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Evans K, Makar T, Larsen T, Banerjee R, Tran H, Miles LF. Causes of and risk factors for unplanned readmission in a large cohort of patients undergoing major surgery: a retrospective cohort study. Anaesthesia 2025; 80:652-661. [PMID: 39956642 PMCID: PMC12066936 DOI: 10.1111/anae.16567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2024] [Indexed: 02/18/2025]
Abstract
INTRODUCTION Unplanned hospital readmissions after surgery are substantial drivers of expenditure and bed occupancy within the healthcare system. As a result, any targeted interventions that reduce readmission in this population can have a significant impact on patient well-being and the health budget. METHODS We performed a large retrospective cohort study analysing data from patients from our institution who underwent major surgery between 1 May 2011 and 1 February 2022. We aimed primarily to study the epidemiology of patients who were readmitted within 90 days of discharge following an index procedure, as well as the reason(s) and risk factors for readmission. These complex, non-linear relationships were modelled with restricted cubic splines. RESULTS We identified 22,143 patients undergoing major surgery within the defined study period, of whom 1801 (12%) had an unplanned readmission. The most common reason for unplanned readmission across the entire cohort was wound complication, which was the primary cause identified in 232 (11%) readmissions. Ileus or small bowel obstruction was the primary cause of readmission identified following abdominal surgery, compared with pneumonia following thoracic surgery, mechanical injury following orthopaedic surgery and wound complication following cardiac surgery. A discharge haemoglobin concentration of < 100 g.l-1 (p < 0.001), duration of hospital stay of 14-30 days (p < 0.001) and Charlson comorbidity index score ≥ 2 (p < 0.001) were associated with increased odds of unplanned readmission. No association was found with patient age or duration of surgery. DISCUSSION Our study identified the causes of readmission after major surgery from a range of surgical specialties. An improved understanding of the causes of and risk factors for unplanned readmissions will enable the development of targeted interventions that can minimise the burden of unplanned readmissions after major surgery on patients and the larger healthcare system.
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Affiliation(s)
- Kirstie Evans
- Department of AnaesthesiaAustin HealthMelbourneAustralia
| | - Tim Makar
- Department of AnaesthesiaAustin HealthMelbourneAustralia
- Department of Critical CareMelbourne Medical School, The University of MelbourneMelbourneAustralia
| | - Tom Larsen
- Data Analysis Research and Evaluation CentreAustin HealthMelbourneAustralia
| | | | - Hai Tran
- Department of AnaesthesiaAustin HealthMelbourneAustralia
| | - Lachlan F. Miles
- Department of AnaesthesiaAustin HealthMelbourneAustralia
- Department of Critical CareMelbourne Medical School, The University of MelbourneMelbourneAustralia
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Barnes EL, Esckilsen S, Ashburn J, Barto A, Bloomfeld R, Cairns A, Mehta K, Patel P, Dziwis J, Dunn MS, Rahbar R, Sadiq TS, Hanson JS, Herfarth HH. Extensive Colitis and Smoking Are Associated With Postoperative Complications Within 30 Days of Ileal Pouch-Anal Anastomosis. Inflamm Bowel Dis 2024; 30:1326-1333. [PMID: 37607334 PMCID: PMC11291612 DOI: 10.1093/ibd/izad177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Our understanding of outcomes after proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) is largely based on analyses of selected populations. We created a state-level registry to evaluate the epidemiology of IPAA surgery and pouch-related outcomes across the major healthcare systems performing these surgeries in our state. METHODS We created a retrospective cohort of all patients undergoing restorative proctocolectomy with IPAA for UC at 1 of 4 centers between January 1, 2018, and December 31, 2020. The primary outcomes of this study were the rate of complications and all-cause readmissions within the first 30 days of the final stage of IPAA surgery. RESULTS During the study period, 177 patients underwent IPAA surgery with 66 (37%) experiencing a complication within 30 days. After adjusting for the number of stages in IPAA surgery, patients with extensive UC (odds ratio, 3.61; 95% confidence interval, 1.39-9.33) and current or former smokers (odds ratio, 2.98; 95% confidence interval, 1.38-6.45) were more likely to experience a complication. Among all patients, 57 (32%) required readmission within 30 days. The most common reasons for readmission were ileus/small bowel obstruction (22%), peripouch abscess (19%), and dehydration (16%). CONCLUSION In this first state-level examination of the epidemiology of IPAA for UC, we demonstrated that the complication rate after IPAA for UC was 37%, with one-third of patients being readmitted within 30 days. Extensive disease at the time of colectomy appears to be an indicator of more severe disease and may portend a worse prognosis after IPAA.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, NC, USA
| | - Scott Esckilsen
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Jean Ashburn
- Division of Colon and Rectal Surgery, Atrium Health at Wake Forest Baptist, Winston-Salem, NC, USA
| | - Amy Barto
- Division of Gastroenterology and Hepatology, Duke University, Durham, NC, USA
| | - Richard Bloomfeld
- Section of Gastroenterology, Atrium Health at Wake Forest Baptist, Winston-Salem, NC, USA
| | - Ashley Cairns
- Division of Colon and Rectal Surgery, Atrium Health at Wake Forest Baptist, Winston-Salem, NC, USA
| | - Kurren Mehta
- Department of Medicine, Duke University, Durham, NC, USA
| | - Pooja Patel
- Department of Medicine, Duke University, Durham, NC, USA
| | - Jennifer Dziwis
- Section of Gastroenterology, Atrium Health at Wake Forest Baptist, Winston-Salem, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
| | - Michael S Dunn
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | | | - John S Hanson
- Division of Gastroenterology and Hepatology, Atrium Health, Charlotte, NC, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, NC, USA
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Balla A, Saraceno F, Di Saverio S, Di Lorenzo N, Lepiane P, Guerrieri M, Sileri P. Ostomy closure rate during COVID-19 pandemic: an Italian multicentre observational study. Updates Surg 2022; 74:1017-1025. [PMID: 35322388 PMCID: PMC8942758 DOI: 10.1007/s13304-022-01274-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/04/2022] [Indexed: 11/05/2022]
Abstract
During the corona virus disease 2019 (COVID-19) pandemic, most of the surgical procedures were performed for emergencies or oncologic reasons to the detriment of the remaining elective procedures for benign conditions. Ileostomy or colostomy creation are sequelae of oncologic or emergency colorectal surgery, but their closure does not fall within the definition of oncologic or emergency surgery. The aim of this retrospective multicentre observational study is to report the impact of COVID-19 pandemic on the ostomy closure rate in Italy. Data regarding ileostomy and colostomy creation and closure from 24 Italian centres, during the study period (March 2020-February 2021) and during the control period (March 2019-February 2020) were collected. Three hospitals (12.5%) were COVID free. The number of colostomies and ileostomies created and closed in the same period was lower ( -18.8% and -30%, respectively) in the study period in comparison to the control period (p = 0.1915 and p = 0.0001, respectively), such as the ostomies closed in the analysed periods but created before (colostomy -36.2% and ileostomy -7.4%, p = 0.2211 and p = 0.1319, respectively). Overall, a 19.5% reduction in ostomies closed occurred in the study period. Based on the present study, a reduction in ostomy closure rate occurred in Italy between March 2020 and February 2021. During the pandemic, the need to change the clinical practice probably prolonged deterioration of quality of life in patients with ostomies, increasing number of stomas that will never be closed, and related management costs, even if these issues have not been investigated in this study.
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Affiliation(s)
- Andrea Balla
- UOC of General and Minimally Invasive Surgery, Hospital “San Paolo”, Largo Donatori del Sangue 1, Civitavecchia, 00053 Rome, Italy
| | - Federica Saraceno
- UOC of General and Minimally Invasive Surgery, Hospital “San Paolo”, Largo Donatori del Sangue 1, Civitavecchia, 00053 Rome, Italy
- Ph.D. Program in Applied Medical-Surgical Sciences, Department of General Surgery, University of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Salomone Di Saverio
- ASUR Marche 5, San Benedetto del Tronto General Hospital, San Benedetto del Tronto, Italy
| | - Nicola Di Lorenzo
- Ph.D. Program in Applied Medical-Surgical Sciences, Department of General Surgery, University of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Pasquale Lepiane
- UOC of General and Minimally Invasive Surgery, Hospital “San Paolo”, Largo Donatori del Sangue 1, Civitavecchia, 00053 Rome, Italy
| | - Mario Guerrieri
- Department of General Surgery, Università Politecnica Delle Marche, Piazza Roma 22, 60121 Ancona, Italy
| | - Pierpaolo Sileri
- Vita-Salute San Raffaele University, Via Olgettina, 58, 20132 Milan, Italy
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What are the risk factors for readmission in patients with an ileostomy? JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2013.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Purpose the aim of this study was to identify the risk factors for readmission among patients submitted to colorectal surgery.
Methods a single-center colorectal quality-assessment database was queried for patients undergoing colorectal procedures with ileostomy during 2009. the sample was divided into readmitted vs. non-readmitted. readmission was defined as admission within the first 30 days after the index procedure. Groups were compared by pre, intra and postoperative characteristics. A multivariate analysis was performed to identify the risk factors for readmission.
Results the query returned 496 patients, [267 (54%) males, median age 48 years (iQr: 34-60)]. Eighty-three (17%) were readmitted; 296 patients (60%), were operated due to inflammatory bowel disease, 89 (18%) for cancer, 16 (3%) for diverticular disease and 95 (19%) for other diagnosis. the three most common procedures were total proctocolectomy with ileal pouch-anal anastomosis (iPAA) in 103 patients (21%), total colectomy with end ileostomy in 117 (24%) and small bowel resections (including enterocutaneous fistula takedown and J-pouch excision) in 149 (30%). the following variables were significantly more common in readmitted patients: current smoking (24% vs. 14%, p = 0.02), postoperative DVt/PE (10% vs. 4%, p = 0.04), wound infection (20% vs. 10% p = 0.01), sepsis (22% vs. 8% p < 0.001) and organ or space surgical site infection (orgSSi) (35% vs. 5%, p < 0.001). Postoperative orgSSi was the only independent factor associated with readmission in a multivariate analysis (p < 0.001).
