Is Readmission a Good Quality Measure for Surgical Care? Examining the Underlying Reasons for Readmissions after Surgery at ACS NSQIP Hospitals

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1 Is Readmission a Good Quality Measure for Surgical Care? Examining the Underlying Reasons for Readmissions after Surgery at ACS NSQIP Hospitals Mila H. Ju, MD, MS Ryan P. Merkow, MD, MS Jeanette W. Chung, PhD Bruce L. Hall, MD, PhD, MBA Mark E. Cohen, PhD Mark V. Williams, MD Thomas C. Tsai, MD, MPH Clifford Y. Ko, MD, MS, MSHS Karl Y. Bilimoria, MD, MS Merkow, Ju, et al, JAMA 2015

2 None related to this work Disclosures

3 Focus on Readmissions Commands attention as a quality and cost containment metric Affordable Care Act mandated Hospital Readmission Reduction Program Medical conditions (MI, CHF, PNA) Surgery (TKA/THA) Plan to expand to additional surgeries CMS penalizes hospitals up to 2% in 2015 Publically reported Hospital wide, TKA/THA, medical conditions

4 Gaps in Existing Literature Lack of comprehensive studies using clinical data from national sample of hospitals Lack of clinical granularity to identify specific reasons for readmission Early vs. late Lack of understanding of relationship between index complications and readmission reasons

5 To Reduce Surgical Readmissions Identification of the reasons and factors associated with unplanned surgical readmissions Surgical quality improvement efforts Policy decisions

6 Objectives Characterize the reasons and timing of readmissions Examine factors associated with unplanned surgical readmissions

7 Methods Data source ACS NSQIP (2012) Patient population All cases and six representative procedures Bariatric, colectomy/proctectomy, ventral hernia repair (VHR), hysterectomy, total hip/knee arthoplasty (THKA), lower extremity arterial bypass (LEB) Readmission Variables All-cause and unplanned Reasons for unplanned readmission Hospital characteristics American Hospital Association Annual Survey (2010)

8 Statistical Analysis Time-to-event modeling Hierarchial Cox proportional hazards models Royston R 2 Factors associated with readmission Patient factors Inpatient complications Discharge destination Hospital characteristics Hospital disproportionate share

9 Readmission Rates of 346 Hospitals All-cause Unplanned Overall (n=498,875) 6.1% 5.7% Bariatric (n=18,143) 5.3% 5.2% Colectomy/ Proctectomy (n=35,112) 11.1% 10.9% VHR (n=33,895) 4.6% 4.6% Hysterectomy (n=25,119) 3.9% 3.8% THKA (n=38,671) 4.5% 4.3% LEB (n=6,341) 15.5% 14.9%

10 Readmission Timing Time to Readmission, median days (interquartile range) Overall 8 (3-14) Bariatric 8 (3-16) Colectomy/ Proctectomy 6 (3-12) VHR 7 (3-14) Hysterectomy 7 (3-13) THKA 9 (4-17) LEB 10 (5-16)

11 Top 3 Reasons for Readmission #1 #2 #3 Overall (20%) Ileus / obstruction (10%) Bleeding (5%) Bariatric Ileus / obstruction (25%) Dehydration / nutrition (18%) (11%) Colectomy/ Proctectomy (26%) Ileus / obstruction (18%) Dehydration / nutrition (7%) VHR (27%) Ileus / obstruction (17%) Bleeding (7%) Hysterectomy (29%) Ileus / obstruction (13%) Bleeding (8%) THKA (19%) Graft / prosthesis (8%) VTE (6%) LEB (36%) Graft / prosthesis (8%) Vascular (7%)

12 Top 3 Reasons for Readmission: Early vs. Late #1 #2 #3 Overall (20%) Ileus / obstruction (10%) Bleeding (5%) Early (<= 7 days after discharge) (17%) Ileus / obstruction (14%) Bleeding (6%) Late (7-30 days after discharge) (23%) Ileus / obstruction (7%) Bleeding (4%)

13 Preexisting Complications Overall, only 2.3% of patients were readmitted for a complication that also occurred during index hospitalization Among patients readmitted for s, only 3.3% had experienced an during their index hospitalization

14 Summary Readmission rates varied by procedure type Timing of readmissions appeared to occur at a constant rate over time Majority of readmissions were associated with new postoperative complications The most common complications are and ileus/obstruction

15 Limitations Reason for readmission may be difficult to ascertain and multifactorial First national comprehensive study based on clinical data to detail causes and timing in surgery ACS NSQIP collects 30 day data from procedure not discharge May under report readmission rates Only ACS NSQIP hospitals Disproportionately higher number of larger, academic centers

16 Conclusions Readmissions after surgery were associated with new postdischarge complications related to the procedure Not exacerbation of prior index hospitalization complications Readmission rates may be difficult to reduce until effective strategies are put forth to reduce common complications Readmissions after surgery may not be an appropriate measure for pay-for-performance programs Better suited as measure for hospitals to track internally

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18 Reasons for Readmission List of Reasons Organ Space / Deep Obstruction / Ileus FEN Superficial Bleeding / Blood Loss Pain Cardiac Sepsis / Septic Shock Gastrointestinal VTE Other Surgical Pneumonia Graft / Prosthesis Failure Vascular Disease Dehiscence Cancer Related UTI Pulmonary Acute Kidney Injury Other Infection Other Medical CVA CNS/Psych GU Orthopedic Social Respiratory Failure Examples abscess nausea/vomiting dehydration, electrolyte disturbance incisional ssi bleeding, acute anemia abdominal pain NOS MI, arrhythmia bacteremia, septicemia cholelithiasis, esophagitis DVT, PE reoperation respiratory infection implant, graft, prosthesis failure peripheral vascular disease, venous ulcers abdominal hernia, evisceration colon cancer NOS urinary infections pneumothorax acute kidney failure leukocytosis, fever, colon infection hypertension, decubitus ulcer stroke, TIA schizophrenia, delirium, headache kidney stones femur fracture homeless, alcohol related Intubation