EXPERT ANALYSIS AT THE ACS NSQIP NATIONAL CONFERENCE
SAN DIEGO (FRONTLINE MEDICAL NEWS) – Despite advances in the way surgeons practice their craft and measure outcomes in a meaningful way, the rate of hospital readmissions remains unacceptably high, according to an Emory University surgeon who has studied the readmission patterns.
“Readmission is a problem, not only from a cost and penalties standpoint but also from the rates of readmission affecting patients’ lives and expectations,” Jyotirmay Sharma, MD, said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference.
Dr. Sharma, director of thyroid and endocrine surgery at Emory University Hospital, Atlanta, cited recent federal data estimating that among Medicare patients discharged from a hospital, 20% are rehospitalized within 30 days, and 34% are rehospitalized within 90 days. In 2013 alone, the Centers for Medicare & Medicaid Services levied readmission penalties against 2,213 hospitals to the tune of $280 million. “So clearly it’s a major issue,” he said.
In a study conducted by one of Dr. Sharma’s associates, researchers evaluated the risk factors for 30-day hospital readmission among general surgery patients treated at Emory University Hospital ( J Am Coll Surg. 2012 Sep;215:322-30 ). Pancreatectomy accounted for 18% of readmissions, followed by colectomy/colostomy (13%), small bowel resection (12%), and gastrectomy and ventral hernia repair (both 11%).
An unrelated analysis of a 498,875 operations found that lower extremity vascular bypass procedures accounted for 16% of readmissions, followed by colectomy or proctectomy (11%), bariatric surgery (5%), and ventral hernia repair (4%). In addition, the readmission rates were 6% among patients with no complications, 16% among those with one complications such as surgical site infections (SSIs), bleeding, and ileus, 37% among those with two or more complications, and 29% among those with three or more complications ( JAMA 2015;313:483-95 ). The most common complication overall was SSI (20%), followed by ileus (10%).
When the Emory study researchers drilled down on their data, they found that the following preexisting conditions were associated with readmissions among colectomy patients: steroid use, hypertension, readmission, cancer, COPD, smoking, poor functional status, and diabetes. At the same time, preexisting conditions associated with readmissions among vascular patients were diabetes and renal failure. The only preexisting condition associated with readmissions among thyroidectomy was renal failure. When the researchers evaluated the association between readmission risk and system-wide complications, they found that vascular surgery and urinary surgery conferred the highest risks (sixfold and fivefold, respectively).
“Just looking at your semiannual report quickly can give you a sense of which complications are associated with that readmission,” Dr. Sharma said. “There are many areas of potential intervention.” Preoperatively, he recommends screening surgery patients for obstructive sleep apnea, hypertension, and diabetes. “Looking at preexisting comorbid dyspnea, cancer, and renal failure can give you those target populations very quickly,” he said.
Intraoperatively, “it’s all about reduction of complications,” he said. These include using the WHO checklist , employing SSI prevention practices and considering certain anesthesia techniques such as low tidal volume ventilation and fluid limitation, control of hyperglycemia, and enhanced recovery after surgery protocols (ERAS).
Postoperative strategies to reduce readmission risk include ERAS for multimodal analgesia, fluid restriction, oral intake, and ambulation, and being aggressive about follow-up with high-risk populations and discharge planning. “The strategies for readmission reduction should be based on the preoperative assessment and the ability to identify high-risk populations,” Dr. Sharma said. “At Emory, we found that ileostomy patients had the highest risk of readmission. This made sense from a dehydration standpoint. So a colorectal surgeon led the creation of an Emory-wide protocol for teaching patients and their families, giving them signs of dehydration, what to look for, direct access to a dedicated nurse for follow-up, and an arrangement with the infusion center for rehydration as needed.”
He concluded by noting that there is no one-size-fits-all approach to reducing hospital readmissions. “I think an overarching readmission improvement process is not the way to go, unless you’re talking about a preoperative assessment area,” he said. “Identifying high-risk patients and giving them a lifeline where they can call so you can intervene and avoid that readmission, is better.”
Dr. Sharma reported having no relevant disclosures.