Conclusion colorectal surgeons should be alert for orgSSi when facing an ileostomy patient readmitted after a colorectal procedure.
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Alyabsi M, Charlton M, Meza J, Islam KMM, Soliman A, Watanabe-Galloway S. Comparison of Urban-Rural Readmission Rates After Colorectal Cancer Surgery: Findings From a Privately Insured Population. Cancer Control 2021; 28:10732748211027169. [PMID: 34387106 PMCID: PMC8369964 DOI: 10.1177/10732748211027169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/17/2021] [Accepted: 05/30/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES We assessed the 30-day readmission rate of a privately insured population diagnosed with colorectal cancer (CRC) who had primary tumor resection in rural and urban communities. METHODS Claims data of people aged <65 with a diagnosis of CRC between 2012 and 2016 and enrolled in a private health plan administered by BlueCross BlueShield of Nebraska were analyzed. Readmission was defined as the number of discharged patients who were readmitted within 30 days, divided by all discharged patients. Multivariate logistic regression was used to estimate the factors associated with readmission. RESULTS The urban population had a higher readmission rate (11%) than the rural population (8%). Although the adjusted odds ratio showed that there is no difference in readmission between rural and urban residents, patients with a Charlson Comorbidity Index (CCI) of >1 were more likely than those without CCI to be readmitted (OR 3.59, 1.41-9.11). Patients with open vs. laparoscopic surgery (OR 2.80, 1.39-5.63) and those with an obstructed or perforated colon vs. none (OR 7.17, 3.75-13.72) were more likely to be readmitted. CONCLUSIONS Readmission after CRC surgery occurs frequently. Interventions that target the identified risk factors should reduce readmission rates in this privately insured population.
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Affiliation(s)
- Mesnad Alyabsi
- Population Health Research Section, King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mary Charlton
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Jane Meza
- Department of Biostatistics, University of Nebraska Medical Center, College of Public Health, Omaha, NE, USA
| | - K. M. Monirul Islam
- Department of Epidemiology, University of Nebraska Medical Center, College of Public Health, Omaha, NE, USA
| | - Amr Soliman
- Community Health and Social Medicine, City University of New York School of Medicine, New York, NY, USA
| | - Shinobu Watanabe-Galloway
- Department of Epidemiology, University of Nebraska Medical Center, College of Public Health, Omaha, NE, USA
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Traynor MD, McKenna NP, Potter DD, Moir CR, Klinkner DB. The effect of diversion on readmission following ileal pouch-anal anastomosis in children. J Pediatr Surg 2020; 55:549-553. [PMID: 31818436 DOI: 10.1016/j.jpedsurg.2019.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/07/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Readmission rates as high as 20% have been reported after ileal pouch-anal anastomosis (IPAA) in children, with obstruction and dehydration as the most commonly listed reasons. We hypothesized that a diverting ileostomy contributes to unplanned readmission after IPAA creation. METHODS Children (age <18) who underwent IPAA creation from January 2007 to August 2018 at two affiliated institutions were reviewed. Patient demographics, operative details, and post-operative length of stay (LOS) were abstracted. Unplanned readmission within 30 days and details on patient readmission were reviewed. RESULTS Ninety-three patients (57% female) with a median age of 15 years (range: 18 months-17 years) underwent IPAA. Indications for IPAA included ulcerative colitis (n = 63; 68%), familial adenomatous polyposis (n = 24; 26%), indeterminate colitis (n = 5; 5%), and total colonic Hirschsprung's (n = 1; 1%). Sixty-one (66%) patients were diverted at the time of IPAA creation. Fourteen patients (15%) were readmitted, and reasons for readmission included bowel obstruction (n = 9; 64%), dehydration (n = 2; 14%), anastomotic leak (n = 2; 14%), and gastrointestinal (GI) bleeding (n = 1; 6%). Patients with a diverting ileostomy at the time of IPAA were more often readmittted than patients who were not diverted (21% vs 3%, p = 0.03). Further, 10 (71%) of the readmitted patients had complications attributable to their ileostomy. In patients readmitted for obstructive symptoms, six (67%) required red rubber catheter insertion for resolution, two (22%) patients required reoperation for obstructions at the level of the stoma, and one (11%) resolved with bowel rest alone. CONCLUSION Readmission following IPAA creation in children is often secondary to preventable issues related to diverting ileostomy. Surgeons should carefully consider the necessity of diversion. When it is necessary, particular attention to fascial aperture size and post-discharge initiatives to reduce dehydration may reduce readmission rates. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Michael D Traynor
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN.
| | | | - D Dean Potter
- Division of Pediatric Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN
| | - Christopher R Moir
- Division of Pediatric Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN
| | - Denise B Klinkner
- Division of Pediatric Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN.
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McKenna NP, Habermann EB, Glasgow AE, Mathis KL, Lightner AL. Risk factors for readmission following ileal pouch–Anal anastomosis: an American College of Surgeons National Surgical Quality Improvement Program analysis. J Surg Res 2018; 229:324-331. [DOI: 10.1016/j.jss.2018.04.037] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/17/2018] [Accepted: 04/17/2018] [Indexed: 02/07/2023]
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Kochar B, Barnes EL, Peery AF, Cools KS, Galanko J, Koruda M, Herfarth HH. Delayed Ileal Pouch Anal Anastomosis Has a Lower 30-Day Adverse Event Rate: Analysis From the National Surgical Quality Improvement Program. Inflamm Bowel Dis 2018; 24:1833-1839. [PMID: 29697787 PMCID: PMC6703434 DOI: 10.1093/ibd/izy082] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Ulcerative colitis (UC) patients requiring colectomy often have a staged ileal pouch anal anastomosis (IPAA). There are no prospective data comparing timing of pouch creation. We aimed to compare 30-day adverse event rates for pouch creation at the time of colectomy (PTC) with delayed pouch creation (DPC). METHODS Using prospectively collected data from 2011-2015 through the National Surgical Quality Improvement Program, we conducted a cohort study including subjects aged ≥18 years with a postoperative diagnosis of UC. We assessed 30-day postoperative rates of unplanned readmissions, reoperations, and major and minor adverse events (AEs), comparing the stage of the surgery where the pouch creation took place. Using a modified Poisson regression model, we estimated risk ratios (RRs) with 95% confidence intervals (CIs) adjusting for age, sex, race, body mass index, smoking status, diabetes, albumin, and comorbidities. RESULTS Of 2390 IPAA procedures, 1571 were PTC and 819 were DPC. In the PTC group, 51% were on chronic immunosuppression preoperatively, compared with 15% in the DPC group (P < 0.01). After controlling for confounders, patients who had DPC were significantly less likely to have unplanned reoperations (RR, 0.42; 95% CI, 0.24-0.75), major AEs (RR, 0.72; 95% CI, 0.52-0.99), and minor AEs (RR, 0.48; 95% CI, 0.32-0.73) than PTC. CONCLUSIONS Patients undergoing delayed pouch creation were at lower risk for unplanned reoperations and major and minor adverse events compared with patients undergoing pouch creation at the time of colectomy. 10.1093/ibd/izy082_video1izy082.video15776112442001.
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Affiliation(s)
- Bharati Kochar
- Multidisciplinary Center for Inflammatory Bowel Disease, North Carolina,Center for Gastrointestinal Biology and Disease, North Carolina
| | - Edward L Barnes
- Multidisciplinary Center for Inflammatory Bowel Disease, North Carolina,Center for Gastrointestinal Biology and Disease, North Carolina
| | - Anne F Peery
- Center for Gastrointestinal Biology and Disease, North Carolina
| | - Katherine S Cools
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Joseph Galanko
- Center for Gastrointestinal Biology and Disease, North Carolina
| | - Mark Koruda
- Multidisciplinary Center for Inflammatory Bowel Disease, North Carolina,Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Hans H Herfarth
- Multidisciplinary Center for Inflammatory Bowel Disease, North Carolina,Center for Gastrointestinal Biology and Disease, North Carolina,Address correspondence to: Hans H. Herfarth, MD, PhD, Division of Gastroenterology and Hepatology, University of North Carolina, Bioinformatics Building, CB#7080, Chapel Hill, NC, 27599 ()
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Dukleska K, Berman L, Aka AA, Vinocur CD, Teeple EA. Short-term outcomes in children undergoing restorative proctocolectomy with ileal-pouch anal anastomosis. J Pediatr Surg 2018; 53:1154-1159. [PMID: 29627174 DOI: 10.1016/j.jpedsurg.2018.02.075] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 02/27/2018] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) commonly undergo restorative proctocolectomy with ileal-pouch anal anastomosis (RP-IPAA). We sought to describe patient characteristics and postoperative outcomes in this patient population. METHODS Using the National Surgical Quality Improvement Program-Pediatric Participant Use Files from 2012 to 2015, children who were 6-18years old who underwent RP-IPAA for FAP or UC were identified. Postoperative morbidity, including reoperation and readmission were quantified. Associations between preoperative characteristics and postoperative outcomes were analyzed. RESULTS A total of 260 children met the inclusion criteria, of which 56.2% had UC. Most cases were performed laparoscopically (58.1%), and the operative time was longer with a laparoscopic versus open approach (326 [257-408] versus 281 [216-391] minutes, p=0.02). The overall morbidity was 11.5%, and there were high reoperation and readmission rates (12.7% and 21.5%, respectively). On bivariate analysis, preoperative steroid use was associated with reoperation (22.5% versus 10.9%, p=0.04). On multivariable regression analysis, obesity was independently associated with reoperation (odds ratio: 3.34 [95% confidence intervals: 1.08-10.38], p=0.04). CONCLUSIONS Children who undergo RP-IPAA have high rates of overall morbidity, reoperation, and readmission. Obesity was independently associated with reoperation. This data can be used by practitioners in the preoperative setting to better counsel families and establish expectations for the postoperative setting. TYPE OF STUDY Retrospective Comparative Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Katerina Dukleska
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA
| | - Loren Berman
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA; Department of Surgery, A.I. duPont Hospital for Children, Wilmington, DE
| | - Allison A Aka
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA
| | - Charles D Vinocur
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA; Department of Surgery, A.I. duPont Hospital for Children, Wilmington, DE
| | - Erin A Teeple
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA; Department of Surgery, A.I. duPont Hospital for Children, Wilmington, DE.
