AT OBESITY WEEK 2016
NEW ORLEANS (FRONTLINE MEDICAL NEWS) – A couple of home nursing visits early after bariatric surgery halved emergency department visits and hospital readmissions within the first 30 days in a case-control study, Linden A. Karas, MD, reported at Obesity Week 2016.
“Home nursing visits during the month following surgery, between doctor’s office visits, are a simple and inexpensive intervention that drastically decreases hospital revisits,” she declared at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
Early readmissions are a major headache for bariatric surgeons. While there is abundant evidence that bariatric surgery treats obesity and its numerous related comorbidities more cost effectively than does medical management, insurers are unhappy about the high 30-day readmission rates, which range up to 24% in some published studies. Medicare imposes financial penalties for these early readmissions.
These early revisits to the hospital following bariatric surgery are not only common, they carry a substantial cost. An ED visit for hydration runs about $3,000 and a 2-day inpatient admission about $18,000. In contrast, the price tag for two home nursing visits in this study was $300, noted Dr. Karas, a surgeon at Mercy Catholic Medical Center in Philadelphia.
The triad of dehydration, nausea, and vomiting in addition to abdominal pain account for up to 40% of early readmissions following bariatric surgery. Because most hospital revisits for these reasons entail very little intervention other than IV fluids, Dr. Karas and her coinvestigators decided to investigate whether preemptive structured home visits by nurses prepared to administer IV fluids on the spot would cut down on hospital revisits. They found that indeed this strategy was successful.
Mercy Catholic Medical Center serves a largely low-income Medicare/Medicaid population. Part of the local culture is for many patients to obtain their primary care in the ED, so bariatric surgery patients are generally not reluctant to show up there if they don’t feel well in the first few weeks post surgery. That’s why in the year prior to the study the 30-day readmission rate was 23.6%, she explained.
The study included 193 consecutive prospectively followed adult participants in the home nursing program who underwent Roux-en-Y gastric bypass, laparoscopic adjustable banding, or revision surgery in 2014 and a control group of 267 matched bariatric surgery patients who underwent the same procedures in 2013, before introduction of the home nursing visits.
The first home visit occurred roughly 3 days after hospital discharge. The second one bridged the period between the first scheduled postoperative office visit at 2 weeks and the next office visit at 4 weeks. At discharge, patients were given a checklist concerning the signs and symptoms of dehydration, dietary recommendations, and lifestyle choices. Patients were encouraged to use the checklist to self-evaluate for dehydration and hand it over to the visiting nurses. The same checklist was provided to the home nurses. If the nurses found that patients met three or more criteria on the dehydration checklist, which included dry mucus membranes, heart rate greater than 90 beats/minute, headache, going more than 8 hours without urination, weakness, abdominal pain, and roughly a dozen other well-known criteria, they were instructed to initiate home hydration therapy with a banana bag and 2 L of normal saline.
If 1-2 days of home hydration failed to resolve the symptoms, the home care nurse was supposed to refer the patient to the ED. If the patient improved in response to home hydration therapy, the home nurse informed the surgeon’s office, which then set up a follow-up office visit to take place within the next 24 hours. Also, if the patient’s responses on the nutrition and behavioral health questionnaire raised any red flags regarding inadequate food and fluid intake, nonadherence to the recommended daily minimum of 30 minutes of physical activity, or depressive symptoms, the nurse was supposed to notify the surgeon to schedule a behavioral or nutrition appointment at the patient’s next scheduled visit.
The 30-day rate of all-cause hospital revisits in the home nursing care group was 11.9%, compared with 23.6% in controls. The rate of hospital revisits specifically for dehydration was 6.2% in the home visit group vs. 8.6% in controls, a 28% relative risk reduction in the home treatment group, which didn’t achieve statistical significance. However, in hindsight, it was evident that some of the visiting nurses didn’t fully understand the treatment protocol; they sent patients straight to the ED without first providing home hydration therapy. The visiting nurses were subcontracted out and weren’t part of the hospital’s bariatric surgery program.
Among those patients who did receive the therapy, however, it prevented readmission in 77% of cases. The 23% of patients who didn’t improve were referred to the hospital for further workup and treatment.
Patients with early hospital readmission had an average of 4.38 comorbid conditions, significantly more than the average 3.46 comorbidities in patients who weren’t readmitted. Several specific comorbid conditions were independently associated with significantly increased risk of hospital readmission: asthma, chronic obstructive pulmonary disease, anxiety, heart failure, and gastroesophageal reflux disease.
“Patients with those comorbidities are the ones to watch aggressively in the postop period,” according to Dr. Karas.
Insurers have paid for the home nursing visits without hesitation.
Her presentation met with an enthusiastic audience reception.
“I think it’s important that you’ve shown a return on investment for this initiative,” one surgeon commented.
Session cochair John J. Kelly, MD , chief of general and minimally invasive surgery at the University of Massachusetts in Worcester, declared, “I think this is a very-important paper. We’re obviously all faced with this dilemma in terms of readmission rates. If you can prevent them, it’s to be commended.”
Dr. Karas reported having no financial conflicts of interest regarding her study.
