INTRODUCTION

Abdominal stoma surgeries are frequently performed for the management of various medical conditions.1,2 Clinical guidelines and recommendations for best practice, technical aspects, and patient assessment and education have been published.1,3–5 However, large-scale research summaries of patients undergoing ostomy surgery are lacking or limited in scope or generalizability.6–12

Complications following ostomy surgery are prevalent and negatively influence physical health and health-related quality of life.8,10,13–18 Factors that may contribute to complications include short length of stay (LOS), type of surgery, inadequate patient education, and lack of preoperative stoma site marking.3,13,14,18–21 Stoma and peristomal complications are also associated with increased morbidity, likelihood of hospital readmission, and health care utilization.10–13,22

Multiple factors, including hospital LOS, postsurgery LOS, and elective versus emergent procedure, influence patient education options. Recent research evaluating LOS and postsurgery LOS is limited.11,12,19,23–25 National guidelines for elective ostomy surgeries strongly support preoperative preparation (eg, patient education, stoma site selection) by an ostomy nurse specialist.1,4,5

Preoperative patient education and stoma site marking and postoperative ostomy nurse care may help improve patient satisfaction and operative outcomes, decrease LOS, and lessen stoma and peristomal complications.19–21,23,25–28 However, education and counseling must occur postoperatively among those undergoing emergent ostomy surgery.1,4 Additional research on the prevalence of elective surgeries, hospital LOS, and the proportion of patients receiving preoperative stoma site marking is needed.

We assert that a study that capitalizes on real-world data by using a large database of administrative records from hospitals across the United States is essential to characterize patients undergoing abdominal ostomy surgery and their hospital course. Research is also needed to evaluate the rates of hospital readmission and emergency department (ED) visits following ostomy surgery. Knowledge from this research has the potential to inform clinical guidelines for patients’ ostomy management and suggest strategies to improve outcomes in patients undergoing ostomy surgery. The aims of this study were to examine patient characteristics (including demographics, diagnoses, and surgery type), LOS (including LOS following surgery), hospital revisits (ie, hospital readmissions and subsequent ED visits), and stoma and peristomal complications of patients who underwent abdominal ostomy surgery.

METHODS

A retrospective cohort study examining characteristics of patients who underwent ostomy surgery was conducted using data from the PINC AI Healthcare Database (PHD; formerly, Premier Healthcare Database). The PHD is a geographically diverse, all-payer, hospital-based database containing administrative, billing, and service information from inpatient and hospital-based outpatient records from hospitals across the United States. The PHD captures approximately 25% of all US inpatient hospital discharges and includes more than 8 million inpatient and 70 million outpatient encounters across more than 800 providers per year. Patient data were tracked within a hospital system through a unique PHD patient key. The PHD has been certified as de-identified and is not considered human subjects research. Study data and recorded information could not be identified directly or through identifiers linked to individuals. No informed consent was pursued. All data were compliant with the Health Insurance Portability and Accountability Act (HIPAA). As a result of these factors and regulations in the US Title 45 Code of Federal Regulations, Part 46, institutional review board approval for this study was not required.

Data were drawn from all inpatient encounters between December 1, 2017, and November 30, 2018. Patients were 18 years or older and had an International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) code for colostomy, ileostomy, or urostomy creation at hospital discharge (Table 1). Three ostomy cohorts were created based on the type of surgery. Patient encounters were excluded if the patient died or if an ICD-10-PCS procedure code for more than 1 ostomy was identified during the index hospitalization. The index hospitalization was the visit in which an ostomy creation procedure occurred during the study time period.