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Modified Pfannenstiel Open Approach as an Alternative to Laparoscopic Total Proctocolectomy and IPAA: Comparison of Short- and Long-term Outcomes and Quality of Life. Dis Colon Rectum 2018; 61:573-578. [PMID: 29630002 DOI: 10.1097/dcr.0000000000001052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND A laparoscopic approach to total proctocolectomy with IPAA has been suggested to have better short-term outcomes and cosmesis, whereas open surgery by midline incision may result in shorter operative times. We hypothesized that a modified Pfannenstiel open approach would combine the advantages of both techniques. OBJECTIVE The purpose of this study was to compare outcomes of open total proctocolectomy with IPAA using a modified Pfannenstiel incision versus those following the laparoscopic approach. DESIGN This was a retrospective study comparing patients submitted to open IPAA using modified Pfannenstiel incision versus laparoscopy from 1998 to 2014. SETTINGS The study was conducted at a high-volume tertiary referral center. PATIENTS Among 1275 patients, 119 patients underwent the laparoscopic approach and 33 underwent the modified Pfannenstiel approach. MAIN OUTCOME MEASURES Short- and long-term outcomes were evaluated, and quality-of-life questionnaires were assessed. RESULTS Patients who underwent the modified Pfannenstiel approach were younger, more often women, and had lower BMI and ASA classification compared with those who underwent laparoscopy. Surgical time was lower in Pfannenstiel, and no difference was observed in length of hospital stay. No difference was observed in postoperative complications, pouch failure rate, or quality of life. Patients were then matched 1:1 by diagnosis, sex, age (±5 y) and BMI (±5 kg/m). The Pfannenstiel approach still had a shorter surgical time. No difference was observed in the length of hospital stay, complications, pouch failure, or quality of life. In long-term follow-up, pouchitis symptoms occurred more frequently in Pfannenstiel (mean follow-up = 7.3 y), and seepage was more frequently observed in the laparoscopy group (mean follow-up = 4.2 y). These differences were not observed in matched patients. LIMITATIONS The study was limited by its retrospective design and inherent selection bias. CONCLUSIONS The modified Pfannenstiel approach provides equivalent short- and long-term outcomes and similar quality of life compared with laparoscopy but with a significantly shorter operative time. The modified Pfannenstiel approach to total proctocolectomy with IPAA may be the most efficient method in selected patients. See Video Abstract at http://links.lww.com/DCR/A562.
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Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of the study was to determine readmission rates and predictors of readmission after posterior cervical fusion (PCF). SUMMARY OF BACKGROUND DATA PCFs are common spinal operations for a variety of spinal disorders including cervical myelopathy, unstable fractures, cervical deformity, and tumors. Data elaborating on risk factors for 30-day readmission are limited. METHODS Data were collected from the 2006 to 2013 American College of Surgeons National Surgical Quality Improvement Program database. Predictors of 30-day readmission comprising patient demographics, comorbidities, operative features, and postoperative complications were identified through logistic multivariable regression. RESULTS A total of 3401 patients met study criteria. Rate of 30-day readmission was 6.20%. Multilevel fusion was performed in 69.16% of patients. Postoperative infection was the most reason, accounting for 17.06% of all readmissions. Age older than 70 years (odds ratio [OR] = 1.61, P = 0.012), renal failure requiring dialysis (OR = 3.69, P = 0.011), anemia (OR = 1.57, P = 0.006), multilevel fusion (OR = 1.61, P = 0.012), surgical site infections (OR = 20.4, P < 0.001), wound dehiscence (OR = 19.08, P < 0.001), postoperative pneumonia (OR = 2.75, P = 0.01), pulmonary embolism (OR = 15.39, P < 0.001), and progressing renal insufficiency (OR = 10.13, P = 0.061) were significant predictors of hospital readmission. CONCLUSION The identified predictors of readmission after PCF can improve patient counseling, identification of high-risk patients, and guide changes in healthcare delivery pathways. Patients with modifiable risk factors such as anemia and kidney failure may benefit from preoperative optimization. In addition, postoperative complications represent a key target for intervention. LEVEL OF EVIDENCE 3.
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McKenna NP, Mathis KL, Khasawneh M, Shariq O, Dozois EJ, Larson DW, Lightner AL. Thirty-Day Hospital Readmission After Restorative Proctocolectomy and Ileal Pouch Anal Anastomosis for Chronic Ulcerative Colitis at a High-Volume Center. J Gastrointest Surg 2017; 21:1859-1864. [PMID: 28840472 DOI: 10.1007/s11605-017-3542-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 08/07/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ileal pouch anal anastomosis (IPAA) is associated with a high 30-day hospital readmission rate. Risk factors and etiology of readmission remain poorly defined. We sought to determine the 30-day hospital readmission rate following IPAA at a high-volume center and identify any modifiable perioperative factors. METHODS A retrospective review of all patients undergoing two- or three-stage IPAA for chronic ulcerative colitis at our institution between 2002 and 2013 was performed. Analysis was performed on rate of readmission, readmission diagnosis, intervention performed upon readmission, and risk factors for readmission. RESULTS Thirty-day primary and secondary readmission rates after IPAA were 20.3% (n = 185) and 2.1% (n = 19), respectively. The leading etiologies for readmission included partial small bowel obstruction/ileus (n = 52, 21.9%), pelvic sepsis (n = 43, 18.1%), dehydration (n = 42, 17.7%), and venous thromboembolism (n = 31, 13.1%). While the majority of readmissions were managed medically (n = 119, 65.4%), 19.2% (n = 35) required radiologic intervention and 15.3% (n = 28) required a return to the operating room. On univariate analysis, younger age (p = 0.03) and female sex (p = 0.04) had a significantly increased risk of readmission. On multivariable analysis, BMI ≥ 30 (OR 0.51; 95% CI, 0.25-0.97, p = 0.04) was protective of readmission. CONCLUSIONS Thirty-day hospital readmission following IPAA remains a common problem. Preventable etiologies of readmission include dehydration and venous thromboembolism (VTE). Future quality improvement efforts should focus on education regarding stoma output and extended VTE prophylaxis to decrease hospital readmission rates following IPAA.
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Affiliation(s)
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Omair Shariq
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA. .,Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55902, USA.
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Factors associated with hospital readmission following diverting ileostomy creation. Tech Coloproctol 2017; 21:641-648. [DOI: 10.1007/s10151-017-1667-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 07/08/2017] [Indexed: 12/24/2022]
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14
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Decreasing readmissions by focusing on complications and underlying reasons. Am J Surg 2017; 215:557-562. [PMID: 28760355 DOI: 10.1016/j.amjsurg.2017.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/06/2017] [Accepted: 07/16/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND To analyze demographics and outcomes of patients focusing on 30-day readmission status and identify procedure-specific risk factors. METHODS Patients undergoing abdominal colorectal surgery (2011-2013) were identified Demographics and outcomes including in-hospital complications were compared based on readmission status. RESULTS A total of 6637 patients were identified with a mean age of 51.2(±17.1) years. Seven hundred and seventy five(11.7%) patients were readmitted at least once within 30-day. The most common index procedures related to readmission were stoma closure (n = 127/775, 16.4%) and total colectomy (n = 105/775, 13.6%). Readmitted patients had longer length of index hospital stay (LOS)(8.2 ± 5.9 vs 7.9 ± 6.9 days,p < 0.001) and operative time(167 ± 104 vs 144 ± 95 min, p < 0.001), higher intraoperative(2% vs 1%,p = 0.04) and in-hospital complication rates(36% vs 28%,p < 0.001). Main reasons for readmissions were gastrointestinal-related causes(n = 222, 29%), small bowel obstruction (n = 133,17%), wound-related complications(n = 108,14%), and dehydration(n = 93,12%). Median readmission LOS was 4(1-71)days and 54%(n = 407) of readmissions occurred within 7 days of discharge. CONCLUSION Increased postoperative complications may be the main preventable underlying reason for increased risk of hospital readmission after colorectal surgery. Preventive measures to decrease complications and actions to identify high risk patients for complications would help to reduce readmissions.
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Modifiable Risk Factors for Hospital Readmission Among Patients with Inflammatory Bowel Disease in a Nationwide Database. Inflamm Bowel Dis 2017; 23:875-881. [PMID: 28426473 PMCID: PMC5512697 DOI: 10.1097/mib.0000000000001121] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Previous studies suggest that disease activity alone does not reliably predict hospital readmission among patients with inflammatory bowel diseases (IBDs). Using a national database, we aimed to further describe the burden of readmissions for IBD and identify modifiable risk factors. METHODS We performed a retrospective cohort study using 2013 data from the Nationwide Readmission Database (NRD). Using International Classification of Diseases, ninth Revision, Clinical Modification (ICD-9-CM) codes, we identified adult patients with discharge diagnoses of ulcerative colitis or Crohn's disease and ascertained diagnoses of anxiety, depression, chronic pain, tobacco use, and other comorbidities during index admission. Logistic regression was used to estimate factors associated with hospital readmission. RESULTS Among 52,498 hospitalizations of patients with IBD (63% Crohn's disease and 37% ulcerative colitis), 12,407 (24%) were readmitted within 90 days of the index hospitalization, resulting in roughly $576 million in excess charges. In multivariable analysis of patients with Crohn's disease, anxiety (odds ratio [OR] 1.31, 95% confidence interval [CI], 1.21-1.43), depression (OR 1.27, 95% CI, 1.07-1.50), chronic pain (OR 1.31, 95% CI, 1.18-1.46), and tobacco abuse (OR 1.13, 95% CI, 1.06-1.22) were associated with a significant increase in odds of readmission. Among patients with ulcerative colitis, anxiety (OR 1.28, 95% CI, 1.14-1.45), depression (OR 1.35, 95% CI, 1.07-1.70), and chronic pain (OR 1.44, 95% CI, 1.21-1.73) were associated with a significant increase in odds of readmission. CONCLUSIONS Readmission occurs frequently in patients with IBD and is costly. Anxiety, depression, and chronic pain may represent targets for interventions to prevent 90-day hospital readmission in this population.
