CME: Surgery, Readmission Destinations, & Mortality

CME: Surgery, Readmission Destinations, & Mortality
Author Information (click to view)

Benjamin S. Brooke, MD, PhD

Assistant Professor of Surgery, Division of Vascular Surgery
Director, Utah Intervention Quality & Implementation Research
University of Utah School of Medicine

Benjamin S. Brooke, MD, PhD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

Figure 1 (click to view)
Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:

 

  • Review the findings of a study that examined the association between readmission destination and mortality risk among Medicare beneficiaries who had a complication after undergoing a common operation.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwApr2.  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at dcotterman@akhcme.com.

Credit Available(click to view)

AKH

CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

Physicians
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

 

AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)

FACULTY DISCLOSURES

Keith D’Oria – Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Benjamin S. Brooke, MD, PhD
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH and PHYSICIAN WEEKLY’S STAFF/REVIEWERS

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.

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Benjamin S. Brooke, MD, PhD (click to view)

Benjamin S. Brooke, MD, PhD

Assistant Professor of Surgery, Division of Vascular Surgery
Director, Utah Intervention Quality & Implementation Research
University of Utah School of Medicine

Benjamin S. Brooke, MD, PhD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

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Striving to maintain continuity of care after surgery in the same hospital and by the same surgical team appears to be critical in helping achieve the best possible outcomes should postoperative complications arise.
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Published research has shown that hospital readmissions are commonly needed to treat complications after patients undergo major surgery. Few studies have explored if patients have better outcomes when they are readmitted to and cared for at the hospital where they initially received surgery when compared with going to another hospital for care of these complications.

To investigate this correlation further, Benjamin S. Brooke, MD, PhD, and colleagues conducted a study to examine the association between readmission destination and mortality risk. Published in the Lancet, the researchers analyzed data from Medicare beneficiaries who had a complication after undergoing a common operation. “Using Medicare data helps us track episodes of care and captures billing codes, allowing us to follow where older patients receive care after undergoing surgery,” says Dr. Brooke.

Data were available on more than 9.4 million Medicare patients who were readmitted within 30 days after undergoing one of 12 major surgeries over a 10-year period. These operations included open abdominal aortic aneurysm repair, infrainguinal arterial bypass, aortobifemoral bypass, CABG surgery, oesophagectomy, colectomy, pancreatectomy, cholecystectomy, ventral hernia repair, craniotomy, hip replacement, or knee replacement. The authors used logistic regression models with propensity weighting to measure associations between readmission destination (index vs non-index hospital) and the risk of mortality within 90 days for patients who underwent surgery and required hospital readmission.

 

Assessing Trends

Results of the study showed that 65.8% to 83.2% of patients who had complications were readmitted to the same hospital. Readmissions were more likely to be back to the index hospital than to a non-index hospital if they were for a surgical complication (Table). “But importantly, we observed a survival benefit when patients returned to the site where the original operation was done for both surgical and medical complications,” says Dr. Brooke.

Statistical analyses demonstrated that patients were more likely to survive 90 days after readmission when returning to their index hospital than those receiving postoperative care at a different hospital. Patients had even better survival when they were treated by the same surgical team who performed the operation. Survival trends were consistent across all surgeries assessed in the study, ranging from a 44% reduced risk of death for those receiving pancreatectomy to a 13% lower mortality rate for CABG surgery.

“These survival data are important considering the large number of patients who are readmitted after common surgical procedures,” says Dr. Brooke. “The trends remained consistent regardless of whether surgery was performed at a large teaching hospital or at a smaller community hospital.” The results add to mounting evidence that continuity of care leads to better outcomes for a variety of acute and chronic medical conditions.

 

Considering Regionalization

Findings of the study may have important implications for efforts to provide surgical care that is cost-effective and regionally centralized. “Returning to index hospitals after a surgical complication may be more important than other measures of healthcare quality,” Dr. Brooke says. This includes receipt of treatment at large medical centers that perform high volumes of specific procedures.

Throughout the United States, patients are sometimes encouraged to travel to larger medical centers for complex elective surgical procedures, a phenomenon that has been dubbed “domestic medical tourism.” In some cases, patients are forced by their healthcare plans to travel long distances to get surgery at premier hospitals that are considered regionally close to where patients reside. This is often done in an effort to save costs. In these cases, it can be difficult for patients to return to their index hospital if they experience complications after surgery.

To overcome this hurdle, Dr. Brooke recommends that patients have surgery performed close to their home whenever possible. “When discussing surgical treatment options, physicians should keep travel distance in mind,” he says. “If patients need to travel to a destination hospital, plans should be made to have them stay in the area for a while during the recovery period. And if patients are readmitted to an outside hospital, it’s important to make every effort to transfer them back to their index hospital within 24 hours of their procedure for postoperative management.”

 

More to Come

Results from the analysis are observational in nature, and the study authors point out that a randomized trial would be needed to prove a causal link. Dr. Brooke adds that future studies should examine the implications of traveling far distances for surgery among both older and younger patients. “We need to determine why outcomes appear to be better when patients return to the index hospital,” he says. “This information may change the way perioperative care is delivered. While it may behoove patients to travel further to get surgery at a particular hospital, doing so may ultimately reduce their access to optimal care in the event of serious complications after discharge.”

 

Dr. Brooke is an Assistant Professor of Surgery in the Division of Vascular Surgery, and the Director of Utah Intervention Quality & Implementation Research at the University of Utah School of Medicine.

Dr. Brooke has indicated to Physician’s Weekly that he has or has had no financial interests to report.

Readings & Resources (click to view)

Brooke BS, Goodney PP, Kraiss LW, Gottlieb DJ, Samore MH, Finlayson SRG. Readmission destination and risk of mortality after major surgery: an observational cohort study. Lancet. 2015 Jun 17 [Epub ahead of print]. Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60087-3/fulltext.

Dimick JB, Miller DC. Hospital readmission after surgery: no place like home. Lancet. 2015 Jun 17 [Epub ahead of print].

Tsai TC, Orav EJ, Jha AK. Care fragmentation in the postdischarge period: surgical readmissions, distance of travel, and postoperative mortality. JAMA Surg. 2015;150:59-64.

Hollenbeck BK, Miller DC, Wei JT, Montie JE. Regionalization of care: centralizing complex surgical procedures. Nat Clin Pract Urol. 2005;2:461.

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