TABLE 1. - ICD-10-CM Diagnoses and ICD-10-PCS Procedures Used to Define Cohorts and Complications Cohort/Condition ICD-10 Code Colostomy creation/study inclusion Procedure 0D1K0Z4, 0D1K4Z4, 0D1L0Z4, 0D1L4Z4, 0D1N0Z4, 0D1N4Z4, 0D1H074, 0D1H0Z4, 0D1H4Z4, 0D1K074, 0D1L074, 0D1L0J4, 0D1L474, 0D1M074, 0D1M0J4, 0D1M0Z4, 0D1M474, 0D1M4Z4, 0D1M8Z4, 0D1N074, 0D1N0J4, 0D1N3J4, 0D1N474, 0D1N8Z4 Ileostomy creation/study inclusion Procedure 0D190Z4, 0D1A0J4, 0D1A0Z4, 0D1A3J4, 0D1A4J4, 0D1A4Z4, 0D1B074, 0D1B0J4, 0D1B0Z4, 0D1B3J4, 0D1B474, 0D1B4Z4, 0D1B8Z4 Urostomy creation/study inclusion Procedure 0T1607C, 0T160ZC, 0T1647C, 0T164ZC, 0T1707C, 0T170ZC, 0T1747C, 0T174ZC, 0T1807C, 0T180JC, 0T180ZC, 0T1847C, 0T184ZC, 0T160Z9, 0T160ZD, 0T163JD, 0T170ZD, 0T173JD, 0T174ZD, 0T18079, 0T1807D, 0T180Z9, 0T180ZD, 0T184Z9, 0T184ZD Colostomy complications Diagnosis K94.00, K94.01, K94.02, K94.03, K94.09, Z43.3, Z93.3 Ileostomy complications Diagnosis K94.10, K94.11, K94.12, K94.13, K94.19, Z43.2, Z93.2 Urostomy complications Diagnosis N99.510, N99.511, N99.512, N99.518, N99.520, N99.521, N99.522, N99.523, N99.524, N99.528, N99.530, N99.531, N99.532, N99.533, N99.534, N99.538, Z43.6, Z93.6 General complications for use with all ostomies Diagnosis K43.3, K43.4, K43.5, E86.0, K31.5, K56.3, K68.11, N39.0, T81.40, T81.41, T81.42, T81.43, T81.44, T81.49 Other skin complications Diagnosis A49.01, A49.02, A49.1, A49.8, A49.9, B37.9, L08.0, L08.89, L08.9, L24.5, L24.9, L88, L92.8, L98.49 Colostomy reversal/repair Procedure 0DQE0ZZ, 0DQE3ZZ, 0DQE4ZZ, 0DQE7ZZ, 0DQE8ZZ, 0DQF0ZZ, 0DQF3ZZ, 0DQF4ZZ, 0DQF7ZZ, 0DQF8ZZ, 0DQG0ZZ, 0DQG3ZZ, 0DQG4ZZ, 0DQG7ZZ, 0DQG8ZZ, 0DQH0ZZ, 0DQH3ZZ, 0DQH4ZZ, 0DQH7ZZ, 0DQH8ZZ, 0DQK0ZZ, 0DQK3ZZ, 0DQK4ZZ, 0DQK7ZZ, 0DQK8ZZ, 0DQL0ZZ, 0DQL3ZZ, 0DQL4ZZ, 0DQL7ZZ, 0DQL8ZZ, 0DQM0ZZ, 0DQM3ZZ, 0DQM4ZZ, 0DQM7ZZ, 0DQM8ZZ, 0DQN0ZZ, 0DQN3ZZ, 0DQN4ZZ, 0DQN7ZZ, 0DQN8ZZ, 0DQP0ZZ, 0DQP3ZZ, 0DQP4ZZ, 0DQP7ZZ, 0DQP8ZZ Ileostomy reversal/repair Procedure 0DQ80ZZ, 0DQ83ZZ, 0DQ84ZZ, 0DQ87ZZ, 0DQ88ZZ, 0DQ90ZZ, 0DQ93ZZ, 0DQ94ZZ, 0DQ97ZZ, 0DQ98ZZ, 0DQA0ZZ, 0DQA3ZZ, 0DQA4ZZ, 0DQA7ZZ, 0DQA8ZZ, 0DQB0ZZ, 0DQB3ZZ, 0DQB4ZZ, 0DQB7ZZ, 0DQB8ZZ Urostomy reversal/repair Procedure 0TQ60ZZ, 0TQ63ZZ, 0TQ64ZZ, 0TQ67ZZ, 0TQ68ZZ, 0TQ70ZZ, 0TQ73ZZ, 0TQ74ZZ, 0TQ77ZZ, 0TQ78ZZ, 0TQB0ZZ, 0TQB3ZZ, 0TQB4ZZ, 0TQB7ZZ, 0TQB8ZZ, 0TQD0ZZ, 0TQD3ZZ, 0TQD4ZZ, 0TQD7ZZ, 0TQD8ZZ, 0TQDXZZ, 0WQFXZ2

Abbreviation: ICD-10, International Classification of Diseases, Tenth Revision.

