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Identifying Post-Op Complications for Readmission in General Surgery

Identifying Post-Op Complications for Readmission in General Surgery

In June 2009, CMS began publishing 30-day readmission data for select medical diseases, resulting in hospital readmissions becoming an important metric for measuring the quality of patient care. The changing regulations issued by CMS means that hospital reimbursements can be reduced based on an adjustment factor determined by a hospital’s expected and observed 30-day readmission rates. These changes have also raised the bar for decreasing unnecessary surgical readmissions. In addition to the financial implications, unplanned hospital readmissions further limit hospital resources. For each patient readmitted, there is an opportunity lost to treat another patient who needs care (see also, Strategies for Reducing Hospital Readmissions). “Reducing the number of 30-day readmissions after surgery is important for institutions as well as patients,” says John F. Sweeney, MD, FACS. “Developing a better understanding of the predictors of readmission for general surgery patients will allow hospitals to develop programs to decrease readmission rates. Surgical patients are different from medical patients because surgery, in and of itself, places them at risk for readmission, above and beyond their medical problems. There is an opportunity to intervene preoperatively to decrease the risk of readmission postoperatively.” Important New Data on Hospital Readmission In the Journal of the American College of Surgeons, Dr. Sweeney and colleagues had a study published that analyzed patient records of 1,442 general surgery patients operated on between 2009 and 2011. Of them, 163 patients (11.3%) were readmitted to the hospital within 30 days of discharge. There is a paucity of information focusing on readmission rates among surgical patients, says Dr. Sweeney. “Although factors associated with 30-day readmission after general surgery procedures are multifactorial,...

Managing Mild Gallstone Pancreatitis With Laparoscopy

Surgeons have historically delayed cholecystectomy in all patients with gallstone pancreatitis until normalization of pancreatic and liver enzymes and resolution of abdominal pain. However, the era of laparoscopic cholecystectomy (LC) has changed treatment approaches. Because of this, elective LC to remove the source of calculi is routinely performed during the same hospital admission to prevent further episodes. In many cases, patients will undergo LC within 48 hours of hospital admission without waiting for pancreatic and liver enzyme levels to return to normal. Performing LC early has the potential to decrease length of hospital stay and minimize the unnecessary use of endoscopic retrograde cholangiopancreatography (ERCP). However, mild pancreatitis can be unpredictable. Some patients may undergo early operative intervention when the disease is actually evolving into a moderate-to-severe pancreatitis that may result in an exacerbation of their disease. Comparative Data for Laparoscopic Cholecystectomy A retrospective review that my colleagues and I had published in the Archives of Surgery addressed potential concerns about performing LC for mild gallstone pancreatitis. Results showed that the medial hospital length of stay was significantly less for patients receiving early LC (3 days) than for those receiving delayed LC (6 days). Early LC was also associated with decreased use of ERCP. The observed decrease in length of hospital stay in our study was achieved without increases in adverse outcomes. No patients in either cohort died, and complication rates were similar for both study groups. Also, no patient with mild pancreatitis progressed to severe pancreatitis. For patients with mild gallstone pancreatitis, delaying an LC until laboratory values normalize appears to be unnecessary. Operating early in these patients is...

A New Guideline for Treating Hypertriglyceridemia

Hypertriglyceridemia can substantially increase the likelihood of patients developing heart disease when compared with those who have normal triglyceride levels. While treatment strategies for this condition are well established, its causes differ from patient to patient, as do the risks they pose to each individual. Clinical practice guidelines from the Endocrine Society on hypertriglyceridemia were published in the September 2012 Journal of Clinical Endocrinology and Metabolism (view and print guideline summary here). They recommend that more attention be paid to how personal history, physiology, and lifestyle interact to affect risk. “In recent years, much of the focus surrounding lipids has concentrated on cholesterol,” explains Lars Berglund, MD, PhD, who chaired the Endocrine Society task force that developed the most recent guidelines. “Although there are evidence–based guidelines from respected medical associations that address lipids, data on the complex role of triglycerides in heart disease continue to accumulate. Considering this recent emergence of data on triglycerides, it was important to focus on a guideline that specifically discusses this component of heart disease care.” Individualized Approach with Elevated Triglycerides Dr. Berglund stresses that clinicians should not view elevated fasting triglyceride levels as a standalone factor. “Triglycerides should be looked at in the context of other risk factors for cardiovascular disease (CVD) and metabolic disease,” he says. “Assessment should include the evaluation of secondary causes of hyperlipidemia, including endocrine conditions and medications [Table 1]. Central obesity, hypertension, abnormalities of glucose metabolism, liver dysfunction, and family history of dyslipidemia and CVD should be assessed.” For example, patients with triglyceride levels in the moderate range—200 mg/dl to 999 mg/ dl—may have changes in HDL and...

Walking Program Benefits Patients With PPC After Resection

Results of a small study of resected patients with pancreas and periampullary cancer (PPC) indicate that a progressive home walking program appears to improve fatigue, physical functioning, and health-related quality of life. When compared with PPC patients who received usual care, participants in the walking program intervention walked twice as far at study completion. Abstract: Journal of the American College of Surgeons, April...

Hospital Volume & Mortality: Trends in High-Risk Surgery

A growing number of studies have reported inverse relationships between hospital volume and surgical mortality, with lower mortality seen in higher-volume institutions. There have been numerous efforts to concentrate selected operations at high-volume hospitals. The Leapfrog Group, a consortium of large corporations and public agencies that purchase healthcare for their employees, has been among the most prominent advocates of volume-based referrals. Private payers and professional organizations have also established minimum-volume standards as part of Centers of Excellence accreditation programs for a variety of operations. “Despite these efforts, little is known if they have altered referral patterns for high-risk surgery,” says Jonathan F. Finks, MD. Throughout the country, more and more surgical patients are being treated at high-volume hospitals, but the net effects on operative mortality can be difficult to predict. Dr. Finks says, “for example, hospital volume of a few high-risk cancer procedures, such as pancreatectomy, appears to be a strong predictor of operative risk. At the same time, relationships between surgical volume and outcome are much weaker for most operations.” “Some strategies that appear to be of particular benefit include use of operating-room checklists, outcomes measurement and feedback programs, and national and regional collaborative quality-improvement initiatives.” In a study published in the June 2, 2011 New England Journal of Medicine, Dr. Finks and colleagues at the University of Michigan used data from national Medicare claims to evaluate trends in the use of high-volume hospitals for major cancer resections and cardiovascular surgery. The investigators identified patients (aged 65 to 99) who underwent one of the following cancer and cardiovascular operations from 1999 through 2008: 1) esophagectomy, 2) pancreatectomy, 3) lung...
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