Understanding Readmissions in Pediatric Surgery

Transcription

1 Understanding Readmissions in Pediatric Surgery Afif Kulaylat MD MSc, Anthony Tsai MD, Dorothy Rocourt MD, Kathryn Martin MD, Brett Engbrecht MD MPH, Mary Santos MD MEd, Robert Cilley MD, Christopher Hollenbeak PhD, Peter Dillon MD MSc Division of Pediatric Surgery Penn State Hershey Children s Hospital Disclosures No disclosures to report Introduction Readmissions Costly Associated with morbidity Public reporting Quality metric Aims Characterize underlying reasons for readmission in children 1

2 Methods NSQIP-P readmission variables include: Readmission Planned readmission Unplanned readmission Related readmission Time from operation/discharge to readmission Suspected readmission reason NSQIP postoperative complications Other (ICD-9/10) Methods NSQIP-P (2013, 2014) Unplanned readmission within 30 days Reason for readmission (NSQIP-P vs. ICD-9/10) ICD-9 codes categorized via AHRQ Clinical Classification Software Multivariate logistic regression for factors associated with unplanned readmission C-statistic for comparisons of model fit Methods NSQIP reasons for readmission Superficial/deep/organ space SSI Wound disruption (superficial/deep) Pneumonia, unplanned intubation Pulmonary embolism/dvt Progressive renal insufficiency Acute renal failure Coma >24 hours CVA/stroke or ICH Nerve Injury Seizure Cardiac Arrest requiring CPR Bleeding requiring transfusion Graft/prosthesis/free-flap Septic shock VT requiring therapy Postoperative systemic sepsis Central line associated blood stream infection 2

3 AHRQ categories Bleeding Cancer Cardiac Dehydration/nutrition GI disorders/ileus/obstruction Graft/prosthesis/device AKI or other GU CNS or CVA Orthopedic Methods Other medical Other surgical (e.g. peripheral nerve injury) Pain Pulmonary Sepsis SSI Vascular VTE N=130,271 N=129,849 Death (0.8%), n=422 Results 6,059 (4.7%) readmitted Planned readmission (0.8%), n=1,018 Unplanned readmission (3.9%), n=5,041 Reoperation (28%), n=1,414 Distribution of Time to Readmission Time from discharge to unplanned readmission: 8 days (IQR 3-14) 3

4 Readmissions by Specialty 30 day Readmission Rate (%) % Neurosurgery n=10, % Gen/Thoracic n=49, % Urology n=14,801 All Readmissions = 3.9% 2.0% 1.9% 1.3% ENT Orthopedic PRS n=14,814 n=26,451 n=12,607 Surgical Specialty Overall Reasons for Readmission All Patients Readmission Rate (%) SSI GI Pulm Device Neuro Pain Other Sepsis Nutri General/Thoracic Surgery Neurosurgery Reasons by Readmission by Specialty ENT Urology Orthopedics Plastic Surgery 4

5 Readmissions Related to Surgery 1. SSIs (23.4%) -- > 94.7% 2. GI/ileus (16.7%) -- > 62.7% 3. Respiratory (8.6%) -- > 39.5% 4. Graft/device (8.0%) -- >82.7% 5. Neurologic (7.0%) -- > 60.6% 6. Pain (5.8%) -- > 61.6% 7. Medical-related disease (5.7%) -- > 36.2% 8. Sepsis/SIRS (5.1%) -- > 57.1% 9. Electrolyte/Nutritional (4.6%) -- > 53.5% 10. (3.0%) -- > 83% Overall: 63% of unplanned readmissions related to surgery Top 5 CPTs Associated w/unplanned Readmission Overall Lap. Appy Replace/revise VP shunt Lap. G-tube Replace/revise ventricular catheter VP Shunt Creation GeneralPeds Lap. Appy Lap. G-tube Lap Nissen Pyloromyotomy Lap Chole Replace/revise Neurosurgery Replace/revise VP shunt VP Shunt Creation Laminectomy Craniectomy ventricular catheter Cutaneous Urology Ureteroneocystostomy Hypospadias repair Entercystoplasty Pyleplasty appendovesicostomy ENT Ortho Plastics Cochlear implant Arthrodesis, spinal deformity 7-12 seg Palatoplasty for cleft palate, soft and/or hard palate only Tympanoplasty w/o mastoidectomy Arthrodesis, spinal deformity 13+ seg Endoscopic procedures on larynx Osteotomy Plastic repair of cleft Craniectomy/Cran lip/nasal deformity; iotomy primary Tympanoplasty w/ mastoidectomy Percutaneous skeletal fixation Palatoplasty for cleft palate; attachment pharyngeal flap I&D retropharyngeal abscess Reinsertion, spinal fixation device Removal benign skin lesions Factors Associated with Unplanned Readmission Variable Odds Ratio Upper 95% Lower 95% P-Value Comorbidities Prematurity Endocrine (DM) Respiratory Cardiac GI <1 CNS <1 Renal <1 Hematologic Immunosuppressive <1 Nutritional <1 ASA Mild (1/2) REFERENCE Severe (3) <1 Life-threatening (4/5)

6 Factors Associated with Unplanned Readmission Variable Odds Ratio Upper 95% Lower 95% P-Value Wound Classification Clean REFERENCE Clean-contaminated <1 Contaminated Dirty <1 Operative Details Elective REFERENCE Urgent/Emergent <1 Postoperative occurrences Pre-discharge occurrences <1 Post-discharge occurrences <1 Model fit Patient characteristics Age Sex Race Comorbidities ASA Model fit Technical/proced ural Urgent/emergent Wound class Subspecialty Postop occurrences 6

7 Model fit Full Model Patient characteristics Technical/proc edural characteristics Limitations Retrospective review of NSQIP-P PUF Still prone to data entry/data interpretation error Discrepancies between postoperative complications and reasons for readmission Could not adjust for clustering at hospital level NSQIP-P still relatively young, standardized definitions will continue to become refined Conclusion Readmission rates and underlying reasons vary between specialties following surgery in children NSQIP-P provides increased granularity on reasons for readmission Surgical site infections and GI-related etiologies most common reasons overall 50% of unplanned readmissions occur by post-discharge day 8 7

8 Conclusion Majority (at least 80%) of postoperative complications occur after discharge in children 1/3 of unplanned readmissions may not be related to surgery Significant proportion of unplanned readmissions result in an additional procedure Both patient-related factors and procedural-related factors drive unplanned readmissions Post-discharge complications intimately linked to readmission Future Directions Review/understand data at the procedural level Continue to develop/refine accuracy and reliability of readmission data Developing specialty/procedural-specific benchmarks Reviewing institutional-level to focus on potentially preventable readmissions and develop targets for improvement 8