Hospital readmission is associated with high morbidity, mortality, and healthcare expenditures and is increasingly being recognized as an important outcome for clinicians, patients, policymakers, and healthcare payers. “Furthermore, CMS has begun assigning financial penalties to hospitals with excessive unplanned readmissions,” explains Jordan M. Cloyd, MD. “For these reasons, much attention has been placed on efforts to reduce hospital readmissions. However, we still have an incomplete understanding of when and why hospital readmissions occur following major surgery.”
The Weekend Effect
The “weekend effect,” which refers to a phenomenon of worse outcomes seen in patients cared for on weekends, has been extensively described in patients admitted to the hospital on weekend days. Few studies have explored the impact of weekend discharge in patients undergoing surgery. To address this issue, Dr. Cloyd and colleagues had a study published in JAMA Surgery that investigated the association between weekend discharge and 30- and 90-day readmissions in patients undergoing major surgery. “We hypothesized that postoperative patients discharged on a weekend, when certain hospital and ambulatory resources are limited, would be at higher risk of readmission to the hospital,” Dr. Cloyd says.
For the investigation, researchers analyzed hospital readmission rates using a large administrative database from California among patients undergoing abdominal aortic aneurysm (AAA) repair, total hip arthroplasty, colectomy, or pancreatectomy. “One of the strengths of our study was that the data source utilized a unique record linkage number to identify hospital readmissions to all non-federal hospitals in the state, not just those where surgery took place,” says Dr. Cloyd.
Overall, the 30-day readmission rate was 9.4% after AAA repair, 13.6% after colectomy, 7.5% after hip replacement, and 16.3% after pancreatectomy. “Among patients undergoing AAA repair and pancreatectomy, those discharged on weekends were not at higher risk for readmissions when compared with those discharged on weekdays,” Dr. Cloyd says. “Patients discharged on weekends after colorectal surgery or hip replacements were actually at lower risk for readmissions. Overall, patients discharged on weekend days following major surgery were not at increased risk for hospital readmissions.” The findings remained even after adjusting for potential confounding variables with statistical modelling.
Applying the Findings
In light of the findings, healthcare professionals at hospitals with adequate staffing, appropriate coordination of care protocols, and discharge systems in place may consider discharging postoperative patients on weekends without concern for an increased risk for readmission, says Dr. Cloyd. “However, this is an active and important area of ongoing research.” He notes that future studies should assess the impact of weekend discharge on clinical outcomes, such as morbidity and mortality, as well as healthcare expenses, especially in light of length of stay differences. Future studies should also assess patient-centered outcomes, such as patient satisfaction and quality of life.
“One unexpected finding from our study was that up to 40% of the hospital readmissions occurred at a hospital other than the discharging hospital,” Dr. Cloyd says. “Other studies have also found that a significant proportion of hospital readmissions occur at hospitals other than the discharging hospital. Future studies are needed to investigate the clinical importance of this observation.”
Cloyd JM, Chen J, Ma Y, Rhoads KF. Association between weekend discharge and hospital readmission rates following major surgery. JAMA Surg. 2015;150:849-856. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=2300047.
Nasir K, Lin Z, Bueno H, et al. Is same-hospital readmission rate a good surrogate for all-hospital readmission rate? Med Care. 2010;48:477-481.
Kostis WJ, Demissie K, Marcella SW, Shao YH, Wilson AC, Moreyra AE; Myocardial Infarction Data Acquisition System (MIDAS 10) Study Group. Weekend versus weekday admission and mortality from myocardial infarction. N Engl J Med. 2007;356:1099-1109.
Goldstein SD, Papandria DJ, Aboagye J, et al. The “weekend effect” in pediatric surgery: increased mortality for children undergoing urgent surgery during the weekend. J Pediatr Surg. 2014;49:1087-1091.