Care Fragmentation in the Post Discharge Period: Surgical Readmissions, Distance of Travel, and Postoperative Mortality

Tsai, Tsung-Hsien; Orav, John; Jha, Ashish

doi:10.1016/j.jvs.2015.04.413

Cited by 57 publications

(107 citation statements)

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“…Using the Medicare data from 2009 to 2011, Tsei et al showed that 25% of readmissions after surgery took place in outside facilities. 15 Our institution is a level 1, primary teaching hospital for a health science center in a suburb of Central Texas where there are no other major health care systems. Many of our patients tend to stay within the network due to location convenience and the ability to have all medical records in one place; therefore, we expect that the ED visit capture rate is much greater than it would be in an urban setting where patients have multiple options within short distances.…”

Section: Discussionmentioning

confidence: 99%

Factors associated with emergency room visits within 30 days of outpatient foot and ankle surgeries

Shibuya

Patel

Graney

et al. 2018

Baylor University Medical Center Proceedings

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The number of emergency department (ED) visits within 30 days after elective surgery has been utilized as a quality measure by many institutions. The significance of the measure as a postoperative complication in foot and ankle surgery, and risk factors for it, are unknown. We conducted a retrospective cohort study involving 386 patients to determine risk factors associated with ED visits after outpatient foot and ankle surgeries. After adjusting for clinically relevant covariates, we found that previous ED visits within 6 months of surgery, and nonelective surgeries were associated with the postoperative ED visit. Having private insurance was protective against postoperative ED visits. Though these risk factors may not be easily modifiable by surgeons, understanding them may improve patient education and transitional care to prevent overcrowding of the ED.KEYWORDS Emergency department; insurance; readmission; surgical complications F oot and ankle surgeries have a low complication rate, but certain patients are predisposed to such events. These complications include surgical site infections, venous thrombotic events, acute blood loss causing anemia, nerve injury, and pain unresponsive to oral analgesics. Complications are devastating for patients and costly for health care institutions.1 They may require additional office and emergency department (ED) visits, admission to a hospital, or further surgery.2 ED visits after elective surgery have recently been utilized as a quality measure by many institutions. 3Readmission after ED presentation may represent major complications after surgery, but many complications present to an ED without subsequent admission. Presentation to an ED is common even after elective surgeries, 4,5 and some of these unplanned visits can be preventable with good postsurgical as well as physician-patient coordination. 6 The occurrence of unplanned postoperative ED visits is significant in terms of ED crowding and increased health care costs and spending. To the authors' knowledge, no studies have evaluated postoperative ED visits after foot and ankle surgery. Therefore, the significance of this quality measure relative to actual postsurgical complications is unknown in foot and ankle surgeries.The purpose of the study was to identify risk factors associated with ED visits within 30 days after foot and ankle surgeries. METHODSWe enrolled adult patients 18 years or older who had foot and ankle surgery from January 2015 to December 2016 at the Baylor Scott and White Health Central Division campuses in Temple, Round Rock, Marble Falls, Waco, and College Station. Patients who presented to the ED after foot/ankle surgeries were identified from our department's quality measure data. To act as controls, we randomly selected an equal number of patients who did not present to the ED within 30 days after surgery. No matching was performed. We excluded (1) inhouse surgical cases, (2) patients with any record of relocation within 30 days of the surgery who no longer utilized the Scott and Whit...

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Section: Discussionmentioning

confidence: 99%

Factors associated with emergency room visits within 30 days of outpatient foot and ankle surgeries

Shibuya

Patel

Graney

et al. 2018

Baylor University Medical Center Proceedings

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“…Hernandez et al 29 demonstrated that early post-discharge follow-up with a primary care provider is associated with decreased 30-day readmissions for patients hospitalized for congestive heart failure exacerbations. Tsai et al 15 highlighted the importance of continuity of care by showing that readmissions in hospitals other than the hospital of the initial procedure resulted in higher mortality rates for surgical Medicare patients. On the other hand, weekend discharges, which have been linked with less coordinated care, were not associated with increased readmissions in surgical patients from California 30.…”

Section: Discussionmentioning

confidence: 99%

“…Patients undergoing clipping or coiling are often evaluated in the ED after discharge for indications such as headache or other neurological changes. The specialized nature of these procedures might be an obstacle to disease-specific care, and the inability of unfamiliar providers to recognize the normal postoperative course of such patients15 might result in the higher rate of readmissions we are observing. These results suggest an important area of quality improvement for hospitals and policy makers.…”