Assessed Variables

Patient characteristics examined included age, sex, patients’ self-reported race (ie, Black, White, Other) and ethnicity (ie, Hispanic or Latino), primary insurance payer, and primary discharge diagnosis. Data were collected on multiple characteristics of the index hospital course (ie, hospital admission for ostomy surgery) including procedure type (ie, traditional open abdominal surgery “open” vs endoscopic), LOS, admission type (urgent vs planned), where patients were admitted from (ie, home, clinic, transfer from another hospital), and discharge status. Hospitals submitted these data according to criteria set by the Centers for Medicare & Medicaid Services (CMS). United States Census 2010 geographical region (ie, Midwest, Northeast, South, West) was used for hospital location. Postsurgery LOS was defined as the number of days between the ostomy surgery day and discharge day. Because ostomy hospitalizations are conventionally thought to be brief, short LOS was defined as total LOS of less than 3 days.

The Charlson Comorbidity Index (CCI) was assessed using a modified algorithm with primary or secondary International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes at discharge for the index hospitalization. The CCI is a well-established scale developed to predict 1-year mortality via weighted scores for specific comorbid conditions.29–31 For purposes of this study, the CCI was used to assess the prevalence of comorbid conditions such as myocardial infarction, heart failure, peripheral vascular disease, cerebrovascular disease, dementia, chronic pulmonary disease, rheumatic disease, peptic ulcer disease, diabetes mellitus, hemiplegia or paraplegia, moderate or severe renal disease, malignancies, liver diseases, metastatic solid tumors, and human immunodeficiency virus (HIV) disease. As a marker of severity of illness, CCI score was categorized as low (0-1), moderate (2), or severe (≥3). Total LOS and postsurgery LOS were reported by CCI score. Vitzthum and colleagues32 found the CCI to have an intraclass correlation of 0.74 (95% confidence interval, 0.58-0.87).

All-cause subsequent hospital-based encounters (ie, hospitalization, ED visit) were captured independently up to 120 days after discharge. Thus, patients could have 1 or more of both a hospital readmission and an ED visit following their index visit. Subsequent encounters were reported by cohort according to the top 10 primary diagnoses, LOS, and postsurgery LOS at index hospitalization. Encounters were characterized by subsequent location, primary ICD-10-CM diagnosis codes, and secondary stomal and peristomal complications, such as infection, hemorrhage, malfunction, ostomy status, and irritant contact dermatitis of the peristomal skin (Table 1). Frequency of reversal surgery within 120 days was also examined.

Data Analysis

All characteristics were evaluated using descriptive statistics. Data measured on a continuous scale were expressed as mean, standard deviation, median, and 25th/75th percentiles (or IQR, interquartile range). Categorical data were expressed as counts and percentages of patients in the categories. Proportions (percentages) and number of patients are listed in the various tables. All analyses were completed using SAS software version 9.4 (SAS Institute, Cary, North Carolina).

RESULTS

Data from 27,658 patients undergoing ostomy surgery in 658 hospitals were analyzed; 56.1% underwent a colostomy procedure, 36.9% underwent an ileostomy procedure, and 7.0% had a urostomy procedure. Table 2 summarizes patient and hospital course characteristics; percentages and numbers of patients in each cohort are provided in the table, and the narrative reports percentages of selected cohorts only. The mean age of the entire sample was 62.5 years (SD = 15.1 years); this statistic varied based on type of ostomy created. The colostomy and ileostomy patient cohorts were almost evenly split based on sex, whereas the urostomy cohort was primarily male. Patients self-identified as primarily White, non-Hispanic, or Latino. Nearly half of patients were from hospitals in the Southern region of the United States (48.4%), followed by Midwest (21.5%), Northeast (18.5%), and West (11.7%). Medicare was the primary payer for half of the sample, nearly a third had commercial insurance, and approximately one-tenth had Medicaid. These distributions also varied based on type of ostomy.

