Most Surgical Readmissions Caused by Common Complications

While the financial stakes for hospitals are rising as penalties for readmissions ratchet up, current policies to reduce readmissions may be provoking unintended consequences.

Complications from surgery for medical conditions—rather than from the medical conditions themselves—are the chief reason surgical patients required readmission within 30 days after their procedures, and life-threatening surgical site infections (SSIs) top the list.

That's according to a report that examined audited medical records of nearly 500,000 patients who underwent surgery at 346 hospitals participating in an American College of Surgeons quality program in 2012.

"It's a simple observation, but it has very profound implications," says Karl Bilimoria, MD, assistant professor in surgery-surgical oncology at Northwestern University in Chicago, corresponding author of the published in JAMA Tuesday. "The world thinks that readmissions of patients are related to problems with transitions of care and how you manage the [medical] conditions, but for patients undergoing surgery, it's not that at all."

Instead, common, known surgical complications that appear after discharge, such as SSIs, bowel obstructions, and bleeding, stem from the surgical procedure itself, Bilimoria says.

That's important, especially since higher rates of readmissions now result in hospital penalties as high as 3% of a hospital's Medicare payment, and hip and knee procedures are now included in the equation, Bilimoria says. In 2016, CMS will add coronary artery bypass graft procedures to the readmission penalty algorithm.

Bilimoria says that despite many initiatives to reduce SSIs, preventing them has been extremely tough and largely unsuccessful. That's because the telltale signs of infection: redness, fever and other signals don't show up until seven to 10 days or longer after the patient is discharged.

"As surgeons, we've been trying hard for centuries, and [there are] a lot of great efforts ongoing to reduce these complications, and we've made a small dent," he says. "But wound infections still happen, and it's just not something we have a magic bullet for, that we can stop and drive to zero," even if a hospital implements all known best practices.

Readmitting these patients is the right thing to do, Bilimoria says.

He adds: "If we're going to act on readmissions to reduce them, it's important to know why they're happening, and important from a policy standpoint to know that it might not be so easy to reduce readmissions for these patients. And therefore, our policy regarding readmission reductions may not be very effective."

Unintended Consequences
Bilimoria says that without a better effort to understand the cause and timing of surgical site infections, the current policy may provoke some unintended consequences. It may, he says, prompt some doctors "to try to skirt a readmission by treating patients with surgical infections in the clinical practice instead of sending them to the hospital, which could lead to a worsening of the condition."

The JAMA study, whose lead author is Ryan Merkow, MD, of Northwestern's Surgical Outcomes and Quality Improvement Center, is unique in capturing the reasons for surgical readmissions because it was drawn from charts reviewed for nearly 500,000 operations within 346 hospitals participating in the ACS's National Surgical Quality Improvement Project.

Readmissions after six surgical procedures were reviewed: bariatric colectomy or proctectomy, hysterectomy, total hip or knee arthroplasty, ventral hernia repair, and lower extremity vascular bypass procedures.

In order of their frequency, the top 10 reasons surgical patients were readmitted were:

Nationally, the NSQIP program is a learning collaborative in which surgeons at about 600 U.S. hospitals agree to share surgical improvement techniques on a variety of procedures. Rather than relying on hospital reports of complications, NSQIP-participating hospitals pay to have an ACS-trained auditor examine surgeons' outcomes with extensive chart reviews and post-discharge follow up, including calling patients at home at intervals for 30 days.

Outside of audited programs like NSQIP's, hospitals may not know their patients got an infection, especially if they went to a physician's office or another hospital or clinic else for treatment, Bilimoria says.

Overall, the unplanned readmission rate from the hospitals participating in this research project was 5.7%, but for patients who had undergone certain types of operations, the rate was much higher. Lower extremity vascular bypass patients, for example, had a readmission rate as high as 14.9%.

Better Discharge Planning
For the second most common reason for unplanned readmissions, bowel obstruction, which occurs most frequently after colectomies, proctectomies, and bariatric surgeries, Bilimoria says a remedy may lie in better discharge planning and better communication with patients.

For example, hospital teams may send patients home with instructions that say, "Monitor ostomy output and report if it exceeds 1500 ml daily."

Bilimoria suggests saying instead, "Record how much output there is in your ostomy bag using the measuring cup we provided. Record it each time you change it. The numbers in cup are in ml. If the amount exceeds 1500 ml in 24 hours, call us as you are in danger of dehydration. Refer to this video on YouTube or call promptly with any questions."

In an accompanying editorial, Lucian Leape, MD, adjunct professor of health policy at the Harvard School of Public Health, says that the report reveals an "extent of harm [that] is sobering," and that it reveals defect rates "far higher than are tolerated by any other industry."

Leape calls for surgeons and others to "refuse to accept harm as inevitable, and to learn from those surgeons who have very low complication rates."