Identification of modifiable factors for reducing readmission after colectomy: A national analysis

doi:10.1016/j.surg.2013.12.016

Surgery

Volume 155, Issue 5, May 2014, Pages 754-766

https://doi.org/10.1016/j.surg.2013.12.016 Get rights and content

Background

Rates of hospital readmission are currently used for public reporting and pay for performance. Colectomy procedures account for a large number of readmissions among operative procedures. Our objective was to compare the importance of 3 groups of clinical variables (demographics, preoperative risk factors, and postoperative complications) in predicting readmission after colectomy procedures.

Methods

Patient records (2005–2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Patient demographics (n = 2), preoperative risk factors (n = 23), and 30-day postoperative complications (n = 17) were identified from ACS-NSQIP, whereas 30-day postoperative readmissions and costs were determined from Medicare. Multivariable logistic regression models were used to examine risk-adjusted predictors of colectomy readmission.

Results

Among 12,981 colectomy patients, the 30-day postoperative readmission rate was 13.5%. Readmitted patients had slightly greater rates of comorbidities and indicators of clinical severity and substantially greater rates of complications than non-readmitted patients. After risk adjustment, patients with a complication were 3.3 times as likely to be readmitted as patients without a complication. Among individual complications, progressive renal failure and organ-space surgical site infection had the highest risk-adjusted relative risks of readmission (4.6 and 4.0, respectively). Demographic, preoperative risk factor, and postoperative complication variables increased the ability to discriminate readmissions (reflected by the c-statistic) by 5.3%, 23.3%, and 35.4%, respectively.

Conclusion

Postoperative complications after colectomy are more predictive of readmission than traditional risk factors. Focusing quality improvement efforts on preventing and managing postoperative complications may be the most important step toward reducing readmission rates.

Section snippets

Data sources and study sample

The study design and procedures were approved by the RAND Health Institutional Review Board. The primary data sources for this study were Medicare inpatient claims and ACS-NSQIP, as previously described.8, 9 Briefly, the 100% Medicare provider analysis and review file (MedPAR) contains inpatient hospital final stay records for Medicare beneficiaries assembled from claims submitted by hospitals for reimbursement. Each Medicare beneficiary has a unique identification number allowing for linkage

Results

Among 12,981 patients undergoing colectomy with an initial length of stay <21 days, 1,752 were readmitted within 30 days of surgery (13.5%). For the readmitted patient population, 82% were readmitted to the same hospital as the index hospitalization, and 18% were readmitted to a different hospital. The median hospital-level, 30-day postoperative readmission rate was 13.0% (interquartile range, 9.1–16.2%; mean, 13.2%; standard deviation [SD], 8.2%). There was no difference in the yearly

Discussion

Hospital readmission has become a topic of increased interest among policymakers interested in improving the quality of health care delivery in the United States while reducing costs. To aid surgeons and hospitals in the development of effective strategies for reducing postoperative readmissions, we sought to characterize readmissions among patients undergoing colectomy procedures and to identify targets for the development of interventions and best practices. In previous work, we demonstrated

