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Identification of Process Measures to Reduce Postoperative Readmission

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery

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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References

  1. Jha AK, Orav EJ, Epstein AM. Public reporting of discharge planning and rates of readmissions. N Engl J Med. Dec 31 2009;361(27):2637-2645.

    Article  CAS  PubMed  Google Scholar 

  2. Kansagara D, Englander H, Salanitro A, et al. Risk prediction models for hospital readmission: a systematic review. JAMA. Oct 19 2011;306(15):1688-1698.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  3. Kocher RP, Adashi EY. Hospital readmissions and the Affordable Care Act: paying for coordinated quality care. JAMA. Oct 26 2011;306(16):1794-1795.

    Article  CAS  PubMed  Google Scholar 

  4. Giamouzis G, Kalogeropoulos A, Georgiopoulou V, et al. Hospitalization epidemic in patients with heart failure: risk factors, risk prediction, knowledge gaps, and future directions. J Card Fail. Jan 2011;17(1):54-75.

    Article  PubMed  Google Scholar 

  5. Zaya M, Phan A, Schwarz ER. The dilemma, causes and approaches to avoid recurrent hospital readmissions for patients with chronic heart failure. Heart Fail Rev. May 2012;17(3):345-353.

    Article  PubMed  Google Scholar 

  6. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. Apr 2 2009;360(14):1418-1428.

    Article  CAS  PubMed  Google Scholar 

  7. Rau J. Medicare Revises Readmissions Penalties – Again 2013. http://www.kaiserhealthnews.org/Stories/2013/March/14/revised-readmissions-statistics-hospitals-medicare.aspx. Accessed May 12, 2013

  8. Centers for Medicare and Medicaide Services (2012) Readmission Measures Overview: Publicly reporting risk-standardized, 30-day readmission measures for AMI, HF, PN, HWR, and THA/TKA. http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1219069855273. Accessed November 28, 2012.

  9. Centers for Medicare and Medicaide Services (2012) Hip/Knee Readmission and Complication Measures. http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1228772504368. Accessed November 28, 2012.

  10. Kiran RP, Delaney CP, Senagore AJ, Steel M, Garafalo T, Fazio VW. Outcomes and prediction of hospital readmission after intestinal surgery. J Am Coll Surg. Jun 2004;198(6):877-883.

    Article  PubMed  Google Scholar 

  11. Lidor AO, Schneider E, Segal J, Yu Q, Feinberg R, Wu AW. Elective surgery for diverticulitis is associated with high risk of intestinal diversion and hospital readmission in older adults. J Gastrointest Surg. Dec 2010;14(12):1867-1873; discussion 1873-1864.

    Article  PubMed  Google Scholar 

  12. Wick EC, Shore AD, Hirose K, et al. Readmission rates and cost following colorectal surgery. Dis Colon Rectum. Dec 2011;54(12):1475-1479.

    Article  PubMed  Google Scholar 

  13. Bilimoria KY, Raval MV, Bentrem DJ, Wayne JD, Balch CM, Ko CY. National assessment of melanoma care using formally developed quality indicators. J Clin Oncol. Nov 10 2009;27(32):5445-5451.

    Article  PubMed  Google Scholar 

  14. McGory ML, Shekelle PG, Ko CY. Development of quality indicators for patients undergoing colorectal cancer surgery. J Natl Cancer Inst. Nov 15 2006;98(22):1623-1633.

    Article  PubMed  Google Scholar 

  15. Manwaring ML, Ko CY, Fleshman JW, Jr., et al. Identification of consensus-based quality end points for colorectal surgery. Dis Colon Rectum. Mar 2012;55(3):294-301.

    Article  PubMed  Google Scholar 

  16. Fitch K, Bernstein S.J., Aguilar MS, et al. The RAND/UCLA Appropriateness Method User’s Manual. Santa Monica, CA: RAND Corporation; 2001: http://www.rand.org/pubs/monograph_reports/MR1269. Accessed November 16, 2011.

  17. Washington DL, Bernstein SJ, Kahan JP, Leape LL, Kamberg CJ, Shekelle PG. Reliability of clinical guideline development using mail-only versus in-person expert panels. Med Care. Dec 2003;41(12):1374-1381.