TABLE 2. - Patient/Visit Characteristics Overall (N = 27,658) Colostomy (N = 15,512) Ileostomy (N = 10,207) Urostomy (N = 1,939) Age, n (%) 18-44 y 3,341 (12.1) 1,632 (10.5) 1,653 (16.2) 56 (2.9) 45-64 y 11,035 (39.9) 6,209 (40.0) 4,227 (41.4) 599 (30.9) 65-74 y 7,176 (26.0) 3,912 (25.2) 2,556 (25.0) 708 (36.5) 75-84 y 4,560 (16.5) 2,665 (17.2) 1,383 (13.6) 512 (26.4) 85+ y 1,546 (5.6) 1,094 (7.1) 388 (3.8) 64 (3.3) Mean (SD) 62.5 (15.1) 63.5 (14.8) 59.9 (15.7) 68.0 (10.8) Median (Q1, Q3) 64 (54, 73) 64 (54, 74) 62 (51, 71) 69 (62, 76) Sex, n (%) Male 14,117 (51.0) 7,505 (48.4) 5,187 (50.8) 1,425 (73.5) Female 13,541 (49.0) 8,007 (51.6) 5,020 (49.2) 514 (26.5) Race, n (%) White 22,133 (80.0) 12,315 (79.4) 8,218 (80.5) 1,600 (82.5) Black 2,665 (9.6) 1,654 (10.7) 892 (8.7) 119 (6.1) Other/unknown 2,860 (10.3) 1,543 (9.9) 1,097 (10.7) 220 (11.3) Ethnicity, n (%) Hispanic or Latino 2,042 (7.4) 1,121 (7.2) 780 (7.6) 141 (7.3) Non-Hispanic or Latino 20,080 (72.6) 11,272 (72.7) 7,411 (72.6) 1,397 (72.1) Unknown 5,536 (20.0) 3,119 (20.1) 2,016 (19.8) 401 (20.7) Primary payer type, n (%) Medicare 14,438 (52.2) 8,414 (54.2) 4,749 (46.5) 1,275 (65.8) Medicaid 3,243 (11.7) 1,867 (12.0) 1,235 (12.1) 141 (7.3) Private/commercial insurance 8,623 (31.2) 4,342 (28.0) 3,812 (37.4) 469 (24.2) Other/uninsured/unknown 1,354 (4.9) 889 (5.7) 411 (4.0) 54 (2.8) Admission type, n (%) Emergency, urgent, trauma 16,279 (58.9) 11,047 (71.2) 5,040 (49.4) 192 (9.9) Elective (ie, planned) 10,981 (39.7) 4,215 (27.2) 5,026 (49.2) 1,740 (89.7) Unknown/missing 398 (1.4) 250 (1.6) 141 (1.4) 7 (0.4) Admission point of origin, n (%) Non-healthcare facilitya 20,536 (74.3) 11,885 (76.6) 7,346 (72.0) 1,305 (67.3) Clinic 4,593 (16.6) 2,029 (13.1) 1,971 (19.3) 593 (30.6) Transfer from acute care 2,167 (7.8) 1,343 (8.7) 790 (7.7) 34 (1.7) Transfer from SNF or hospice 283 (1.0) 204 (1.3) 76 (0.7) 3 (0.2) Other 79 (0.3) 51 (0.3) 24 (0.2) 4 (0.2) Procedure type, n (%) Endoscopic 6,168 (22.3) 3,282 (21.2) 2,299 (22.5) 587 (30.3) Open 21,434 (77.5) 12,201 (78.7) 7,883 (77.2) 1,350 (69.6) Both endoscopic and openb 42 (0.2) 29 (0.2) 11 (0.1) 2 (0.1) Unknown endoscopic or open 14 (0.1) 0 (0) 14 (0.1) 0 (0) Short length of stay, n (%) Yes (ie, <3 d) 852 (3.1) 475 (3.1) 371 (3.6) 6 (0.3) No (ie, ≥3 d) 26,806 (96.9) 15,037 (96.9) 9,836 (96.4) 1,933 (99.7) Discharge type, n (%) Home/home with home healthcare 18,775 (67.9) 9,855 (63.5) 7,340 (71.9) 1,580 (81.5) Transferred to acute care 357 (1.3) 217 (1.4) 135 (1.3) 5 (0.3) SNF, rehab, ICF, or long-term care 8,182 (29.6) 5,224 (33.7) 2,621 (25.7) 337 (17.4) Other 344 (1.2) 216 (1.4) 111 (1.1) 17 (0.9) All-cause hospital readmission, n (%) 11,638 (42.1) 5,625 (36.3) 5,343 (52.3) 670 (34.6) All-cause subsequent ED visit, n (%) 5,729 (20.7) 3,156 (20.3) 2,280 (22.3) 293 (15.1)

Abbreviations: ED, emergency department; ICD-10-PCS, International Classification of Diseases, Tenth Revision, Procedure Coding System; ICF, intermediate care facility; Q1, Q3, 25th, 75th percentiles; SD, standard deviation; SNF, skilled nursing facility.

aNon-healthcare facility indicates the patient was admitted from home or workplace.

bCategorization as “both endoscopic and open” indicated that more than 1 type of ICD-10-PCS code for the surgical procedure was specified for the surgery.