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Nicolescu TO. Perioperative Surgical Home. Meeting tomorrow's challenges. Rom J Anaesth Intensive Care 2016; 23:141-147. [PMID: 28913487 DOI: 10.21454/rjaic.7518/232.sho] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
New healthcare models pose a variety of changes for anesthesiologists, ranging from the need to improve quality and to cost containment: as such, the concept of Perioperative Surgical Home (PSH) has been developed. Modelled after the UK's Enhanced Recovery After Surgery (ERAS), PSH takes a step further by coordinating care starting from the time a surgical decision is made for the patient to as many as 30 days postoperatively, taking a logical evidenced-based approach to judicious preoperative testing. Perioperative surgical home also relies heavily on engineering imported strategies such as the use of Lean Six Sigma methodologies, and involves active participation of all stakeholders. By comparison, ERAS is a series of well-defined clinical protocols that do not extend beyond the episode of surgical care. As an added aspect of its benefits, PSH also helps to control costs by decreasing unnecessary testing and cancellations, and allowing for more OR access by inpatients.
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Affiliation(s)
- Teodora O Nicolescu
- Department of Anesthesiology, Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Abstract
BACKGROUND Hospital readmissions remain a major medical and financial concern to the healthcare system and have become an area of interest in health outcomes performance metrics. There is a pressing need to identify process measures that may help reduce readmissions. OBJECTIVE Our aim was to assess the patient characteristics and surgical factors associated with 30-day readmissions for colorectal surgery in Upstate New York. DESIGN This was a retrospective cohort study. SETTINGS The study included colectomy cases abstracted for the National Surgical Quality Improvement Program in the Upstate New York Surgical Quality Initiative from June 2013 to June 2014. PATIENTS The study consists of 630 colectomies. Patients with a length of stay >30 days or who died during the index admission were excluded. MAIN OUTCOME MEASURES Readmission within 30 days of surgery was the main outcome measure. RESULTS Of 630 colectomy patients, 76 patients (12%) were readmitted within 30 days of surgery. Major and minor complications were associated with 30-day postoperative readmission (OR = 2.99 (95% CI, 1.70-5.28) and OR = 2.19 (95% CI, 1.09-4.43)) but excluded from final analysis because they included both predischarge and postdischarge complications. Risk factors independently associated with 30-day postoperative readmission included diabetes mellitus (OR = 1.94 (95% CI, 1.02-3.67)), smoker within the past year (OR = 2.01 (95% CI, 1.12-3.60)), no scheduled follow-up (OR = 2.20 (95% CI, 1.25-3.86)), and ileostomy formation (OR = 1.97 (95% CI, 1.03-3.77)). LIMITATIONS Limitations include the retrospective design and only 30 days of postoperative follow-up. CONCLUSIONS Consistent with national trends, 1 in 8 patients in the Upstate New York Surgical Quality Initiative program was readmitted within 30 days after colorectal surgery. This study identified several risk factors that may act as tangible targets for intervention, including preoperative smoking cessation programs, optimization of diabetic management, mandatory scheduled follow-up appointments on discharge, and ostomy care pathways.
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A validated, risk assessment tool for predicting readmission after open ventral hernia repair. Hernia 2015; 20:119-29. [PMID: 26286089 DOI: 10.1007/s10029-015-1413-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 07/29/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND/PURPOSE To present a validated model that reliably predicts unplanned readmission after open ventral hernia repair (open-VHR). STUDY DESIGN A total of 17,789 open-VHR patients were identified using the 2011-2012 ACS-NSQIP databases. This cohort was subdivided into 70 and 30% random testing and validation samples, respectively. Thirty-day unplanned readmission was defined as unexpected readmission for a postoperative occurrence related to the open-VHR procedure. Independent predictors of 30-day unplanned readmission were identified using multivariable logistic regression on the testing sample (n = 12,452 patients). Subsequently, the predictors were weighted according to β-coefficients to generate an integer-based Clinical Risk Score (CRS) predictive of readmission, which was validated using receiver operating characteristics (ROC) analysis of the validation sample (n = 5337 patients). RESULTS The rate of 30-day unplanned readmission was 4.7%. Independent risk factors included inpatient status at time of open-VHR, operation time, enterolysis, underweight, diabetes, preoperative anemia, length of stay, chronic obstructive pulmonary disease, history of bleeding disorders, hernia with gangrene, and panniculectomy (all P < 0.05). ROC analysis of the validation cohort rendered an area under the curve of 0.71, which demonstrates the accuracy of this prediction model. Predicted incidence within each 5 risk strata was statistically similar to the observed incidence in the validation sample (P = 0.18), further highlighting the accuracy of this model. CONCLUSION We present a validated risk stratification tool for unplanned readmissions following open-VHR. Future studies should determine if implementation of our CRS optimizes safety and reduces readmission rates in open-VHR patients.
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Damle RN, Alavi K. Risk factors for 30-d readmission after colorectal surgery: a systematic review. J Surg Res 2015. [PMID: 26216748 DOI: 10.1016/j.jss.2015.06.052] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Readmission rates after colorectal surgery remain an ongoing clinical concern. Recent initiation of penalties for excess readmissions in medical patients has encouraged surgeons to reduce readmissions for surgical patients. We conducted a systematic review of the published literature for the purpose of identifying patient-related risk factors for 30-d readmissions after colorectal surgery. METHODS PubMed and Web of Science were queried for relevant English-language studies published before January 1, 2015, evaluating 30-d hospital readmissions after colorectal surgery in adult patients. Studies were included in this review only if they used a multivariable model to assess various patient-associated predictors and were excluded if the study size was less than 100 patients. RESULTS A total of 20 clinical research studies made up of 8 (40%) chart reviews and 12 (60%) administrative data met inclusion criteria. Most studies took place in the United States, and a variety of procedures (e.g., colectomy, rectal resection, stoma creation) and indications for surgery (e.g., cancer, inflammatory bowel disease, diverticular disease) were evaluated. The average ages of included patients was between 37 and 78 y and 36%-97% were men. Readmission rates ranged from 9%-25%. Overall, older age, comorbid conditions, preoperative immunosuppressive therapy, postoperative complications, and nonhome discharge were the most consistent and strongest predictors of readmission. CONCLUSIONS These identifiable risk factors highlight targets for interventions in an effort to reduce unplanned readmissions. Determining the most efficacious and cost-efficient means to reduce these preventable hospitalizations could save millions of valuable health care dollars.
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Affiliation(s)
- Rachelle N Damle
- Department of Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts.
| | - Karim Alavi
- Division of Colorectal Surgery, Department of Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts
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Hanzlik TP, Tevis SE, Suwanabol PA, Carchman EH, Harms BA, Heise CP, Foley EF, Kennedy GD. Characterizing readmission in ulcerative colitis patients undergoing restorative proctocolectomy. J Gastrointest Surg 2015; 19:564-9. [PMID: 25560185 PMCID: PMC4565166 DOI: 10.1007/s11605-014-2734-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 12/15/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative readmissions increase costs and affect patient quality of life. Ulcerative colitis (UC) patients are at a high risk for hospital readmission following restorative proctocolectomy (RP). OBJECTIVE The objective of this study is to characterize UC patients undergoing RP and identify causes and risk factors for readmission. DESIGN A retrospective review of a prospectively maintained institutional database was performed. Postoperative readmission rates and reasons for readmission were examined following RP. Univariate and multivariate analyses were performed to evaluate for risk factors associated with readmission. RESULTS Of 533 patients who met our inclusion criteria, 18.2 % (n = 97) were readmitted within 30 days while 22.7 % (n = 121) were readmitted within 90 days of stage I of RP. Younger patient age (OR 1.825, 95 % CI 1.139-2.957), laparoscopic approach (OR 1.943, 95 % CI 1.217-3.104), and increased length of initial stay (OR 1.155, 95 % CI 1.090-1.225) were all associated with 30-day readmission. The most common reason for readmission was dehydration/ileus/partial bowel obstruction, with 10 % of patients readmitted for this reason within 30 days. CONCLUSIONS Patients undergoing restorative proctocolectomy are at high risk for readmission, particularly following the first stage of the operation. Novel treatment pathways to prevent ileus and dehydration as an outpatient may decrease the rates of readmission following RP.