    Article  PubMed  Google Scholar 

  18. Brook RH, McGlynn EA, Shekelle PG. Defining and measuring quality of care: a perspective from US researchers. Int J Qual Health Care. Aug 2000;12(4):281-295.

    Article  CAS  PubMed  Google Scholar 

  19. Shekelle PG. Are appropriateness criteria ready for use in clinical practice? N Engl J Med. Mar 1 2001;344(9):677-678.

    Article  CAS  PubMed  Google Scholar 

  20. Donabedian A. The quality of care. How can it be assessed? JAMA. Sep 23-30 1988;260(12):1743-1748

    Article  CAS  PubMed  Google Scholar 

  21. Project RED (Re-Engineered Discharge) Training Program. March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/red/index.html. Accessed May 7, 2013.

  22. Abarca F, Saclarides TJ, Brand MI. Laparoscopic colectomy: complications causing reoperation or emergency room/hospital readmissions. Am Surg. Jan 2011;77(1):65-69.

    PubMed  Google Scholar 

  23. Asgeirsson T, El-Badawi KI, Mahmood A, Barletta J, Luchtefeld M, Senagore AJ. Postoperative ileus: it costs more than you expect. J Am Coll Surg. Feb 2010;210(2):228-231.

    Article  PubMed  Google Scholar 

  24. Azimuddin K, Rosen L, Reed JF, 3rd, Stasik JJ, Riether RD, Khubchandani IT. Readmissions after colorectal surgery cannot be predicted. Dis Colon Rectum. Jul 2001;44(7):942-946.

    Article  CAS  PubMed  Google Scholar 

  25. Bliss LA, Ross-Richardson CB, Sanzari LJ, et al. Thirty-day outcomes support implementation of a surgical safety checklist. J Am Coll Surg. Dec 2012;215(6):766-776.

    Article  PubMed  Google Scholar 

  26. Chun LJ, Haigh PI, Tam MS, Abbas MA. Defunctioning loop ileostomy for pelvic anastomoses: predictors of morbidity and nonclosure. Dis Colon Rectum. Feb 2012;55(2):167-174.

    Article  PubMed  Google Scholar 

  27. da Luz Moreira A, Kiran RP, Kirat HT, et al. Laparoscopic versus open colectomy for patients with American Society of Anesthesiology (ASA) classifications 3 and 4: the minimally invasive approach is associated with significantly quicker recovery and reduced costs. Surg Endosc. Jun 2010;24(6):1280-1286.

    Article  PubMed  Google Scholar 

  28. Datta I, Buie WD, Maclean AR, Heine JA. Hospital readmission rates after ileal pouch-anal anastomosis. Dis Colon Rectum. Jan 2009;52(1):55-58.

    Article  PubMed  Google Scholar 

  29. Devon KM, Urbach DR, McLeod RS. Postoperative disposition and health services use in elderly patients undergoing colorectal cancer surgery: a population-based study. Surgery. May 2011;149(5):705-712.

    Article  PubMed  Google Scholar 

  30. Faiz O, Haji A, Burns E, Bottle A, Kennedy R, Aylin P. Hospital stay amongst patients undergoing major elective colorectal surgery: predicting prolonged stay and readmissions in NHS hospitals. Colorectal Dis. Jul 2011;13(7):816-822.

    Article  CAS  PubMed  Google Scholar 

  31. Feroci F, Lenzi E, Baraghini M, et al. Fast-track colorectal surgery: protocol adherence influences postoperative outcomes. Int J Colorectal Dis. Jan 2013;28(1):103-109.

    Article  PubMed  Google Scholar 

  32. Greenblatt DY, Weber SM, O’Connor ES, LoConte NK, Liou JI, Smith MA. Readmission after colectomy for cancer predicts one-year mortality. Ann Surg. Apr 2010;251(4):659-669.

    Article  PubMed Central  PubMed  Google Scholar 

  33. Guinier D, Mantion GA, Alves A, Kwiatkowski F, Slim K, Panis Y. Risk factors of unplanned readmission after colorectal surgery: a prospective, multicenter study. Dis Colon Rectum. Sep 2007;50(9):1316-1323.

