A study including data from 346 hospitals found that readmissions during the first 30 days after surgery were associated with new complications—post-discharge problems related to the surgical procedure—and not, as previously suspected, to the worsening of medical conditions the patient already had or acquired while hospitalized for surgery.
In this study, published in the February 3 issue of JAMA, Ryan P. Merkow, MD, MS, a clinical scholar in residence at the American College of Surgeons, now chief surgery resident at the University of Chicago, and colleagues examined the reasons, timing, and factors associated with unplanned postoperative hospital readmissions within 30 days after surgery.
Financial penalties for readmissions have made them an important quality and cost-containment issue for hospitals and clinicians. Hospitals try to reduce readmissions, but until now little has been known about the reasons for readmission after surgery. Identifying these reasons could advance quality-improvement efforts and reduce surgical readmissions.
“The Hospital Readmission Reduction Program is federal law and is here to stay,” Merkow said. “Hospital administrators and quality departments must determine how to approach readmissions, and in particular readmissions after surgery.”
“Until recently, efforts were primary focused on medical conditions,” he said, “namely heart failure, myocardial infarction and pneumonia. However, a growing emphasis by policy makers now specifically targets readmissions after surgery. Yet, surprisingly, little is known about why surgical patients are being readmitted. It is completely unclear if oversight initiatives such as public reporting and pay-for-performance should be similarly applied to both medical and surgical patients.”
“Unlike patients being admitted for a medical condition, surgical patients experience a discrete, invasive event (i.e., surgery) with known risks of complications,” Merkow said. “We believe this study definitively separates medical and surgical readmissions as distinct entities that require unique reduction strategies.”
In this study, the unplanned 30-day readmission rate following 498,875 operations was 5.7 percent. Rates ranged from 3.8 percent after hysterectomy to 14.9 percent after lower-extremity vascular bypass. Only 2.3 percent of patients were readmitted for a complication they had experienced during their index hospitalization.
The researchers found that the most common reason for unplanned readmissions was surgical-site infections, followed by intestinal ileus or obstruction, bleeding or anemia, blood clots, and surgical-device issues. Surgical-site infections (SSI) ranged from 11.4 percent after bariatric surgery to 36.4 percent after lower extremity vascular bypass.
The study included data from almost 500,000 patients undergoing surgery at one of 346 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program during calendar year 2012. Readmission rates and reasons were assessed for all surgical procedures and for six representative operations: bariatric procedures, colectomy or proctectomy, hysterectomy, total hip or knee arthroplasty, ventral hernia repair, and lower extremity vascular bypass.
The findings have at least two significant policy implications, the authors insist. First, because most readmissions result from post-operative complications, “readmissions after surgery penalize hospitals twice.” And second, because it has been difficult to reduce the most common post-operative complications, such as surgical site infections, penalizing hospitals for problems they do not know how to prevent could be counterproductive, leading to untested solutions that may be ineffective or even counterproductive.
“Understanding the underlying reasons for readmission, the timing, and the associated factors should help hospitals undertake targeted quality-improvement initiatives to reduce readmissions,” the authors wrote. “However, surgical readmissions mostly reflect post-discharge complications, and readmission rates may be difficult to reduce until effective strategies are put forth to reduce common complications such as SSI.”
Efforts should focus on reducing complication rates overall rather than just those that occur after discharge, the authors insist. “This will subsequently reduce readmission rates as well. Readmissions after surgery may not be an appropriate measure for pay-for-performance programs but rather better suited as a measure for hospitals to track internally.”
“The findings reported by Merkow et al are noteworthy,” according to an accompanying editorial by Lucian L. Leape, MD, of the Harvard School of Public Health. “They contrast with most readmission studies that rely on administrative data, which are known to have major deficiencies.”
Instead, this study provides “an unprecedented opportunity to apply these lessons to make substantial reductions in surgical complications,” Leape added.
“The authors make several useful suggestions as to how these findings could be used to reduce readmissions,” he wrote, “but an important question is how can the data be used to reduce the pain and suffering that complications cause for patients?”