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Affiliation(s)
| | - Sarah E. Tevis
- Department of Surgery, University of Wisconsin School of Medicine and Public Health
| | | | - Evie H. Carchman
- Department of Surgery, University of Wisconsin School of Medicine and Public Health
| | - Bruce A. Harms
- Department of Surgery, University of Wisconsin School of Medicine and Public Health
| | - Charles P. Heise
- Department of Surgery, University of Wisconsin School of Medicine and Public Health
| | - Eugene F. Foley
- Department of Surgery, University of Wisconsin School of Medicine and Public Health
| | - Gregory D. Kennedy
- Department of Surgery, University of Wisconsin School of Medicine and Public Health
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Kasten KR, Marcello PW, Roberts PL, Read TE, Schoetz DJ, Hall JF, Francone TD, Ricciardi R. All things not being equal: readmission associated with procedure type. J Surg Res 2014; 194:430-440. [PMID: 25541235 DOI: 10.1016/j.jss.2014.11.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 11/05/2014] [Accepted: 11/26/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND There is an accelerated effort to reduce hospital readmissions despite minimal data detailing risk factors associated with this outcome. MATERIALS AND METHODS We analyzed National Surgical Quality Improvement Project data from January 1, 2011-December 31, 2011, evaluating all patients undergoing one of 34 targeted operative procedures across all surgical specialties. Multivariate regression models of risk for readmission were developed including targeted procedure codes, demographic variables, preoperative variables, intraoperative variables, and postoperative adverse events. Our main outcome measure was hospital readmission. RESULTS A total of 217, 389 patients met study inclusion criteria. Minimal associations existed between patient factors and risk of readmission. Adverse events including unplanned operating room return (odds ratio [OR] 8.5; confidence interval [CI] 8.0-9.0), pulmonary embolism (OR 8.2; CI 7.1-9.6), deep incisional infection (OR 7.5; CI 6.7-8.5), and organ space infection (OR 5.8; CI 5.3-6.3) were associated with increased risk of readmission. Our data suggest the type of procedure performed is significantly associated with risk of readmission. Furthermore, multivariate analysis revealed procedures, involving the pancreas, rectum, bladder, and lower extremity vascular bypass, were associated with the highest risk of readmission. CONCLUSIONS Postoperative complications demonstrated stronger association with readmission than patient factors. Focused analysis of higher risk procedures may provide insight into strategies for risk reduction.
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Affiliation(s)
- Kevin R Kasten
- Section of Colon and Rectal Surgery, Brody School of Medicine at ECU, Greenville, North Carolina
| | - Peter W Marcello
- Department of Colon and Rectal Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Patricia L Roberts
- Department of Colon and Rectal Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Thomas E Read
- Department of Colon and Rectal Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - David J Schoetz
- Department of Colon and Rectal Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Jason F Hall
- Department of Colon and Rectal Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Todd D Francone
- Department of Colon and Rectal Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Rocco Ricciardi
- Department of Colon and Rectal Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts.
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Factors associated with 30-day readmission after restorative proctocolectomy with IPAA: a national study. Dis Colon Rectum 2014; 57:1371-8. [PMID: 25380002 DOI: 10.1097/dcr.0000000000000227] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hospital readmission has been identified by many payers as a surrogate for surgical quality. The 30-day readmission rate and factors associated with hospital readmission after restorative proctocolectomy with IPAA have not been well studied. OBJECTIVE The purpose of this work was to identify the rate of and factors associated with hospital readmission within 30 days of restorative proctocolectomy with IPAA. DESIGN A retrospective review of patients undergoing IPAA from 2009 to 2012 in the University HealthSystem Consortium database was performed. Hospitals were stratified into quartiles according to the number of cases performed annually. SETTING This study was conducted using a national database of university hospitals. PATIENTS A total of 4952 patients within the 4-year study period were included in the analysis. MAIN OUTCOME MEASURES The primary outcome measured was readmission within 30 days of discharge. RESULTS The 30-day readmission rate was 22.8% overall, although high-volume centers performed significantly better than low-volume centers (high vs low volume: 19.7% vs 28.2%; p < 0.001). When controlling for confounding variables, multivariate analysis identified female sex (OR, 1.191; p = 0.02), government-based (vs private) insurance (OR, 1.364; p < 0.001), and higher preoperative severity of illness (OR, 1.491; p = 0.001) to be associated with readmission. In addition, a significant volume-dependent relationship on 30-day readmission was identified, wherein undergoing operation at the higher-volume hospitals was protective for predicting readmission. Hierarchical regression modeling indicated that 31% of the variation in readmission rates among individual hospitals was accounted for by hospital volume. LIMITATIONS This study was limited by its retrospective nature and limited postoperative complication data. CONCLUSIONS The national 30-day readmission after IPAA creation was 22.8%, at least double that of other colorectal procedures. This high rate of readmission was mitigated by centers performing the highest volume of cases. Avoidance of referral to centers performing very few of these procedures annually may improve perioperative outcomes and reduce associated morbidity.
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Clinical and financial impact of hospital readmissions after colorectal resection: predictors, outcomes, and costs. Dis Colon Rectum 2014; 57:1421-9. [PMID: 25380009 DOI: 10.1097/dcr.0000000000000251] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND After passage of the Affordable Care Act, 30 -day hospital readmissions have come under greater scrutiny. Excess readmissions for certain medical conditions and procedures now result in penalizations on all Medicare reimbursements. OBJECTIVE The purpose of this work was to define the risk factors, outcomes, and costs of 30-day readmissions after colorectal surgery. DESIGN Adults undergoing colorectal surgery were studied using data from the University HealthSystem Consortium. Univariate and multivariable analyses were used to identify patient-related risk factors for, and 30-day outcomes of, readmission after colorectal surgery. SETTINGS This study was conducted at an academic hospital and its affiliates. PATIENTS Adults ≥18 years of age who underwent colorectal surgery for cancer, diverticular disease, IBD, or benign tumors between 2008 and 2011 were included in this study. MAIN OUTCOME MEASURES Readmission within 30 days of index discharge was the main outcome measured. RESULTS A total of 70,484 patients survived the index hospitalization after colorectal surgery; 9632 (13.7%) were readmitted within 30 days of discharge. The strongest independent predictors of readmission were length of stay ≥4 days (OR 1.44; 95% CI 1.32-1.57), stoma (OR 1.54; 95% CI 1.46-1.51), and discharge to skilled nursing (OR 1.62; 95% CI 1.49-1.76) or rehabilitation facility (OR 2.93; 95% CI 2.53-3.40). Of those readmitted, half of the readmissions occurred within 7 days, 13% required the intensive care unit, 6% had a reoperation, and 2% died during the readmission stay. The median combined total direct hospital cost was more than 2 times higher ($26,917 vs $13,817; p < 0.001) for readmitted than for nonreadmitted patients. LIMITATIONS Follow-up was limited to 30 days after initial discharge. CONCLUSIONS Readmissions after colorectal resection occur frequently and incur a significant financial burden on the health-care system. Future studies aimed at targeted interventions for high-risk patients may reduce readmissions and curb escalating health-care costs.
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Hartney M, Liu Y, Velanovich V, Fabri P, Marcet J, Grieco M, Huang S, Zayas-Castro J. Bounceback branchpoints: using conditional inference trees to analyze readmissions. Surgery 2014; 156:842-7. [PMID: 25239331 DOI: 10.1016/j.surg.2014.07.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 07/18/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND We sought to identify risks for 30-day readmission in patients undergoing colorectal surgery. METHODS We reviewed 2011 American College of Surgery National Surgical Quality Improvement Program data to identify patients readmitted after colorectal surgery. We found 3,228 readmissions from 30,412 records. Using statistically suggestive variables from logistic regression (P < .1), we built conditional inference trees (CTREES) with subsampled records to identify combined risks. RESULTS Logistic regression identified 27 potentially significant variables. Using these in new logistic regression and CTREES, we found classification accuracies of 0.70 and 0.63, respectively. CTREES predicted that the majority of patients who required reoperation during their hospitalization were predicted to require readmission (n = 496), along with the majority of patients who developed organ space infection (n = 671). Patients with deep infections discharged ≤10 days from their index operation required readmission in 443 of 459 of records; this approach predicted a >99% risk of readmission in patients with these infections who were discharged ≤5 days (220/222). Additionally, >90% (253/271) of patients who returned to the operating room and were discharged ≤8 days from the first operation are predicted to return. CONCLUSION Subgroups identified using the CTREES model demonstrate that patients with deep space infections or who return to the operating room have a greater readmission rate if they are discharged early. Modeled patients found to have organ space infections and who returned to the operating room had 30-day readmission risks of >50%, with those discharged a rate of >90%. We show herein that CTREES can be used with retrospective data on surgery populations to bring hidden patterns into relief.
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Affiliation(s)
- Mark Hartney
- Department of Surgery, University of South Florida, Tampa, FL.
| | - Yazhuo Liu
- Department of Surgery, University of South Florida, Tampa, FL
| | - Vic Velanovich
- Department of Surgery, University of South Florida, Tampa, FL
| | - Peter Fabri
- Department of Surgery, University of South Florida, Tampa, FL
| | - Jorge Marcet
- Department of Surgery, University of South Florida, Tampa, FL
| | - Michael Grieco
- Department of Surgery, University of South Florida, Tampa, FL
| | - Shuai Huang
- Department of Surgery, University of South Florida, Tampa, FL
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Copertino LM, McCormack JE, Rutigliano DN, Huang EC, Shapiro MJ, Vosswinkel JA, Jawa RS. Early unplanned hospital readmission after acute traumatic injury: the experience at a state-designated level-I trauma center. Am J Surg 2014; 209:268-73. [PMID: 25194759 DOI: 10.1016/j.amjsurg.2014.06.026] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 06/15/2014] [Accepted: 06/20/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND There is limited literature on early unplanned hospital readmission after acute traumatic injury, especially at suburban facilities. METHODS A retrospective review of the trauma registry at a suburban, state-designated, level-I academic trauma center from July 2009 to June 2012 was performed for all admitted (≥24 hours) adult (age ≥18 years) trauma patients who were discharged alive, including unplanned readmissions within 30 days of discharge. RESULTS Of 3,622 admitted adult trauma patients, 6.57% were readmitted at a median of 9 days. Major surgery was required in 15.9% patients on readmission. The mortality rate at readmission was 4.6%. Multiple factors were associated with readmission on univariate analysis; however, on multivariate analysis, only major comorbidities (odds ratio [OR], 1.53), hospital length of stay (OR, 1.01), abdominal Abbreviated Injury Score greater than or equal to 3 (OR, 2.10), and discharge to a skilled nursing facility or subacute facility (OR, 1.56) were significant predictors. Meanwhile, index admission to surgical services was associated with a significantly lower readmission risk (OR, .60). CONCLUSIONS Trauma patients are infrequently readmitted. Index admission to a surgical service reduces the risk of readmission. Earlier medical follow-up should be considered.