    Article  CAS  PubMed  Google Scholar 

  34. Hendren S, Morris AM, Zhang W, Dimick J. Early discharge and hospital readmission after colectomy for cancer. Dis Colon Rectum. Nov 2011;54(11):1362-1367.

    Article  PubMed  Google Scholar 

  35. Kariv Y, Wang W, Senagore AJ, Hammel JP, Fazio VW, Delaney CP. Multivariable analysis of factors associated with hospital readmission after intestinal surgery. Am J Surg. Mar 2006;191(3):364-371.

    Article  PubMed  Google Scholar 

  36. Kassin MT, Owen RM, Perez SD, et al. Risk factors for 30-day hospital readmission among general surgery patients. J Am Coll Surg. Sep 2012;215(3):322-330.

    Article  PubMed Central  PubMed  Google Scholar 

  37. Kelly M, Sharp L, Dwane F, Kelleher T, Comber H. Factors predicting hospital length-of-stay and readmission after colorectal resection: a population-based study of elective and emergency admissions. BMC Health Serv Res. 2012;12:77.

    Article  PubMed Central  PubMed  Google Scholar 

  38. Kennedy ED, Rothwell DM, Cohen Z, McLeod RS. Increased experience and surgical technique lead to improved outcome after ileal pouch-anal anastomosis: a population-based study. Dis Colon Rectum. Jul 2006;49(7):958-965.

    Article  CAS  PubMed  Google Scholar 

  39. Kiran RP, El-Gazzaz GH, Vogel JD, Remzi FH. Laparoscopic approach significantly reduces surgical site infections after colorectal surgery: data from national surgical quality improvement program. J Am Coll Surg. Aug 2010;211(2):232-238.

    Article  PubMed  Google Scholar 

  40. Larson DW, Batdorf NJ, Touzios JG, et al. A fast-track recovery protocol improves outcomes in elective laparoscopic colectomy for diverticulitis. J Am Coll Surg. Oct 2010;211(4):485-489.

    Article  PubMed  Google Scholar 

  41. Martin RC, Brown R, Puffer L, et al. Readmission rates after abdominal surgery: the role of surgeon, primary caregiver, home health, and subacute rehab. Ann Surg. Oct 2011;254(4):591-597.

    Article  PubMed  Google Scholar 

  42. Medress Z, Fleshner PR. Can we predict unplanned hospital readmission after colectomy for ulcerative colitis and indeterminate colitis? Am Surg. Oct 2007;73(10):998-1001.

    PubMed  Google Scholar 

  43. Messaris E, Sehgal R, Deiling S, et al. Dehydration is the most common indication for readmission after diverting ileostomy creation. Dis Colon Rectum. Feb 2012;55(2):175-180.

    Article  PubMed  Google Scholar 

  44. Obokhare ID, Champagne B, Stein SL, Krpata D, Delaney CP. The effect of alvimopan on recovery after laparoscopic segmental colectomy. Dis Colon Rectum. Jun 2011;54(6):743-746.

    Article  PubMed  Google Scholar 

  45. O’Brien DP. Predictors and outcome of readmission after laparoscopic intestinal surgery. World J Surg. Nov 2007;31(11):2138-2143.

    Article  PubMed  Google Scholar 

  46. Okolica D, Bishawi M, Karas JR, Reed JF, Hussain F, Bergamaschi R. Factors influencing postoperative adverse events after Hartmann’s reversal. Colorectal Dis. Mar 2012;14(3):369-373.

    Article  CAS  PubMed  Google Scholar 

  47. Ozturk E, Kiran RP, Geisler DP, Hull TL, Vogel JD. Hand-assisted laparoscopic colectomy: benefits of laparoscopic colectomy at no extra cost. J Am Coll Surg. Aug 2009;209(2):242-247.

    Article  PubMed  Google Scholar 

  48. Ozturk E, Kiran RP, Remzi F, Fazio VW. Early readmission after ileoanal pouch surgery. Dis Colon Rectum. Nov 2009;52(11):1848-1853.

    Article  PubMed  Google Scholar 

  49. Reinke CE, Kelz RR, Zubizarreta JR, et al. Obesity and readmission in elderly surgical patients. Surgery. Sep 2012;152(3):355-362.