Admission type varied by ostomy type. Specifically, most patients who underwent a colostomy procedure were admitted emergently, urostomy procedures were primarily elective (planned), and ileostomies were evenly split between emergent and elective admissions. Across ostomy types, admission point of origin for patients was primarily from home, physician's office, or clinic. Less than 10% of patients were transferred from another hospital. Nearly three-fourths or more of ostomy surgeries were completed using an open approach. Most patients were discharged home (23.7%) or home with home healthcare (43.0%).

Within 120 days after index hospitalization, 42.1% of all patients had at least one all-cause hospital readmission and approximately 21% had at least one all-cause subsequent ED visit. There were 16,763 readmission visits and 8605 ED visits after hospital discharge; thus, some patients had multiple readmissions and/or ED visits. Subsequent encounters were evaluated independently, so a single patient may have had both a readmission and an ED visit during the follow-up period. Frequencies of subsequent encounters varied by ostomy cohort. Specifically, about one-third of patients in the colostomy or urostomy cohort had a subsequent hospitalization compared to half of patients in the ileostomy cohort. In contrast, subsequent ED visits were observed in approximately one-fifth of patients in the colostomy or ileostomy cohort compared to 15% of patients in the urostomy cohort.

Hospital and Postoperative LOS

The mean LOS and postsurgical LOS varied by ostomy, procedure, and admission type (Figure, panels A-C; Table 3). Total LOS for patients who underwent a colostomy or ileostomy procedure was 2 to 3 days longer than postsurgery LOS, whereas for patients who underwent a urostomy procedure, LOS and postsurgery LOS were similar and indicative of surgery on day of elective admission. Compared to emergency surgery, average LOS decreased by 3 to 7 days, and postsurgery LOS decreased by 1 to 3 days if the surgery was elective. Compared to open surgery, LOS and postsurgery LOS decreased by 1 to 4 days if the surgery was performed using an endoscopic approach (Figure, panel C). Seventy-three patients (0.3%) were discharged on day of surgery; they were not included in the analysis of postsurgery LOS results. The analysis also revealed a small percentage of all patients undergoing surgery (3.1%, n = 852) who had a particularly short LOS, defined as less than 3 days.

Figure.:

Mean length of stay overall and by ostomy cohort. (A) Length of stay; (B) total LOS by admission type; (C) total LOS by procedure type; and (D) total LOS by CCI score. Error bars indicate standard deviation; LOS, length of stay; CCI, Charleston Comorbidity Index. CCI score was categorized as low (0-1), moderate (2), or severe (≥3).

TABLE 3. - Median Index Length of Stay and Postsurgery LOS Days by Ostomy Cohort and Characteristicsa Overall (N = 27,658) Colostomy (N = 15,512) Ileostomy (N = 10,207) Urostomy (N = 1,939) Overall Total LOS, d 9 (6, 15) 10 (6, 15) 9 (5, 16) 7 (5, 9) Postsurgery LOS, d 7 (5, 10) 7 (5, 12) 7 (5, 13) 7 (5, 9) Emergent admission Total LOS, d 12 (8, 18) 11 (7, 17) 13 (8, 21) 10 (6, 18) Postsurgery LOS, d 8 (6, 13) 8 (6, 12) 9 (6, 16) 7 (6, 12) Elective admission Total LOS, d 6 (4, 9) 6 (4, 10) 6 (4, 10) 7 (5, 9) Postsurgery LOS, d 6 (4, 9) 6 (4, 8) 6 (4, 9) 6 (5, 9) Open surgery Total LOS, d 10 (6, 16) 10 (7, 16) 10 (6, 18) 7 (6, 10) Postsurgery LOS, d 8 (5, 13) 8 (5, 12) 8 (5, 14) 7 (5, 9) Endoscopic procedure Total LOS, d 7 (4, 12) 7 (4, 13) 6 (4, 10) 6 (5, 8) Postsurgery LOS, d 5 (3, 8) 5 (3, 8) 5 (3, 8) 6 (5, 8)

Abbreviation: LOS, length of stay.

aValues are median (25th, 75th percentile); patients with more than 1 procedure or whose procedure type was unknown are excluded from open surgery and endoscopic procedure results.

