Association for Academic Surgery
The Surgical Revolving Door: Risk Factors for Hospital Readmission

https://doi.org/10.1016/j.jss.2011.04.049Get rights and content

Background

Unplanned hospital readmissions increase healthcare costs and patient morbidity. We sought to identify risk factors associated with early readmission in surgical patients.

Materials and Methods

All admissions from a mixed surgical unit during 2009 were retrospectively reviewed and unplanned readmissions within 30 d of discharge were identified. Demographic data, length of stay, pre-existing diagnoses, and complications during the index admission were evaluated. T-tests and Fisher exact tests were used to examine the relationship of independent variables with readmission. Univariate and multivariate regression analysis were performed.

Results

A total of 1808 index admissions occurred during the study period. In all, 51 (3%) patients were readmitted within 30 d of discharge. The majority of readmissions (53%) were for infectious reasons. On univariate analyses, DVT (P = 0.004) and acute renal failure (P = 0.002) were associated with increased risk of readmission. Readmitted patients were also more likely to have public insurance (63% versus 37%, P = 0.03) and have a longer stay in the hospital (8 d, range 4–14 d versus 3 d, range 2–7 d, P = 0.001). Initial admission after trauma evaluation was associated with a decreased risk of readmission (OR 0.374, P = 0.004). Other demographic variables and pre-existing conditions were not associated with increased readmission. On multivariate logistic regression only DVT (P = 0.039) and LOS (P = 0.014) remained significant.

Conclusions

Increased LOS and the development of a DVT are risk factors for early unplanned hospital readmission. Admission following trauma is associated with a decreased risk of readmission, possibly due to proactive multidisciplinary discharge planning and geographically-based nurse practitioner involvement.

Introduction

Unplanned readmission to the hospital is a common problem. Jencks et al. recently reported that approximately 20% of Medicare patients are readmitted within 30 d of discharge, resulting in an annual cost of over $17 billion. Furthermore, the cost of readmission represents 17% of all annual Medicare payments [1].

In the current era of health care reform, policy makers have targeted hospital readmissions as a potential source of cost savings [2]. Hospitals are now required to publicize their readmission rates for patients with three common admitting diagnoses: heart failure, pneumonia, and acute myocardial infarction [3]. Despite the lack of universal agreement on the proper interpretation of these data or their clinical significance, hospitals will soon face a reduction in Medicare reimbursement if readmission rates are higher than expected 3, 4, 5, 6.

Many studies have tried to identify risk factors for early readmission in specific patient populations, such as the elderly [7], veterans [8], patients with heart failure [9], or patients who have experienced a particular surgical procedure 10, 11, 12, 13, 14. Several systematic reviews have been conducted to try to interpret the various risk factors identified in these studies in a more generalized patient population 15, 16. However, due to the heterogeneity of the methods used and the populations analyzed by the available studies, broader application has been difficult. Data regarding risk factors for readmission in a more generalized surgical population are lacking.

We hypothesized that certain comorbidities and complications that occur during a patient’s initial hospital admission would predict the need for unplanned readmission.

Section snippets

Methods

The study design was reviewed and approved by the IRB of the Hospital of the University of Pennsylvania. Using a prospectively maintained administrative database, we retrospectively evaluated all admissions from a mixed surgical unit in our urban, tertiary referral center during fiscal year 2009 (7/01/2008–6/30/2009). This mixed surgical unit provides care for a variety of surgical patients. Trauma, acute care surgery, and orthopedics patients constitute the majority, but elective surgical

Results

The study period included 1808 index admissions (Table 1). Of these, 1087 (60%) were to the trauma/emergency surgery service (ESS), 446 (25%) to orthopedic surgery, 99 (5%) to plastic surgery, and 76 (4%) to neurosurgery; the remaining 100 patients were admitted to other surgical services such as general surgery, urology, thoracic surgery, and otorhinolaryngology. The average age of this cohort was 44 ± 19 y and 64% were male (Table 2). The racial makeup was 48% African-American, 44% Caucasian,

Discussion

In 2008, nearly 40 million patients were discharged from a hospital after an inpatient stay. This number has steadily increased since 1996 and is unlikely to decrease in the near future [26]. According to a recent review of the Medicare Provider Analysis and Review file, nearly 20% of patients discharged from the hospital were rehospitalized within 30 d. The cost of readmissions in 2004 for this population was $17.4 billion—roughly 17% of total hospital payments during this time frame [1].

Conclusion

In the very near future, unplanned hospital readmissions will take on new significance, as hospitals will be forced to publicly report their rates and will be penalized for poor performance. In this changing environment, identifying the patients at highest risk for readmission will be of paramount importance. From our mixed surgical population, DVT and increased LOS increased the risk of rehospitalization within 30 d of discharge. Strategies aimed at the preventing DVTs and acute renal failure

References (34)

  • Available at: http://docs.house.gov/rules/health/111_ahcaa.pdf. Accessed December 2010. Patient Protection and...
  • K.A. Schwarz

    Predictors of early hospital readmissions of older adults who are functionally impaired

    J Gerontol Nurs

    (2000)
  • W.B. Weeks et al.

    Do older rural and urban veterans experience different rates of unplanned readmission to VA and non-VA hospitals?

    J Rural Health Winter

    (2009)
  • E.L. Hannan et al.

    Predictors of readmission for complications of coronary artery bypass graft surgery

    JAMA

    (2003)
  • Z. Medress et al.

    Can we predict unplanned hospital readmission after colectomy for ulcerative colitis and indeterminate colitis?

    Am Surg

    (2007)
  • E. Ozturk et al.

    Early readmission after ileoanal pouch surgery

    Dis Colon Rectum

    (2009)
  • J.R. Vest et al.

    Determinants of preventable readmissions in the United States: A systematic review

    Implement Sci

    (2010)
  • Cited by (0)

    View full text