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, our study was undertaken to better understand which factors appeared to be most commonly associated with readmission.”
According to results, postoperative complications were the most significant independent risk factor leading to 30-day hospital readmissions among general surgery patients. Patients who had one or more complications after their surgery were four times more likely to be readmitted to the hospital compared with those who had no complications (Table 1). “The more postoperative complications that patients experience, the greater their risk is for hospital readmission,” Dr. Sweeney adds. Patients with the highest rate of readmissions were those who experienced two postoperative complications.
The median length of hospital stay in the study was 5 days for patients with no complications, but it increased to 9 days for those with one complication and 24 days for those with three or more complications. Hospitalized patients who experience a complication had a lower risk of readmission when compared with those who develop a complication after being discharged.
Patients at Highest Risks for Readmission
Based on analysis of ICD-9 coding data, Dr. Sweeney and colleagues found that gastrointestinal complications carried a high risk of readmission (27.6%), while surgical infections reached 22.1% (Table 2). These top two reasons accounted for nearly half of all readmissions, according to study findings. Complex gastrointestinal procedures, such as pancreatectomy, colectomy, and liver resection, likely had higher complication rates because of the complexity of these surgeries.
The top surgical complications identified in the study were wound infections, pulmonary complications, and urinary tract infections (UTIs). Patients with postoperative sepsis or UTIs were about five times more likely to be readmitted than patients without these complications. Postoperative wound infections and postoperative pulmonary complications were associated with a 3.5-fold increase in readmission rates. Additionally, several comorbidities substantially affected readmission risk, most notably cancer, open wounds, and dyspnea. Patients who were immunosuppressed, poor wound healers, and with baseline pulmonary disease were also vulnerable to complications that raise the likelihood of postoperative readmission.
The Implications on Healthcare Savings
Dr. Sweeney notes that if resources can be focused on certain high-risk patient populations undergoing complex inpatient procedures, the number of postoperative complications could be reduced significantly, resulting in potentially substantial healthcare savings. “A reduction in postoperative complications would have substantial financial implications for hospitals, patients, and payers,” he says. “Focusing our efforts on preventing and appropriately managing postoperative complications in high-risk patients could greatly impact the number of readmissions after surgical procedures.”
Results of the investigation by Dr. Sweeney and colleagues provide a framework for developing a simple complication-prevention plan to minimize risks for surgical patients who have complications. “The key is to engage the postoperative care team to start planning for transitions of care early, especially for high-risk patients. By encouraging early discharge, we can reduce the risk of complications and decrease the length of stay. In turn, this will help to reduce the number of hospital readmissions.”
Kassin MT, Owen RM, Perez SD, et al. Risk factors for 30-day hospital readmission among general surgery patients. J Am Coll Surg. 2012;215:322-330. Available at: http://www.journalacs.org/article/S1072-7515(12)00413-9/fulltext.
Adeyemo D, Radley S. Unplanned general surgical re-admissions—how many, which patients and why? Ann R Coll Surg Engl. 2007;89:363-367.
Aust JB, Henderson W, Khuri S, Page CP. The impact of operative complexity on patient risk factors. Ann Surg. 2005;241:1024-1027; discussion 1027-1028.
Cheadle WG. Risk factors for surgical site infection. Surg Infect. 2006;7(Suppl 1):S7-S11.
Schilling PL, Dimick JB, Birkmeyer JD. Prioritizing quality improvement in general surgery. J Am Coll Surg. 2008;207:698-704.
Khuri SF, Henderson WG, DePalma RG, et al. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg. 2005;242:326-341; discussion 341-343.
Friedman B, Basu J. The rate and cost of hospital readmissions for preventable conditions. Med Care Res Rev. 2004;61:225-240.