    Article  PubMed Central  PubMed  Google Scholar 

  50. Schneider EB, Hyder O, Brooke BS, et al. Patient readmission and mortality after colorectal surgery for colon cancer: impact of length of stay relative to other clinical factors. J Am Coll Surg. Apr 2012;214(4):390-398; discussion 398-399.

    Article  PubMed  Google Scholar 

  51. Senagore AJ, Madbouly KM, Fazio VW, Duepree HJ, Brady KM, Delaney CP. Advantages of laparoscopic colectomy in older patients. Arch Surg. Mar 2003;138(3):252-256.

    Article  PubMed  Google Scholar 

  52. Tan JJ, Foo AY, Cheong DM. Colorectal clinical pathways: a method of improving clinical outcome? Asian J Surg. Oct 2005;28(4):252-256.

    Article  PubMed  Google Scholar 

  53. Tiwari MM, Reynoso JF, High R, Tsang AW, Oleynikov D. Safety, efficacy, and cost-effectiveness of common laparoscopic procedures. Surg Endosc. Apr 2011;25(4):1127-1135.

    Article  PubMed  Google Scholar 

  54. White EC, Melmed GY, Vasiliauskas E, et al. Does preoperative immunosuppression influence unplanned hospital readmission after surgery in patients with Crohn’s disease? Dis Colon Rectum. May 2012;55(5):563-568.

    Article  PubMed  Google Scholar 

  55. Hemingway H, Crook AM, Feder G, et al. Underuse of coronary revascularization procedures in patients considered appropriate candidates for revascularization. N Engl J Med. Mar 1 2001;344(9):645-654.

    Article  CAS  PubMed  Google Scholar 

  56. Cheema FN, Abraham NS, Berger DH, Albo D, Taffet GE, Naik AD. Novel approaches to perioperative assessment and intervention may improve long-term outcomes after colorectal cancer resection in older adults. Ann Surg. May 2011;253(5):867-874.

    Article  PubMed  Google Scholar 

  57. Carli F, Charlebois P, Stein B, et al. Randomized clinical trial of prehabilitation in colorectal surgery. Br J Surg. Aug 2010;97(8):1187-1197.

    Article  CAS  PubMed  Google Scholar 

  58. Inouye SK, Peduzzi PN, Robison JT, Hughes JS, Horwitz RI, Concato J. Importance of functional measures in predicting mortality among older hospitalized patients. JAMA. Apr 15 1998;279(15):1187-1193.

    Article  CAS  PubMed  Google Scholar 

  59. Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. Oct 2012;215(4):453-466.

    Article  PubMed  Google Scholar 

  60. Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery. Jun 2011;149(6):830-840.

    Article  PubMed  Google Scholar 

  61. Nagle D, Pare T, Keenan E, Marcet K, Tizio S, Poylin V. Ileostomy pathway virtually eliminates readmissions for dehydration in new ostomates. Dis Colon Rectum. Dec 2012;55(12):1266-1272.

    Article  PubMed  Google Scholar 

  62. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. Feb 2012;141(2 Suppl):e227S-277S.

    CAS  PubMed Central  PubMed  Google Scholar 

  63. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. Feb 3 2009;150(3):178-187.

    Article  PubMed Central  PubMed  Google Scholar 

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Acknowledgments

The members of the expert panel:

Karl Y. Bilimoria, MD, MS, FACS

Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center at Northwestern. He is an Assistant Professor at the Feinberg School of Medicine, Northwestern University, with joint appointments in the Department of Surgery, the Institute for Healthcare Studies, and the Department of Medicine and the Social Sciences

Amy L. Halverson, MD, FACS

Dr. Halverson is an Associate Professor of Surgery at the Feinberg School of Medicine, Northwestern University and the Director of the Nora Institute for Surgical Patient Safety, American College of Surgeons.

Mary T. Hawn, MD, FACS

Dr. Hawn is a Professor of Surgery and the Chief of Gastrointestinal Surgery at the University of Alabama Medical Center in Birmingham, AL, and Director of the Center for Surgical, Medical Acute Care Research and Transitions at the Birmingham VAMC.

P. Ravi Kiran, MBBS, MS, FACS

Dr. Kiran is currently appointed as a Staff Surgeon and Section Head of Research in the Department of Colorectal Surgery at Cleveland Clinic.