Section: Discussionmentioning

confidence: 99%

“…One rarely recognized case of fragmentation of care is the evaluation of surgical patients in the immediate post-discharge period in hospitals other than that in which the original procedure was performed. As most hospitals do not share data electronically with each other,16 emergency department (ED) evaluation in different hospitals rarely involves clinical information exchange or shared patient management 15. Particularly in the case of complex interventions, such as cerebral aneurysm treatment (with surgical clipping or endovascular coiling), the lack of familiarity with these patients and their normal postoperative course might be an obstacle to efficient care 11 22 23.…”

Section: Introductionmentioning

confidence: 99%

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Continuity of care and 30-day readmission for patients evaluated in the emergency room after cerebral aneurysm treatment

Bekelis

Missios

MacKenzie

2016

J NeuroIntervent Surg

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“…this is an important strength of the study because approximately 25% of readmitted postoperative patients are cared for at hospitals different from the index hospital. 6,7 Postoperative (either pre-or postdischarge) complications were not part of their multivariable analysis. in light of previous research that shows the strong correlation between postoperative complications and readmissions, one might question the usefulness of an analysis that does not account for these complications.…”

mentioning

confidence: 99%

Can Large Database Studies Help Us Decrease Readmissions After Colorectal Surgery?

Kwaan

2015

Diseases of the Colon &Amp; Rectum

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t he current focus on hospital readmission as a proxy for quality of care has encouraged surgeons from nearly every surgical specialty to reexamine their postoperative outcomes. studies on surgical readmissions show that postoperative complications, when included in the analysis, independently predict readmissions, and usually with large effect estimates. 1-3 in fact, postoperative complications have been shown to be more important than patient demographics through the use of statistical model diagnostic tests. 4 Programs that significantly reduce complications are therefore very likely to reduce readmissions. Because not all complications are preventable, opportunities to mitigate the effects of complications through early detection or patient education may also be helpful.Bliss and colleagues use florida state hospital claims data to study risk factors for and costs related to readmission after colorectal surgery in 93,913 patients. 5 their choice of a population-based data source reassures us that a complete capture of readmissions is likely. this is an important strength of the study because approximately 25% of readmitted postoperative patients are cared for at hospitals different from the index hospital. 6,7 Postoperative (either pre-or postdischarge) complications were not part of their multivariable analysis. in light of previous research that shows the strong correlation between postoperative complications and readmissions, one might question the usefulness of an analysis that does not account for these complications. in their adjusted multivariable model, young age (<65 years), nonwhite race, medicare or medicaid insurance, and comorbidities were the patient factors that predicted readmission. With the exception of young age, these are all typical risk factors for complications after colorectal surgery. in addition, patients who had ischemia, volvulus, iBD, Gi bleed, or obstruction as the indication for surgery, and those who had a stoma created (19% of the cohort), rectal resection, or total colectomy had the highest odds of readmission. interventions targeted toward these patients may be higher yield. Data on the interval between hospital discharge and readmission shows us that the median time to first readmission for dehydration was 4 days. therefore, surgeons and hospitals should not be surprised that a plan for a postoperative clinic visit 2 weeks after discharge, for example, would be insufficient to potentially prevent these readmissions.an inherent limitation of administrative data sets is that we have no information on nonbillable variables related to the care transition between inpatient and outpatient settings of care. Pertinent unmeasured variables related to processes of care may include the timing of the postoperative clinic visit and whether this was scheduled at discharge, the quality of discharge instructions and contingency planning for symptoms, 8 telephone follow-up of recently discharged patients, and the processes related to providers involved in the decision surrounding an emergen...

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Care Fragmentation in the Post Discharge Period: Surgical Readmissions, Distance of Travel, and Postoperative Mortality

Cited by 57 publications

References 0 publications

Factors associated with emergency room visits within 30 days of outpatient foot and ankle surgeries

Factors associated with emergency room visits within 30 days of outpatient foot and ankle surgeries

Continuity of care and 30-day readmission for patients evaluated in the emergency room after cerebral aneurysm treatment

Can Large Database Studies Help Us Decrease Readmissions After Colorectal Surgery?

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