1 in 7 Surgery Patients Readmitted Within 30 Days Nationwide

Larry Hand

September 18, 2013

More than 13% of hospitalized patients who undergo major surgery are readmitted within 30 days, according to a study published online September 18 in the New England Journal of Medicine. The rate of surgical readmissions varies widely among hospitals though, and may be a valid quality measure for policy makers, clinical leaders, and patients.

Thomas C. Tsai, MD, MPH, from the Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, and colleagues analyzed Medicare data and hospital characteristics data for 2009 and 2010. They focused on patients who had 1 of 6 procedures: coronary-artery bypass grafting, pulmonary lobectomy, endovascular repair of abdominal aortic aneurysm, open repair of abdominal aortic aneurysm, colectomy, and hip replacement.

They analyzed data on 479,471 discharges from 3004 hospitals, accounting for 90.7% of all discharges of Medicare fee-for-service patients from US acute care hospitals during the study period.

Readmission rates varied between 10.5% and 17.4% across the procedures studied.

The researchers calculated a median risk-adjusted 30-day readmission rate of 13.1% (n=61,785; interquartile range 10.5% - 17.4%) when all procedures were included. As expected, readmitted patients were older than patients not readmitted (mean age, 78.0 vs 77.0 years; P < .001) and had more coexisting conditions. Hypertension was the most common comorbidity in both groups of patients (55.9% readmitted vs 61.6% not readmitted; P < .001).

Hospital Characteristics

Hospitals with the highest volume of surgeries had lower composite readmission rates than the lowest-volume hospitals (12.8% vs 16.5%; P < .001). The lowest-mortality hospitals had lower composite readmission rates than the highest-mortality hospitals (13.0% vs 13.8%; P = .001). However, the hospitals with the best Hospital Quality Alliance scores showed only marginally lower readmission rates compared to hospitals with the lowest scores (13.1% vs 13.6%, P = 0.02).

Hospitals with readmission rates below the median were more likely to be nonprofit than for-profit (66.3% vs 63.6%; P = .04), nonteaching vs teaching (93.2% vs 89.1%; P < .001), and located in the western United States (24.1% vs 14.8%; P < .001).

Higher-volume, lower-mortality hospitals "are better versed in protecting patients from postoperative complications," the researchers write. "[H]igh-quality hospitals may also use systematic approaches to determine when patients are ready for discharge and engage in readmission-prevention strategies that may have a greater effect on surgical patients than on medical patients."

Hospitals with lower readmission rates also had more full-time nurses per 1000 patient days (median 7.2 vs 6.9; P < .001) and a lower proportion of Medicaid patients (median, 16.2% vs 17.0%; P = .005) than hospitals with higher readmission rates. No significant difference appeared between urban and rural hospitals, and rates were similar across all procedures.

"Our findings suggest that focusing on surgical readmissions may be a smart policy approach to both improving care and reducing unnecessary spending," senior author Ashish Jha, MD, MPH, professor of health policy at the Harvard School of Public Health, said in a press release.

Not Surprising

The researchers point out that although these findings are different from hospital readmission rates for medical reasons, they are not surprising because surgical readmissions are more likely to be a consequence of surgical complication than social and general issues related to medical readmissions.

"The results were not surprising," Clifford Ko, MD, a colorectal surgeon, professor of surgery at University of California at Los Angeles, and director of the University of California at Los Angeles Center for Surgical Outcomes and Quality, told Medscape Medical News. "I think good quality has a number of factors, and mortality, volume, and readmission all go in the same direction, since good quality will have an effect on all 3. They measured many things and showed the interplay between quality and many factors."

Dr. Ko said that to reduce readmission rates, hospitals can measure quality with high-quality data, use multidisciplinary teamwork to perform surgery, and "have standards for everyone to follow, whether it's the hospital or individual provider."

Limitations of the study include a possible lack of generalizability to nonelderly patients.

One researcher reports serving on boards at Lifebox, RX Foundation, and New America, and another author reports receiving grant funding from the National Cancer Institute. The other authors have disclosed no relevant financial relationships.

N Engl J Med. Published online September 18, 2013.

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