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Emergency General Surgery Plagued by High Readmission Rate

BOSTON – Increasingly, hospital readmission rates following surgery are used as markers of quality patient care in pay-for-performance metrics. So, when one group of surgery patients has especially high complication and readmission rates, hospital administrators sit up and take notice.

A study published online recently by JAMA Surgery points out that about half of all patients undergoing emergency general surgery (EGS) will have a postoperative complication, which are closely linked to hospital readmission.

To help determine the extent of the problem, a study team led by researchers from Brigham and Women's Hospital in Boston examined adult rates and risk factors for readmission after common EGS procedures using the California State Inpatient Database from 2007-2011. The five most commonly performed EGS procedures in each of 11 diagnosis groups were identified with information collected on patient demographics, hospital length of stay, complications, and discharge disposition.

Most (57%) of the 177,511 patients meeting inclusion criteria were white and older than 45 (51%); about half were privately insured.

Laparoscopic appendectomy (35%) and laparoscopic gallbladder removal (19%) were the most common procedures. With the overall 30-day hospital readmission rate at 5.9%, readmission rates ranged from 4% for upper gastrointestinal surgery to 17% for cardiothoracic surgery. Readmissions occurred at a different hospital than the surgery site for 17% of cases.

Among the predictors of readmission were the following:

  • scoring higher on an index of coexisting illnesses,
  • being discharged against medical advice, and
  • having public insurance.

Surgical site infections (17%), gastrointestinal complications (11%), and pulmonary complications (4%) were the most common reasons for readmission, according to the study results.

"Reducing readmissions is a noble cost-saving goal with benefits not only to the hospitals, but also to the patients. However, it is critical to understand the underlying factors associated with readmission to appropriately identify quality-improvement measures that address the true problem,” study authors write. “Focused and concerted efforts should be made to incorporate readmission-reducing strategies into the care of EGS patients, particularly among those at higher risk for readmission.”

In an associated commentary, O. Joe Hines, MD, of the David Geffen School of Medicine at the University of California, Los Angeles, points out that while “local programs can be instituted to prevent complications and readmissions, the incorporation of electronic health records and the creation of large health systems will facilitate better care for the 15% to 20% of patients who are readmitted to a different hospital. All of the components are in place to make meaningful progress in surgery, and with our leadership, we can realize substantial change and, most importantly, happy healthy patients."