With hospital readmission rates following surgery being increasingly used as a marker of quality of care and used in pay-for-performance metrics, efforts to reduce these rates has become a focus for physicians, hospital administrators, and policy makers. Patients undergoing emergency general surgery (EGS) are at high risk for medical errors and complications following surgery. Previous research has shown that about half of all patients undergoing EGS will have a postoperative complication, and postoperative complications have been closely linked to hospital readmission.
According to Joaquim M. Havens, MD, there is a great need to closely examine readmission rates in EGS because of the uniqueness of these patients. “Data are needed to identify the patterns of readmissions in this population,” he says. However, studies on readmission rates in surgical patients can be limited by the restricted number of procedures being examined, the exclusive age categories that are included, and the lack of distinction of EGS patients from other surgical patients. Readmission rates and outcomes can also vary significantly by patient age, procedure type, and surgical specialty.
Characterizing EGS Patients
In a study published in JAMA Surgery, Dr. Havens and colleagues sought to define hospital readmission rates, identify risk factors, and describe patterns of readmission among EGS patients. The analysis also aimed to account for variations in patients’ age groups and diagnoses. The investigators used hospital discharge records from a statewide database in California and identified the five most commonly performed EGS procedures in each of 11 EGS diagnosis groups. Data were collected on patient demographics, comorbidities, length of stay, complications, and discharge disposition and examined within the context of 30-day hospital readmission.
The study had more than 177,000 patients who met inclusion criteria, the majority of which were white and aged 45 or older and nearly half were privately insured. Laparoscopic appendectomy (35.2%) and laparoscopic cholecystectomy (19.3%) were the most common procedures.
“The overall 30-day readmission rate was 5.9%, but rates varied considerably between procedures,” says Dr. Havens. For example, the 30-day readmission rate was 4.1% for upper gastrointestinal operations but 16.8% for cardiothoracic surgeries. The research team also identified several predictors of readmission. These included:
- Having a Charlson Comorbidity Index score of 2 or greater (adjusted odds ratio [AOR], 2.26).
- Leaving against medical advice (AOR, 2.24).
- Having public insurance (AOR, 1.55).
Overall, the most common reasons for readmission were surgical site infections (16.9%), gastrointestinal complications (11.3%), and pulmonary complications (3.6%).
The study also found that 16.8% of EGS patients who were readmitted after their procedure were readmitted at a different hospital. “We need to determine why patients went to another hospital for postoperative care in future research,” Dr. Havens says.
The study helps to characterize the demographics of EGS patients and identified patient-level risk factors for readmissions to index hospital as well as other hospitals. “By gaining a better understanding of the underlying factors associated with readmission, we may be able to appropriately identify quality-improvement measures that address these problems,” says Dr. Havens. Focused and concerted efforts are needed to incorporate readmission-reducing strategies into the care of EGS patients, particularly among those at higher risk for readmission.
Havens JM, Olufajo OA, Cooper ZR, Haider AH, Shah AA, Salim A. Defining rates and risk factors for readmissions following emergency general surgery. JAMA Surg. 2015 Nov 11 [Epub ahead of print]. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=2468540.
Havens JM, Peetz AB, Do WS, et al. The excess morbidity and mortality of emergency general surgery. J Trauma Acute Care Surg. 2015;78:306-311.
Dawes AJ, Sacks GD, Russell MM, et al. Preventable readmissions to surgical services: lessons learned and targets for improvement. J Am Coll Surg. 2014;219:382-389.