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Affiliation(s)
- Leonard M Copertino
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, HSC 18, Room 040, Stony Brook, NY 11794-8191
| | - Jane E McCormack
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, HSC 18, Room 040, Stony Brook, NY 11794-8191
| | - Daniel N Rutigliano
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, HSC 18, Room 040, Stony Brook, NY 11794-8191
| | - Emily C Huang
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, HSC 18, Room 040, Stony Brook, NY 11794-8191
| | - Marc J Shapiro
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, HSC 18, Room 040, Stony Brook, NY 11794-8191
| | - James A Vosswinkel
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, HSC 18, Room 040, Stony Brook, NY 11794-8191
| | - Randeep S Jawa
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, HSC 18, Room 040, Stony Brook, NY 11794-8191.
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Identification of process measures to reduce postoperative readmission. J Gastrointest Surg 2014; 18:1407-15. [PMID: 24912913 DOI: 10.1007/s11605-013-2429-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 12/02/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Readmission rates after intestinal surgery have been notably high, ranging from 10 % for elective surgery to 21 % for urgent/emergent surgery. Other than adherence to established strategies for decreasing individual postoperative complications, there is little guidance available for providers to work toward reducing their postoperative readmission rates. STUDY DESIGN Processes of care that may affect postoperative readmissions were identified through a systematic literature review, assessment of existing guidelines, and semi-structured interviews with individuals who have expertise in hospital readmissions and surgical quality improvement. Eleven experts ranked potential process measures for validity on the basis of the RAND/University of California, Los Angeles Appropriateness Methodology. RESULTS Of 49 proposed process measures, 34 (69 %) were rated as valid. Of the 34 valid measures, two measures addressed care in the preoperative period. These included evaluation of patient's comorbidities, providing written instruction detailing the anticipated perioperative course, and communication with the patient's referring or primary care doctor. A measure addressing perioperative care stated that institutions should have a standardized perioperative care protocol. Additional measures focused on discharge instructions and communication. CONCLUSIONS An expert panel identified several aspects of care that are considered essential to quality patient care and important to reducing postoperative readmissions.
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Glasgow MA, Shields K, Vogel RI, Teoh D, Argenta PA. Postoperative readmissions following ileostomy formation among patients with a gynecologic malignancy. Gynecol Oncol 2014; 134:561-5. [PMID: 24933101 DOI: 10.1016/j.ygyno.2014.06.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 06/06/2014] [Accepted: 06/07/2014] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Ileostomy results in a relatively poorer water reabsorption and is associated with dehydration and renal injury. These problems may be exacerbated in the setting of gynecologic cancers owing to both patient and disease-related factors. We evaluated the rate and reasons for hospital readmission within 30 days of ileostomy creation in patients with a gynecologic malignancy. METHODS We performed a retrospective review of women with gynecologic malignancies who underwent ileostomy creation between 2002 and 2013. RESULTS Fifty-three patients were eligible for analysis. The mean age was 63.3 years. Most patients had ovarian cancer (86.5%). Indications for ileostomy included small bowel obstruction (45.3%), as part of primary debulking (18.9%), or treatment of an anastomotic leak (15.1%). The 30-day readmission rate was 34%. Co-morbid diseases such as hypertension (p=0.008) and chronic kidney disease (p=0.010) were more common among women who were readmitted. The most common reasons for readmission were dehydration (38.9%) and acute renal failure (33.3%); women readmitted for these conditions had higher average serum creatinine levels at initial postoperative discharge (1.00 mg/dL versus 0.71 mg/dL, p=0.017) than women who did not require readmission. Readmitted women had a trend toward shorter overall survival (0.41 years versus 1.67 years, p=0.061). CONCLUSIONS Readmission rates for gynecologic oncology patients undergoing ileostomy were similar to, but higher than those previously reported in the colorectal literature. In our population, patients with preexisting cardiovascular or renal disease were at the highest risk of readmission and may benefit from preemptive strategies to decrease high ostomy output and dehydration.
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Affiliation(s)
- Michelle A Glasgow
- Department of Obstetrics, Gynecology and Women's Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Kristin Shields
- Maricopa Medical Center and St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Rachel Isaksson Vogel
- Masonic Cancer Center, Biostatistics and Bioinformatics, University of Minnesota, Minneapolis, MN, USA
| | - Deanna Teoh
- Department of Obstetrics, Gynecology and Women's Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Peter A Argenta
- Department of Obstetrics, Gynecology and Women's Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA.
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Kim BD, Smith TR, Lim S, Cybulski GR, Kim JYS. Predictors of unplanned readmission in patients undergoing lumbar decompression: multi-institutional analysis of 7016 patients. J Neurosurg Spine 2014; 20:606-16. [DOI: 10.3171/2014.3.spine13699] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Object
Unplanned hospital readmission represents a large financial burden on the Centers for Medicare and Medicaid Services, commercial insurance payers, hospitals, and individual patients, and is a principal target for cost reduction. A large-scale, multi-institutional study that evaluates risk factors for readmission has not been previously performed in patients undergoing lumbar decompression procedures. The goal of this multicenter retrospective study was to find preoperative, intraoperative, and postoperative predictive factors that result in unplanned readmission (UR) after lumbar decompression surgery.
Methods
The National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed to identify all patients who received lumbar decompression procedures in 2011. Risk-adjusted multivariate logistic regression analysis was performed to estimate independent predictors of UR.
Results
The overall rate of UR among patients undergoing lumbar decompression was 4.4%. After multivariate logistic regression analysis, anemia (odds ratio [OR] 1.48), dependent functional status (OR 3.03), total operative duration (OR 1.003), and American Society of Anesthesiologists Physical Status Class 4 (OR 3.61) remained as independent predictors of UR. Postoperative complications that were significantly associated with UR included overall complications (OR 5.18), pulmonary embolism (OR 3.72), and unplanned reoperation (OR 56.91).
Conclusions
There were several risk factors for UR after lumbar spine decompression surgery. Identification of high-risk patients and appropriate allocation of resources to reduce postoperative incidence may reduce the readmission rate.
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Affiliation(s)
- Bobby D. Kim
- 1Rosalind Franklin University of Medicine and Science, Chicago Medical School, North Chicago; and
| | | | - Seokchun Lim
- 1Rosalind Franklin University of Medicine and Science, Chicago Medical School, North Chicago; and
| | | | - John Y. S. Kim
- 3Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
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General and vascular surgery readmissions: a systematic review. J Am Coll Surg 2014; 219:552-69.e2. [PMID: 25067801 DOI: 10.1016/j.jamcollsurg.2014.05.007] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 04/08/2014] [Accepted: 05/14/2014] [Indexed: 01/08/2023]
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Kim BD, Ver Halen JP, Lim S, Kim JY. Predictors of 61 unplanned readmission cases in microvascular free tissue transfer patients: Multi-institutional analysis of 774 patients. Microsurgery 2014; 35:13-20. [DOI: 10.1002/micr.22230] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 01/04/2014] [Accepted: 01/08/2014] [Indexed: 12/14/2022]
Affiliation(s)
- Bobby D. Kim
- Rosalind Franklin University of Medicine and Science, Chicago Medical School; North Chicago IL
| | - Jon P. Ver Halen
- Department of Plastic Surgery; University of Tennessee Health Science Center; Memphis TN
| | - Seokchun Lim
- Rosalind Franklin University of Medicine and Science, Chicago Medical School; North Chicago IL
| | - John Y.S. Kim
- Division of Plastic and Reconstructive Surgery; Northwestern University, Feinberg School of Medicine; Chicago IL
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Krell RW, Girotti ME, Fritze D, Campbell DA, Hendren S. Hospital readmissions after colectomy: a population-based study. J Am Coll Surg 2014; 217:1070-9. [PMID: 24246621 DOI: 10.1016/j.jamcollsurg.2013.07.403] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 06/11/2013] [Accepted: 07/29/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND Surgical readmissions will be targeted for reimbursement cuts in the near future. We sought to understand differences between hospitals with high and low readmission rates in a statewide surgical collaborative to identify potential quality improvement targets. STUDY DESIGN We studied 5,181 patients undergoing laparoscopic or open colectomy at 24 hospitals participating in the Michigan Surgical Quality Collaborative between May 2007 and January 2011. We first calculated hospital risk-adjusted 30-day readmission rates. We then compared reasons for readmission, risk-adjusted complication rates, risk-adjusted inpatient length of stay, and composite process compliance across readmission rate quartiles. RESULTS Hospitals with the lowest 30-day readmission rates averaged 5.1%, compared with 10.3% in hospitals with the highest rates (p < 0.01). Despite wide variability in readmission rates, reasons for readmission were similar between hospitals. Compared with hospitals with low readmission rates, hospitals with high readmission rates had higher risk-adjusted complication rates (29% vs 22%, p = 0.03), but similar median lengths of stay (5.5 days vs 5.6 days, p = 0.61). Although measures to reduce complications were associated with lower surgical site infection rates, they were not associated with reduced overall complication or readmission rates. There was wide variation in complication rates among hospitals with similar readmission rates. CONCLUSIONS There is wide variation in hospital readmission rates after colectomy that correlates with overall complication rates. However, the wide variation in complication rates among hospitals with similar readmission rates suggests that hospital complication rates explain little about their readmission rates. Preventing readmissions after colectomy in hospitals with high readmission rates will require more attention to different care processes currently unmeasured in many clinical registries as well as complication prevention.
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Affiliation(s)
- Robert W Krell
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI.