Robin McLeod, MD, FACS

Dr. McLeod is currently the Head of the Division of General Surgery at the Mount Sinai Hospital, a Professor in the Department of Surgery, and Head of the Surgical Clinical Epidemiology Group at the University of Toronto. She formerly was Head of the Colorectal Surgery Program at the University of Toronto.

June M. McKoy, MD

Dr. McKoy is an Associate Professor of Medicine and Preventive Medicine, Associate Director of the Geriatric Medicine Fellowship Program, and Director of Geriatric Oncology at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. She is also a NIH-funded clinical cancer and health services researcher whose investigations are steeped in patient safety related to cohorts 65 years of age and older.

John R. T. Monson, MB, BCH, FACS

Dr. Monson is a Professor of Surgery and oncology at the University of Rochester Medical Center. He serves as Chief of Colorectal Surgery and Vice Chairman of the Department of Surgery.

Michele Rubin, APN

Ms. Rubin has 34 years of experience in inflammatory bowel disease (IBD) at the University of Chicago Medical Center. Michele is currently in a collaborative practice as an APN with three IBD surgeons managing the pre- and postsurgical follow-up care of IBD patients. She is on the Crohn’s & Colitis Foundation of America (CCFA) National Board of Trustees and the CCFA National Scientific Advisory Council. She has initiated a CCFA Nurse Initiatives Committee comprised of 20 IBD nurses across the country to facilitate and promote IBD patient and professional education, to establish IBD standards of nursing practices, and to increase nurse/patient participation in CCFA. She is also the Chair of the Advanced Practice Nurses (APN) and a member of the Metropolitan Chicago Healthcare Council (MCHC) and MCHC APN Task Force.

Rudolph B. Rustin, MD

Dr. Rustin is a colorectal surgeon practicing in Mt. Pleasant, SC. He is a Diplomat and Fellow of the American College of Surgery and American Society of Colon and Rectal Surgeons.

John F. Sweeney, MD

Dr. Sweeney is the W. Dean Warren Distinguished Professor and Chief of the Division of General and GI Surgery and Chief Quality Officer of the Department of Surgery at Emory University.

Mark V. Williams, MD

Dr. Williams is Professor and Chief of the Division of Hospital Medicine at Feinberg School of Medicine, Northwestern University. He is the principal investigator for the Society of Hospital Medicine’s Project BOOST (Better Outcomes by Optimizing Safe Transitions) which is a national initiative to improve the care of patients as they transition from hospital to home or other care settings.

Funding

This study was supported by funding from the Nora Institute for Surgical Patient Safety.

Author information

Authors and Affiliations

  1. Department of Surgery, Feinberg School of Medicine, Northwestern University, 676 North St. Clair, Suite 650, Chicago, IL, 60611, USA

    Amy L. Halverson & Karl Y. Bilimoria

  2. American College of Surgeons, Nora Institute for Surgical Patient Safety, Chicago, IL, USA

    Amy L. Halverson

  3. Department of Surgery, Mt. Sinai School of Medicine, New York, NY, USA

    Morgan M. Sellers

  4. Department of Surgery, University of Alabama, Birmingham, AL, USA

    Mary T. Hawn

  5. Department of Hospital Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    Mark V. Williams

  6. Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

    Robin S. McLeod

  7. Department of Surgery, Mt. Sinai Hospital, Toronto, ON, Canada

    Robin S. McLeod

  8. Division of Research and Quality Patient Care, American College of Surgeons, Chicago, IL, USA

    Clifford Y. Ko

  9. Department of Surgery, University of California, Los Angeles, CA, USA

    Clifford Y. Ko

Authors
  1. Amy L. Halverson
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  2. Morgan M. Sellers
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  3. Karl Y. Bilimoria
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  4. Mary T. Hawn
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  5. Mark V. Williams
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  6. Robin S. McLeod
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  7. Clifford Y. Ko
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Corresponding author

Correspondence to Amy L. Halverson.

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Halverson, A.L., Sellers, M.M., Bilimoria, K.Y. et al. Identification of Process Measures to Reduce Postoperative Readmission. J Gastrointest Surg 18, 1407–1415 (2014). https://doi.org/10.1007/s11605-013-2429-5

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