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Risk Factors Associated with 30-Day Postoperative Readmissions in Major Gastrointestinal Resections

  • 2013 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Purpose

Preventable readmissions represent a major burden on the health care system and risk stratification of patients can help direct costly resources. This study examines patient characteristics, surgical factors, and postoperative complications associated with 30-day postoperative readmissions in gastrointestinal (GI) resections.

Methods

Inpatients undergoing major GI surgery were selected from the 2011 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Resections were classified into foregut, small bowel, colorectal, liver, and pancreatic using Current Procedural Terminology (CPT) codes. Postoperative complications were divided into pre- and post-discharge groups using time to complication and discharge. Univariate analysis compared patient and surgical characteristics and pre-discharge complications with 30-day unplanned readmission rates. Factors with a p value <0.1 were included in multivariate logistic regression. A p value <0.05 was considered statistically significant.

Results

For 42,609 patients undergoing GI resection, the overall 30-day unplanned readmission rate was 12.3 % ranging from 11.8 % for colorectal resections to 16.3 % for pancreatic resections. Major predictors of 30-day readmissions included pre-discharge major complications (odds ratio [OR] = 1.28, 95 % confidence interval [CI] 1.18–1.39, p < 0.0001), chronic steroid use (OR = 1.67, 95 % CI 1.50–1.86, p < 0.0001), operative time ≥4 h (OR = 1.45, 95 % CI 1.35–1.56, p < 0.0001) and discharge to a facility other than home (OR = 1.37, 95 % CI 1.23–1.50, p < 0.0001).

Conclusions

Unplanned 30-day readmissions represent a major clinical and financial concern, but some may be foreseeable and potentially modifiable. This model provides insight into factors that could inform resource utilization and postoperative care to help prevent readmissions in select GI surgical patients.

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Author information

Authors and Affiliations

  1. Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY, 14642, USA

    Kristin N. Kelly, James C. Iannuzzi, Aaron S. Rickles, John R. T. Monson & Fergal J. Fleming

Authors
  1. Kristin N. Kelly
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  2. James C. Iannuzzi
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  3. Aaron S. Rickles
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  4. John R. T. Monson
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  5. Fergal J. Fleming
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Corresponding author

Correspondence to Kristin N. Kelly.

Additional information

Discussant

Dr. Taylor Riall (Galveston, Texas): Dr. Kelly, I congratulate you on an excellent presentation. With looming changes in Medicare policy regarding reimbursement for readmissions after surgery, it is critical that we, as surgeons, understand the root cause of these readmissions and identify potential targets for intervention and improvement.

We all strive to lower complication rates. However, given the complexity of what we do, we recognize that a 30-day readmission rate of zero is likely not feasible. Based on your data, it seems to me there are two real opportunities for intervention. The first is better recognition and management with regard to post-discharge complications. You report approximately 2,700 complications that occurred post-discharge, with a nearly 60-fold increase in the odds of readmission in this group. This may be an artifact of your methodology — as you demonstrate, patients experiencing post-discharge complications had shorter lengths of stay, and therefore, longer time "at risk" for readmission based on the NSQIP definition of 30 days from surgery. Do you think that these complications are unrecognized at the time of discharge? Are patients are discharged to early? For example, are patients being discharged with a slightly increasing WBC despite no fever with a smoldering infection? It would be interesting to look back on patients who develop post-discharge infections and see if there were subtle signs prior to discharge.

The second opportunity is improving postoperative follow-up. I know you can't do this with NSQIP, but you may be able to do this with other datasets. It would be interesting to evaluate postoperative visits to the operating surgeon and/or primary care physician between discharge and readmission — both if and when they occurred. I suspect that postoperative follow-up would be less adequate in patients requiring readmission. Systems-level interventions to improve surgeon follow-up, may increase recognition and decrease the impact of post-discharge infections on readmission. Since a significant proportion of readmissions seemed unrelated to documented operative complications, PCP follow-up might decrease readmissions related to exacerbations of chronic illness. And, while you argue that discharge to skilled nursing facility is a "non-modifiable" risk factor, I would disagree. I think better communication of the plan, expected course, and management of drains, etc. would decrease readmissions from SNFs. How do you communicate with SNFs after patient discharge? How early do you see patients back? Do you ensure PCP follow-up as well? Have you put any systems in place to address these issues?

Again, I congratulate Dr. Kelly on an excellent presentation and manuscript.

Closing Discussant

Dr. Kristin Kelly: I would like to thank Dr. Riall for some very interesting thoughts and questions. She has truly captured many of the important issues and challenges we face in trying to better understand surgical readmissions as a means of improving patient care and postoperative outcomes.

To her first point regarding postoperative complications and the timing of interventions, we agree there are really two opportunities for potential intervention. The first opportunity for intervention, that Dr. Riall highlighted, is in developing better, earlier means to identify which patients are at risk for later postoperative complications. Not surprisingly, patients who experience a major complication at home after discharge almost inevitably and appropriately return to the hospital. In an age of decreasing length of stay and more protocolized postoperative care there may be a few patients whose subtle signs of early infection or future complications are missed, but arguably many patients are probably at home well before any indication of trouble is present. In our study patients with post-discharge complications returned to the hospital a mean 7–10 days after discharge, so keeping them for an extra day or two probably would not have significantly impacted their clinical course. Certainly keeping patients an extended time is not clinically or fiscally practical. To date, no literature has explored in depth our ability to predict these postoperative complications and moving forward this will probably be a very critical area to study for directing interventions to address this opportunity.

The second opportunity occurs in recognizing the increased risk of subsequent complications and readmissions in patients who have a major complication prior to discharge. These patients remain in the hospital for longer periods of time meaning they have less "at risk" time at home for readmission based upon NSQIP's 30-day definition, but interestingly we still find that they have an increased risk of readmission compared to patients who did not have a major complication before discharge. These patients would likely benefit from close outpatient monitoring or early improved follow-up with attention to any barriers or challenges they may face during the transition home. We agree with Dr. Riall that studying and improving the systems in place for discharge and postoperative follow-up will likely decrease readmission rates in patients who currently have unmet needs after discharge.

The issue regarding skilled nursing facilities after discharge is a complex one. We initially classified this variable as non-modifiable from the standpoint that there is likely little that can be done at the time of surgery to change the patient's comorbidities, functional status, social support, or other factors driving the need for skilled nursing after discharge. While we may not have the ability to impact the requirement for a nursing facility, we do agree with the point that improving the communication with these facilities could be a targetable point of intervention. This might be achieved by working with the SNFs to increase the understanding of common postoperative surgical issues and warning signs or by calling the physicians responsible for SNF patients at the time of discharge to ensure open lines of communication. Currently the system is not formally structured to ensure this valuable communication. Timely follow-up appointments with the PCP and surgeon, the discussion of any critical information, and conveying any changes in chronic illness as a result of surgery depend upon the initiative and preferences of individual providers. If SNFs are considered from this perspective, then there are most certainly modifiable targets for improving readmission rates in this at risk population.

Appendix

Appendix

Table 6 Gastrointestinal surgery current procedural terminology codes by resection site
Full size table

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Kelly, K.N., Iannuzzi, J.C., Rickles, A.S. et al. Risk Factors Associated with 30-Day Postoperative Readmissions in Major Gastrointestinal Resections. J Gastrointest Surg 18, 35–44 (2014). https://doi.org/10.1007/s11605-013-2354-7

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