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Morris DS, Rohrbach J, Sundaram LMT, Sonnad S, Sarani B, Pascual J, Reilly P, Schwab CW, Sims C. Early hospital readmission in the trauma population: are the risk factors different? Injury 2014; 45:56-60. [PMID: 23726120 PMCID: PMC4149179 DOI: 10.1016/j.injury.2013.04.029] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 04/08/2013] [Accepted: 04/27/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Hospital readmission rates will soon impact Medicare reimbursements. While risk factors for readmission have been described for medical and elective surgical patients, little is known about their predictive value specifically in trauma patients. PATIENTS AND METHODS We retrospectively identified all admissions after trauma resuscitation to our urban level 1 trauma centre from 1/1/2004 to 8/31/2010. All patients discharged alive were included. Data collected included demographics, Injury Severity Score (ISS), and length of stay (LOS). We analyzed these index admissions for the development of complications that have previously been shown to be associated with readmission. Readmissions that occurred within 30 days of index admission were identified. Univariable and multivariable analyses were performed. p<0.05 was considered significant. RESULTS We identified 10,306 index admissions, with 447 (4.3%) early (within 30 days) readmissions. Mean ISS was 11.1 (SD 10.4). On multivariable analysis, African-American race (OR 1.3, p=0.009), pre-existing chronic obstructive pulmonary disease (COPD) (OR 1.5, p=0.02), and diabetes mellitus (OR 1.8, p<0.001) were associated with readmission, along with higher ISS (OR 1.01, p<0.001), ICU admission (OR 2.1, p<0.001), and increased LOS (OR 1.01, p<0.001). Among many in-hospital complications examined, only the development of surgical site infection (SSI) (OR 1.9, p=0.02) was associated with increased risk of readmission. CONCLUSIONS Trauma patients have a low risk of readmission. In contrast to elective surgical patients, the only modifiable risk factor for readmission in our trauma population was SSI. Other risk factors may present clinicians with opportunities for targeted interventions, such as proactive follow up or early phone contact. With future changes to health care policy, clinicians may have even greater motivation to prevent readmission.
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Affiliation(s)
- David S. Morris
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Jeff Rohrbach
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Latha Mary Thanka Sundaram
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Seema Sonnad
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Babak Sarani
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Jose Pascual
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Patrick Reilly
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - C. William Schwab
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Carrie Sims
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
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Abstract
OBJECTIVE In 2012, Medicare began cutting reimbursement for hospitals with high readmission rates. We sought to define the incidence and risk factors associated with readmission after surgery. METHODS A total of 230,864 patients discharged after general, upper gastrointestinal (GI), small and large intestine, hepatopancreatobiliary (HPB), vascular, and thoracic surgery were identified using the 2011 American College of Surgeons National Surgical Quality Improvement Program. Readmission rates and patient characteristics were analyzed. A predictive model for readmission was developed among patients with length of stay (LOS) 10 days or fewer and then validated using separate samples. RESULTS Median patient age was 56 years; 43% were male, and median American Society of Anesthesiologists (ASA) class was 2 (general surgery: 2; upper GI: 3; small and large intestine: 2; HPB: 3; vascular: 3; thoracic: 3; P < 0.001). The median LOS was 1 day (general surgery: 0; upper GI: 2; small and large intestine: 5; HPB: 6; vascular: 2; thoracic: 4; P < 0.001). Overall 30-day readmission was 7.8% (general surgery: 5.0%; upper GI: 6.9%; small and large intestine: 12.6%; HPB: 15.8%; vascular: 11.9%; thoracic: 11.1%; P < 0.001). Factors strongly associated with readmission included ASA class, albumin less than 3.5, diabetes, inpatient complications, nonelective surgery, discharge to a facility, and the LOS (all P < 0.001). On multivariate analysis, ASA class and the LOS remained most strongly associated with readmission. A simple integer-based score using ASA class and the LOS predicted risk of readmission (area under the receiver operator curve 0.702). CONCLUSIONS Readmission among patients with the LOS 10 days or fewer occurs at an incidence of at least 5% to 16% across surgical subspecialties. A scoring system on the basis of ASA class and the LOS may help stratify readmission risk to target interventions.
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Turina M, Remzi FH, Dietz DW, Kiran RP, Seyidova-Khoshknabi D, Hammel JP, Vogel JD. Quantification of Risk for Early Unplanned Readmission after Rectal Resection: A Single-Center Study. J Am Coll Surg 2013; 217:200-8. [DOI: 10.1016/j.jamcollsurg.2013.05.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Revised: 05/17/2013] [Accepted: 05/17/2013] [Indexed: 10/26/2022]
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Cumulative incidence and risk factors for hospitalization and surgery in a population-based cohort of ulcerative colitis. Inflamm Bowel Dis 2013; 19:1858-66. [PMID: 23660997 PMCID: PMC4526131 DOI: 10.1097/mib.0b013e31828c84c5] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND We sought to identify clinical and demographic features influencing hospitalization and colectomy in a population-based inception cohort of ulcerative colitis. METHODS Between 1970 and 2004, a total of 369 patients (58.5% males) from Olmsted County, MN, were followed from diagnosis for 5401 person-years. The cumulative probability of hospitalization and colectomy were estimated using the Kaplan-Meier method. Cox proportional hazards regression was used to identify factors associated with hospitalization and colectomy. RESULTS The cumulative probability of first hospitalization was 29.4% at 5 years (95% confidence interval [CI], 24.5%-34.1%), 38.7% at 10 years (33.1%-43.8%), 49.2% at 20 years (42.7%-55.2%), and 52.3% at 30 years (45.1%-59.7%). The incidence rate of hospitalizations decreased over the last 4 decades, although cumulative probability of first hospitalization increased with successive decades of diagnosis. Early need for corticosteroids (hazard ratio [HR], 1.8; 95% CI, 1.1%-2.7%) and early need for hospitalization (HR, 1.5; 95% CI, 1.02-2.4) were independent predictors of hospitalization after 90 days of illness. The cumulative probability of colectomy from the time of diagnosis was 13.1% at 5 years (95% CI, 9.4%-16.6%), 18.9% at 10 years (95% CI, 14.4%-23.2%), and 25.4% at 20 years (95% CI, 19.8%-30.8%). Male gender (HR, 2.1; 95% CI, 1.3-3.5), diagnosis in the 1990s (HR, 2.0; 95% CI, 1.01-4.0), and diagnosis in 2000 to 2004 (HR, 3.7; 95% CI, 1.7-8.2) were significantly associated with colectomy risk. CONCLUSIONS Colectomy rates were comparable to reports from northern Europe. The numbers of hospitalizations show a decreasing trend. Male gender and being diagnosed in the 2000 to 2004 period predicted colectomy while extensive colitis predicted future hospitalizations.
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Abstract
OBJECTIVES We aimed to identify the frequency and costs of, and the disease predictors and inpatient process issues that may predispose to, 30-day readmission for an inflammatory bowel disease (IBD) patient. METHODS IBD patients admitted to an inpatient gastroenterology service were followed for a time-to-readmission analysis assessing factors associated with readmission within 30 days. RESULTS Index admissions were more costly among those readmitted than among those not readmitted. Patients admitted with evidence of increased inflammation, infection, or obstruction or for dehydration or pain control had a higher risk of readmission. Patients treated with opioid analgesia during index admission were no less likely to be readmitted, and there was a 2.2-fold increase in readmissions when patients were discharged with no opioid analgesia. Scheduling variability and outpatient follow-up compliance were associated with readmission. CONCLUSIONS Predicting readmission is complex. A predictive model developed to be used at discharge yielded an area under the curve of 0.757.
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Hospital Readmission by Method of Data Collection. J Am Coll Surg 2013; 216:1150-8. [DOI: 10.1016/j.jamcollsurg.2013.01.057] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 01/10/2013] [Accepted: 01/25/2013] [Indexed: 11/18/2022]
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Hospital readmission for fluid and electrolyte abnormalities following ileostomy construction: preventable or unpredictable? J Gastrointest Surg 2013. [PMID: 23192425 DOI: 10.1007/s11605-012-2073-5] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ileostomy creation has complications, including rehospitalization for fluid and electrolyte abnormalities. Although studies have identified predictors of this morbidity, readmission rates remain high. METHODS The researchers conducted a retrospective chart review of all patients with ileostomy creation at a tertiary institution from January 2008 to June 2011. RESULTS One hundred fifty-four patients (154) were included in this study; 71 (46.1 %) were female. Mean age was 49 ± 17.64 (range 16-91), and mean BMI was 26.9 ± 6.44 (range 13-52). The readmission rate for fluid and electrolyte abnormalities was 20.1 % for the study population; of those readmitted for all diagnoses, dehydration accounted for 40.7 % of all readmissions. Cancer was associated with readmission (χ(2) = 4.73, p = 0.03) as was neoadjuvant therapy (χ(2) = 9.20, p = 0.01). After multivariate analysis, only the use of anti-diarrheals and neoadjuvant therapy remained significant. High stoma output, adjuvant treatment, and postoperative complications were not significant. CONCLUSIONS Our study found that the use of anti-diarrheals and neoadjuvant therapy for rectal cancer were associated with readmission. Our findings imply that the use of anti-diarrheals may be a marker for patients at risk for fluid and electrolyte abnormalities; these patients should be strictly monitored at home. Our study also suggests consideration of avoidance of ileostomy creation or different discharge criteria for at-risk patients. Prospective studies focused on stoma monitoring after discharge may help reduce rehospitalizations for fluid and electrolyte abnormalities after ileostomy creation.
