Many Postoperative Hospital Readmissions Are Unavoidable

Dr. Ryan Merkow, M.D. M.S. American College of Surgeons Chicago, Interview with:
Dr. Ryan Merkow, M.D. M.S.
American College of Surgeons
Chicago, Illinois What is the background for this study? What are the main findings?

Dr. Merkow: The measurement of hospital readmissions has become an important quality and cost-containment metric. Hospitals, policy makers, and individual practitioners are closely tracking readmissions. For the past decade the focus has been primarily on three medical conditions (pneumonia, heart failure and myocardial infarction) and although controversial, many thought leaders and policy makers believed that readmissions were preventable, and stemmed from poor transition of care, outpatient follow up or simply a failure of the medical system to appropriately care for these patients. Recently, the Center for Medicare and Medicaid Services has become increasingly interested in using readmissions as a quality measure and is now mandated by the Hospital Readmission Reduction Program to track hospital-wide readmissions (including all surgical patients), and for the first time, after individual surgical procedures (i.e., total hip and knee replacement). Future inclusion of additional surgical procedures is anticipated.

However, despite the growing focus on readmissions after surgery, there have been few studies comprehensively evaluating the underlying reasons and factors associated with readmissions after surgical hospitalizations. Furthermore, the relationship between readmissions and complications that occur during the initial hospitalization after surgery is not clearly established. Importantly, unlike medical conditions, surgical patients undergo a discrete invasive event with known risks of complications. By studying this topic, initiatives to decrease readmissions can be more precisely determined, and national policy decisions that are now targeting readmissions can be appropriately formulated.

The primary findings of our study identified surgical site infections as the most frequent reason that patients are readmitted after surgery, Importantly, in >95% of patients this complication was new, occurring after they left the hospital. The other common reason for readmission was obstruction or ileus, which was the second most frequent reason for readmission, particularly after abdominal surgery. Overall, the vast majority of readmissions were the result of new postdischarge, postoperative complications. With respect to factors associated with readmissions, most of the variation was due to differences in patient factors, such as ASA class, renal failure, ascites and/or steroid use.  What should clinicians and patients take away from your report?

Dr. Merkow: There are a number of take home messages from this study. First, most readmissions were the result of well-described postoperative complications and therefore readmissions after surgery are mostly a proxy for postdischarge complications and in effect hospitals are being penalized twice for complications.

Second, the most common reasons for readmissions were surgical site infection and ileus and therefore identifying clinical interventions to reduce the occurrence of these complications is important, but historically proved remarkably challenging. Implementation of a policy penalizing hospitals for readmitting patients with these complications may be ineffective and even counterproductive. Thus, readmissions after surgery may not be an appropriate measure for pay-for-performance programs but rather may be better suited for hospitals when identifying targets for readmission reduction efforts internally. It should be further emphasized that many readmissions are unavoidable and are the correct course of action for the safety of a surgical patient in dire need of efficient and effective care.  What recommendations do you have for future research as a result of this study?

Dr. Merkow: Because we found that most readmissions occur as a result of postoperative complications, the continued effort should focus on effective strategies to reduce these events.  In addition, it is feasible that some hospitals are better able to reduce the severity of outpatient complications (and subsequently reduce the number requiring readmission) or have systems in place (e.g., complex surgical site infection clinic) to manage complications in the outpatient setting once they occur. Theses approaches should be further studied.


Underlying Reasons Associated With Hospital Readmission Following Surgery in the United States

Ryan P. Merkow MD, MS, Mila H. Ju MD, MS, Jeanette W. Chung PhD, Bruce L. Hall MD, PhD, MBA, Mark E. Cohen PhD, Mark V. Williams MD, Thomas C. Tsai MD, MPH, Clifford Y. Ko MD, MS, MSHS, Karl Y. Bilimoria MD, MS

JAMA. 2015;313(5):483-495. doi:10.1001/jama.2014.18614

[wysija_form id=”1″] Interview with:, & Dr. Ryan Merkow, M.D. M.S. (2015). Many Postoperative Hospital Readmissions Are Unavoidable

Last Updated on February 3, 2015 by Marie Benz MD FAAD