Monday, February 17, 2014

Complications of Surgery and Readmission - the 4 Ps

The Relationship Between Timing of Surgical Complications and Hospital Readmission

There is an increasing emphasis on safety of surgical care. Commonly used metrics include length of stay, mortality and in-hospital complications. In the future, however, reimbursement will be decreased for excessive readmissions, initially for those readmissions within 30 days for heart problems and pneumonia, but the list is expected to expand in the near future.

These authors sought to determine the timing of postoperative complications with respect to hospital discharge and the frequency of readmission. They examined the records of patients having surgery from January 2005 to August 2009, including arthroplasty, vascular, colorectal, and gynecologic procedures at 112 Department of Veterans Affairs (VA) hospitals.  They were particularly interested in the association between timing of complication with respect to index hospitalization and 30-day readmission.

The study of 59 273 surgical procedures performed found an overall complication rate of 22.6% of which over 25% were discovered after discharge; many of these required readmission. Over half of the surgical site infections were discovered after discharge.

The overall 30-day readmission rate was 11.9%, of which only 56.0% of readmissions were associated with a currently assessed complication. Readmission was predicted by patient comorbid conditions, procedure factors, and the occurrence of postoperative complications.  Readmissions were commonly needed for infections, CNS issues, venous thromboembolism, respiratory issues, cardiac issues and urinary tract issues.

The authors concluded that hospital discharge is an insufficient end point for quality assessment.

Comment: this is a powerful article. Close reading reveals the following risk factors for length of stay, complications and readmission shown in the table below, indicating the importance of factors related to the Patient and the Procedure (see more about the 4 Ps here)

These data suggest that risk stratification and post discharge surveillance for complications and readmissions will be important to the evaluation of health care quality.
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