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Abstract
BACKGROUND New ileostomates face significant physical and psychological adaptations. Despite advanced resources, such as wound, ostomy, and continence nurses, we observed a high readmission rate for dehydration among patients with new ileostomies. OBJECTIVE Our goal was to create a pathway to reduce readmission and facilitate patient education and well-being. DESIGN The 'Ileostomy Pathway' was established by a collaborative group at Beth Israel Deaconess Medical Center. A standardized set of patient education tools was developed to be used throughout the perioperative process. Patient's education started with the preoperative visit. All patients were directly engaged in ostomy management and trained in a stepwise progression. Patients were discharged from the hospital with flow sheets, supplies for recording intake/output, and visiting nurse services. Prospectively collected data from the first 7 months was compared with a retrospective database of the previous 4 years. SETTINGS This study was conducted at a tertiary academic center. PATIENTS Patients with a new permanent or temporary ileostomy were included. INTERVENTIONS A new ileostomy pathway was created. MAIN OUTCOME MEASURES The primary outcome measured was readmission rates. RESULTS One hundred sixty-one patients were assigned to prepathway implementation and 42 were assigned to postpathway implementation. One hundred three of 203 (50.7%) patients were men, and 58 of 203 (28.6%) patients had permanent ostomies. Overall readmission rate was 35.4% and 21.4% for the prepathway and postpathway groups. The readmission rate for dehydration was 15.5% (25/161) for prepathway patients, but dropped to 0% in the study group. The average length of stay after creation of the new ostomy was 7.5 days and 6.6 days for prepathway and postpathway groups. LIMITATIONS This study was limited by its small sample size and the lack of randomization. CONCLUSIONS A simple, educational program for new ileostomy patients that includes preoperative teaching, standardized teaching materials, in-hospital engagement, observed management, and postdischarge tracking of intake and output is very effective in decreasing hospital readmission. The average length of stay remained stable, despite the addition of this teaching program to our perioperative/inpatient care.
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Broucek JR, Francescatti AB, Swanson GR, Keshavarzian A, Brand MI, Saclarides TJ. Unusual Thrombotic Complications. Am Surg 2012. [DOI: 10.1177/000313481207800631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Joseph R. Broucek
- Department of General Surgery Section of Colon & Rectal Surgery Rush University Medical Center Chicago, Illinois
| | - Amanda B. Francescatti
- Department of General Surgery Section of Colon & Rectal Surgery Rush University Medical Center Chicago, Illinois
| | - Garth R. Swanson
- Department of Gastroenterology Rush University Medical Center Chicago, Illinois
| | - Ali Keshavarzian
- Department of Gastroenterology Rush University Medical Center Chicago, Illinois
| | - Marc I. Brand
- Department of General Surgery Section of Colon & Rectal Surgery Rush University Medical Center Chicago, Illinois
| | - Theodore J. Saclarides
- Department of General Surgery Section of Colon & Rectal Surgery Rush University Medical Center Chicago, Illinois
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van Middendorp JJ, Barbagallo G, Schuetz M, Hosman AJF. Design and rationale of a Prospective, Observational European Multicenter study on the efficacy of acute surgical decompression after traumatic Spinal Cord Injury: the SCI-POEM study. Spinal Cord 2012; 50:686-94. [DOI: 10.1038/sc.2012.34] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
BACKGROUND Early readmission after discharge from the hospital is an undesirable outcome. Ileostomies are commonly used to prevent symptomatic anastomotic complications in colorectal resections. OBJECTIVE The aim of this study was to identify factors predictive of readmission after colectomy/proctectomy and diverting loop ileostomy. DESIGN This study is a retrospective review. PATIENTS Patients were included who underwent colon and rectal resections with ileostomy at our institution. Sex, age, type of disease, comorbidities, elective vs urgent procedure, type of ileostomy, operative method, steroid use, ASA score, and the use of diuretics were evaluated as potential factors for readmission. MAIN OUTCOME MEASURES The primary outcomes measured were the need for readmission and the presence of dehydration (ostomy output ≥1500 mL over 24 hours and a blood urea nitrogen/creatinine level ≥20, or physical findings of dehydration). RESULTS Six hundred three loop ileostomies were created mostly in white (95.3%), male (55.6%) patients undergoing colon or rectal resections. IBD was the most common indication at 50.9%, with rectal cancer at 16.1%, and other at 31.0%. The 60-day readmission rate was 16.9% (n = 102) with the most common cause dehydration (n = 44, 43.1%). Regression analysis demonstrated that the laparoscopic approach (p = 0.02), lack of epidural anesthesia (p = 0.004), preoperative use of steroids (p = 0.04), and postoperative use of diuretics (p = 0.0001) were highly predictive for readmission. Furthermore, regression analysis for readmission for dehydration identified the use of postoperative diuretics as the sole risk factor (p = 0.0001). LIMITATIONS This study is limited by the retrospective analysis of data, and it does not capture patients that were treated at home or in clinic. CONCLUSION Readmission after colon or rectal resection with diverting loop ileostomy was high at 16.9%. Dehydration was the major cause for readmission. Patients receiving diuretics are at increased risk for readmission for dehydration. High-risk patients should be treated more cautiously as inpatients and closely monitored in the outpatient setting to help reduce dehydration and readmission.
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Abstract
BACKGROUND Hospital readmission is emerging as a quality indicator by the state, federal, and private payors with the goal of denying payment for select readmissions. OBJECTIVE We designed a study to measure the rate, cost, and risk factors for hospital readmission after colorectal surgery. STUDY DESIGN/SETTING We reviewed commercial health insurance records of 10,882 patients who underwent colorectal surgery over a 7-year period (2002-2008). PATIENTS All patients undergoing colon and/or rectal resection ages 18 to 64 were included. MAIN OUTCOME MEASURE The 30-day and 90-day readmission rates, the number of readmissions per patient, the median cost, length of stay, and risk factors for readmission were analyzed. RESULTS Thirty-day readmission occurred in 11.4% (1239/10,882) of patients. Readmission between 31 and 90 days occurred in an additional 11.9% (1027/10,882) of patients for a total 90-day readmission rate of 23.3%. Two or more readmissions occurred in 1.4% (155) and 5.2% (570) of patients in the first 30 and 90 days. Mean readmission length of stay was 8 days, and the median cost per stay was $8885. Initial hospitalization risk factors for readmission were the diagnosis of a surgical site infection (OR 1.2), creation of a stoma (OR 1.2), discharge to nursing home (OR 1.2), index admission length of stay >7 days (OR 1.2), proctectomy (OR 1.1), and severity of illness score (severity of illness 3 = OR 1.1; severity of illness 4 = OR 1.3). CONCLUSIONS Readmission after colorectal surgery occurs frequently and is associated with a cost of approximately $9000 per readmission. Nationwide these findings account for $300 million in readmission costs annually for colorectal surgery alone. Clinical and systems-based prevention strategies are needed to reduce readmission.
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Morris DS, Rohrbach J, Rogers M, Thanka Sundaram LM, Sonnad S, Pascual J, Sarani B, Reilly P, Sims C. The Surgical Revolving Door: Risk Factors for Hospital Readmission. J Surg Res 2011; 170:297-301. [DOI: 10.1016/j.jss.2011.04.049] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 03/29/2011] [Accepted: 04/21/2011] [Indexed: 10/18/2022]
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Vest JR, Gamm LD, Oxford BA, Gonzalez MI, Slawson KM. Determinants of preventable readmissions in the United States: a systematic review. Implement Sci 2010; 5:88. [PMID: 21083908 PMCID: PMC2996340 DOI: 10.1186/1748-5908-5-88] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Accepted: 11/17/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hospital readmissions are a leading topic of healthcare policy and practice reform because they are common, costly, and potentially avoidable events. Hospitals face the prospect of reduced or eliminated reimbursement for an increasing number of preventable readmissions under nationwide cost savings and quality improvement efforts. To meet the current changes and future expectations, organizations are looking for potential strategies to reduce readmissions. We undertook a systematic review of the literature to determine what factors are associated with preventable readmissions. METHODS We conducted a review of the English language medicine, health, and health services research literature (2000 to 2009) for research studies dealing with unplanned, avoidable, preventable, or early readmissions. Each of these modifying terms was included in keyword searches of readmissions or rehospitalizations in Medline, ISI, CINAHL, The Cochrane Library, ProQuest Health Management, and PAIS International. Results were limited to US adult populations. RESULTS The review included 37 studies with significant variation in index conditions, readmitting conditions, timeframe, and terminology. Studies of cardiovascular-related readmissions were most common, followed by all cause readmissions, other surgical procedures, and other specific-conditions. Patient-level indicators of general ill health or complexity were the commonly identified risk factors. While more than one study demonstrated preventable readmissions vary by hospital, identification of many specific organizational level characteristics was lacking. CONCLUSIONS The current literature on preventable readmissions in the US contains evidence from a variety of patient populations, geographical locations, healthcare settings, study designs, clinical and theoretical perspectives, and conditions. However, definitional variations, clear gaps, and methodological challenges limit translation of this literature into guidance for the operation and management of healthcare organizations. We recommend that those organizations that propose to reward reductions in preventable readmissions invest in additional research across multiple hospitals in order to fill this serious gap in knowledge of great potential value to payers, providers, and patients.
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Affiliation(s)
- Joshua R Vest
- Jiann-Ping Hsu College of Public Health, Georgia Southern University Hendricks Hall, PO Box 8015, Statesboro, GA 30460-8015, USA
| | - Larry D Gamm
- Texas A&M Health Science Center, School of Rural Public Health, Department of Health Policy & Management, 1266 TAMU, College Station, TX 77843, USA
| | - Brock A Oxford
- Texas A&M Health Science Center, School of Rural Public Health, Department of Health Policy & Management, 1266 TAMU, College Station, TX 77843, USA
| | - Martha I Gonzalez
- Texas A&M University, Dwight Look College of Engineering, Department of Industrial & Systems Engineering. 241 Zachry Engineering Research Center, Texas A&M University, 3131 TAMU, College Station, TX 77843-3131, USA
| | - Kevin M Slawson
- Texas A&M University, Dwight Look College of Engineering, Department of Industrial & Systems Engineering. 241 Zachry Engineering Research Center, Texas A&M University, 3131 TAMU, College Station, TX 77843-3131, USA
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