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After cytoreductive surgery (CRS) for ovarian cancer (OC), a grade 3 + postoperative complication is associated with a high risk of subsequent death [2]. Beyond mortality, complications increase the cost of hospitalization [3,4], readmissions [5,6] and delay return to work [7] resulting in significant financial burden [8]. Postoperative complications are thus an attractive target for surgical quality improvement (QI) efforts.
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A total of 1434 women met inclusion criteria. Any adverse clinical outcome (composite of death, reoperation, or end organ dysfunction) occurred in 9.1% of women, and AL was the largest contributor to adverse clinical outcomes [PAF = 33.4% (95%CI: 22.3%–45.6%)]. The rates of increased resource utilization were as follows; prolonged hospitalization in 23.7%, non-home discharge in 10.7% and unplanned readmission in 14.8% of women. AL was the largest contributor to prolonged hospitalizations [PAF = 75.7% (95%CI: 51.4%–90.0%)] and readmissions [PAF = 17.1% (95%CI: 11.5%–22.6%)]; while transfusion was the largest contributor to non-home discharge [PAF = 22.8% (95%CI: 0.7%–42.4%)]. By comparison, the impact of other complications, including those targeted by the Surgical Care Improvement Project (SCIP), such as incisional SSI, venous thromboembolism, myocardial infarction, and urinary infection, was small.
Anastomotic leak is the largest contributor to adverse clinical outcomes and increased resource utilization after complex cytoreductive surgery. Quality improvement efforts to reduce AL and its impact should be of highest priority in OC surgery.
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Colostomies comprise more than a third of ostomy operations performed.11,12 Previous work on readmissions after colorectal operations have indicated the presence of an ostomy as well as postoperative complications to be significant predictors of rehospitalization.7,13 Several prior reports have found stoma creation to be associated with significant postoperative morbidity and complication rates as high as 70%, surpassing that of most cancer operations.7,14,15
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Colostomy creation is associated with a steady and high rate of rehospitalization. Nonhome discharge, in addition to several patient comorbidities, is associated with higher odds of readmission. Programs aimed at reduction of immediate readmission are warranted.
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Enhanced recovery pathways (ERPs) can decrease length of stay (LOS) and improve colorectal surgery outcomes in private health care; however, their efficacy in the public realm, comprised largely of underserved and uninsured patients, remains uncertain.
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ERP reduced LOS in both private and safety-net settings without addressing social determinants of health. Readmission and reoperation rates were unchanged. As health care moves toward a bundled payment model, ERP can help optimize outcomes and control costs in the public arena.
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Addressing causes of readmission may also prevent them. Multiple studies have identified risks of readmission: LOS, proctectomy, increased comorbidities, diabetes, smoking, ileostomy, other stoma, postoperative complications, or nonhome discharge.2,3,11,15,17,27,28 Specifically, Al-Mazrou et al.29, were able to identify causes of early and late readmissions, suggesting later readmissions may be associated with identifiable causes that can be prevented, such as ostomy care and appropriate hydration.
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Moreover, the use of steroids is more likely a sign of underlying chronic disease, inflammation, and the additional complications related to the comorbidities. A number of studies have reported similar findings after gastrointestinal surgery.9,12–15,18–20 The finding that perioperative blood transfusion was independently associated with readmission may reflect the fact that patients requiring transfusion have undergone a more complex surgery or experience a complication during the index surgery.10
To analyze demographics and outcomes of patients focusing on 30-day readmission status and identify procedure-specific risk factors.
Patients undergoing abdominal colorectal surgery (2011–2013) were identified Demographics and outcomes including in-hospital complications were compared based on readmission status.
A total of 6637 patients were identified with a mean age of 51.2(±17.1) years. Seven hundred and seventy five(11.7%) patients were readmitted at least once within 30-day. The most common index procedures related to readmission were stoma closure (n = 127/775, 16.4%) and total colectomy (n = 105/775, 13.6%). Readmitted patients had longer length of index hospital stay (LOS)(8.2 ± 5.9 vs 7.9 ± 6.9 days,p < 0.001) and operative time(167 ± 104 vs 144 ± 95 min, p < 0.001), higher intraoperative(2% vs 1%,p = 0.04) and in-hospital complication rates(36% vs 28%,p < 0.001). Main reasons for readmissions were gastrointestinal-related causes(n = 222, 29%), small bowel obstruction (n = 133,17%), wound-related complications(n = 108,14%), and dehydration(n = 93,12%). Median readmission LOS was 4(1–71)days and 54%(n = 407) of readmissions occurred within 7 days of discharge.
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Transforming Surgical and Interventional Care: Insights from the Robert Wood Johnson Foundation Clinical Scholars ProgramIdentification of modifiable factors for reducing readmission after colectomy: A national analysis

Background

Methods

Results

Conclusion

Section snippets

Data sources and study sample

Results

Discussion

J Am Coll Surg

Adv Surg

Surgery

Surgery

J Am Coll Surg

J Am Coll Surg

J Am Coll Surg

Hospital readmissions and the Affordable Care Act: paying for coordinated quality care

JAMA

Transforming Surgical and Interventional Care: Insights from the Robert Wood Johnson Foundation Clinical Scholars Program
Identification of modifiable factors for reducing readmission after colectomy: A national analysis