respiratory 0.0% .00%
MI/TIA/CVA 0.0% 1.9% 0.31
Transfusion 33.0% 44.0% 0.21
Use of NGT 14.0% 29.6% <0.05
TPN/PPN 7.0% 20.0% <0.05
GI Readmit 7.0% 1.9% 0.18
Overall Complication 51.7% 62.0% 0.28
LOS (days) 5 8.5 <0.01
30-d readmit 19.0% 14.8% 0.55

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