A study out in the February 3 issue of the Journal of the American Medical Association found that patients who are readmitted to the hospital after surgery are almost always coming back due to post-discharge complications rather than something that happened during their care in the hospital.

The study (which can be viewed online at http://jama.jamanetwork.com/article.aspx?articleid=2107788) used data from the National Surgical Quality Improvement Program (NSQIP) and looked at almost a half million cases from 2012 involving several kinds of surgery:

• bariatric surgery;

• colectomy or proctectomy;

• hysterectomy;

• total hip or knee replacement;

• ventral hernia repair;

• lower extremity vascular bypass.

It marks the first time a study has looked this in-depth at the reasons for unplanned readmission after surgery. The study mentions that the NSQIP data, which notes the specific reason for readmission, makes this level of study possible.

Of the cases, 5.7% resulted in a readmission, and just 2.3% of those patients returned to the hospital because of something that happened during their stay. The results for the various surgeries differed, with a low of 3.8% for hysterectomy and a high of almost 15% for lower extremity vascular bypass. Surgical-site infection was the most common reason for return for all the surgeries except bariatric procedures, ranging from 18.8% for total hip or knee, to 36.4% for lower extremity vascular bypass. For bariatric patients, ileus, or obstruction, was the most common cause of readmission, causing just under a quarter of the returns.

The researchers could find no relationship between the day of the return and the reason; however, there were some risk indicators. Patients with co-morbidities, those treated in academic hospitals, and those who were not discharged home were more likely to return to the hospital before 30 days were up.

Karl Bilimoria, MD, MS, a surgical oncologist at Northwestern Memorial Hospital in Chicago and one of the authors of the paper, says the last point highlights both a problem and an opportunity: The problem is that care at skilled nursing facilities may not be what it needs to be to prevent complications after discharge that result in returns to the hospital, at least partly as a result of poor communication. The opportunity is to improve communication with those facilities and help them improve care to benefit the patients.

Interestingly, patients who experienced a complication in the hospital and then had an unplanned readmission rarely came back for the same reason. For instance, only 3.3% of patients who were readmitted for surgical-site infections had such an infection during their initial hospitalization.

“I do not think most surgeons would be surprised at this,” says Bilimoria. “But it is important for us to study the reasons why our patients come back to the hospital.”

Currently the Centers for Medicare & Medicaid Services requires hospitals to report information on readmissions for surgical patients who have had knee or hip replacement, but Bilimoria says other surgical procedures are going to follow. Getting a handle on the reasons behind complications for them is vital given the financial penalties that will likely be involved.

He and other surgeons bristle a bit at what they consider double jeopardy related to those penalties. Surgical-site infections are already penalized by payers. Now, if a patient comes back to the hospital because of one, it will be twice dinged: for the complication of the infection and the readmission, when the infection is not something in its control once the patient leaves the building.

In the study, the authors put it this way: “…because most readmissions were attributable to well-described postoperative complications, readmissions after surgery are mostly a proxy measure for post discharge complications and in effect penalize hospitals twice for postoperative complications (i.e., other pay-for-performance programs include postoperative complications such as SSI).”

Another concern the authors have is that efforts to tackle the two largest reasons for readmission — infection and obstruction — have not been hugely successful. To penalize hospitals for conditions that have been intractable may be counterproductive “because performance targets without accepted courses of intervention might be more prone to unintended or ineffective behaviors and consequences.”

It makes Bilimoria wonder if readmission rates may be the wrong thing to focus on for surgical care quality indicators. In most patients with surgical complications, were it not for the surgery, the complication would never have occurred, Bilimoria explains. To a certain degree, many of these complications are expected. Or perhaps a better way to put it is that it is not really a complication, but more a part of the surgical procedure that surgeons have come to expect. They are not things that are exacerbated or created by poor care, but created by the very fact that any care was given, and to some degree, they will be extremely difficult to attack and perhaps impossible to completely eliminate.

For now, however, he understands it is what is being used, and for that reason, looking at the numbers, understanding them, and learning from them is vital.

Some of the other reasons for readmission can be more readily addressed. For example, bariatric patients had issues with vitamin deficiencies and colorectal surgical patients had issues with dehydration. Better patient education may address some of those issues. Another idea, says Bilimoria, is some sort of intermediate clinic for postsurgical patients after discharge that will more closely monitor them.

For more information on this topic, contact Karl Bilimoria, MD, MS, Surgical Oncologist, Northwestern Memorial Hospital, Chicago, IL. Email: k-bilimoria@northwestern.edu.