Primary Diagnosis at Index Hospitalization

Table 4 summarizes the 10 most frequent diagnoses leading to colostomy surgery and the all-cause ED visits and admissions occurring within 120 days of the index hospital stay; the table provides number of patients and percentages, and the narrative provides most pertinent percentages alone. The most frequent primary diagnoses at the index hospitalization for patients who underwent a colostomy procedure were diverticulitis of large intestine (19.6%), malignant neoplasm (17.0%), and sepsis (15.8%). Hospital LOS and postsurgery LOS varied by procedure; they were longest for sepsis: mean = 16.1, SD = 14.0 days, and mean = 12.8, SD = 12.4 days, respectively. The hospital LOS and postsurgery LOS were shortest for index diagnosis of neoplasm of the rectum: mean = 7.3, SD = 6.2 days, and mean = 6.6, SD = 5.7 days, respectively. Subsequent encounters within 120 days of the index hospitalization varied across primary index diagnoses and ranged from 27.1% to 42.6% of patients, with a particular diagnosis being readmitted to a hospital and 16.9% to 24.7% having a subsequent ED visit. Hospital readmissions were least frequent for patients with a primary diagnosis of malignant neoplasm of the rectum and most frequent for patients with a diagnosis of diverticulitis of the large intestine. In contrast, ED visits within 120 days were least frequent for patients with a primary diagnosis at index hospitalization of malignant neoplasm of the rectosigmoid junction and most frequent for patients with a diagnosis of volvulus at the time of ostomy surgery. Approximately one-fifth of patients with an ED visit or hospital readmission had a diagnosis of diverticulitis of the large intestine with perforation at the index hospitalization. More than 40% of all patients who underwent a colostomy procedure had an index hospitalization diagnosis that was not listed in the top 10; this cohort accounted for over 40% of all hospital readmissions and subsequent ED visits.

TABLE 4. - Colostomy Top 10 Most Frequent Primary Diagnosis Categories on Index and All-Cause Subsequent Encounters Within 120 Days Index Visit Hospital Readmission Subsequent ED Visit ICD-10-CM Diagnosis Description [Code #] N % of Index Total LOSa Postsurgery LOSa N % of Readmission Total % of Patients With Diagnosis N % of ED Visit Total % of Patients With Diagnosis 1 Diverticulitis of large intestine with perforation and abscess without bleeding [K57.20] 2,755 17.8% 9 (7, 13) 7 (6, 10) 1,144 20.3% 41.5% 570 18.1% 20.7% 2 Sepsis, unspecified organism [A41.9] 2,448 15.8% 13 (9, 19) 10 (7, 15) 933 16.6% 38.1% 507 16.1% 20.7% 3 Malignant neoplasm of rectum [C20] 1,449 9.4% 6 (4, 9) 5 (4, 7) 392 7.0% 27.1% 262 8.3% 18.1% 4 Malignant neoplasm of sigmoid colon [C18.7] 723 4.7% 9 (6, 13) 7 (5, 10) 208 3.7% 28.8% 140 4.4% 19.4% 5 Malignant neoplasm rectosigmoid junction [C19] 455 2.9% 8 (6, 13) 6 (4, 9) 143 2.5% 31.4% 77 2.4% 16.9% 6 Per other diseases of intestine, perforation intestine (nontraumatic) [K63.1] 305 2.0% 10 (7, 15) 9 (6, 14) 121 2.2% 39.7% 58 1.8% 19.0% 7 Diverticulitis of large intestine without perforation and abscess without bleeding [K57.32] 284 1.8% 9 (6, 14) 7 (4, 10) 121 2.15% 42.6% 63 2.0% 22.2% 8 Volvulus [K56.2] 271 1.8% 9 (6, 15) 7 (5, 12) 100 1.8% 36.9% 67 2.1% 24.7% 9 Fistula of vagina to large intestine [N82.3] 220 1.4% 6 (4, 10) 5 (3, 7) 61 1.1% 27.7% 51 1.6% 23.2% 10 Pressure ulcer sacral region stage 4 [L89.154] 198 1.3% 11 (6, 18) 7 (4, 13) 75 1.3% 37.9% 48