Return to system within 30 days of discharge following pediatric shunt surgery

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The rate of readmission after CSF shunt surgery is significant and has caught the attention of purchasers of health care. However, a detailed description of clinical scenarios that lead to readmissions and reoperations after index shunt surgery is lacking in the medical literature.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>This study included 1755 shunt revision and insertion surgeries that were performed at a single institution between May 1, 2009, and April 30, 2013. Demographic, socioeconomic, and clinical characteristics were prospectively collected in the administrative, business, and operating room databases. Clinical events within the 30 days following discharge were reviewed and analyzed. Two events of interest, Emergency Department (ED) utilization and reoperation, were further analyzed for risk factor associations by using multivariate logistic regression.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>There were 290 readmissions within 30 days of discharge (16.5%). Admission sources included ED (n = 216), hospital transfers (n = 23), and others. Of the 290 readmissions, 184 were associated with an operation, but only 165 of these were performed by the neurosurgical service. These included surgeries for shunt occlusion and externalization (n = 150), wound revision (n = 7), and other neurosurgical procedures that were not shunt related (n = 8). The remaining readmissions (n = 106) were not associated with an operation, and only 59 patients were admitted for issues related to the index shunt surgery.</jats:p> <jats:p>When return to the ED was the dependent variable in a multivariate regression model, patients who returned to the ED were more likely to be from the Atlanta metropolitan area and to be either uninsured or insured with public assistance. When reoperation was the dependent variable, patients whose surgery started after 3 p.m. were more likely to undergo subsequent CSF shunt revision surgery on readmission.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Of the readmissions within 30 days of shunt surgery, 74.5% were related to the index shunt surgery. Whether and to what extent these readmissions are preventable continues to be controversial. Further study is needed to identify modifiable risk factors that may eventually improve patient care.</jats:p></jats:sec>

Return to system within 30 days of discharge following pediatric non-shunt surgery

“…This finding matches the finding from our previously conducted shunt readmission study, 3 thereby confirming that after-hours surgery is a promising factor for future study (Table 4). It is crucial to point out that procedure start time is only a surrogate marker (similar to hospital LOS).…”

“…Previously we had documented the strong relationship between shunt surgery itself and early patient readmissions. 3,14 This correlation, while vital to a complete apprehension of factors driving early readmission after all pediatric neurosurgical procedures, is a powerful confounder in statistical models. Carefully teasing the impact of shunt surgery apart from non-shunt neurosurgical procedures allows for a clearer analysis of clinical factors that are not shunt related.…”

Risk factors for unplanned readmission within 30 days after pediatric neurosurgery: a nationwide analysis of 9799 procedures from the American College of Surgeons National Surgical Quality Improvement Program

“…To our knowledge, this is the first study in which the NSQIP database has been used to examine rates and risk factors for readmission after pediatric neurosurgery. While previous studies have reported return to system after pediatric neurosurgery at single institutions 9,21,26 or after pediatric shunt surgery, 20 the statistical power of a large national patient sample may provide a more representative picture of readmission outcomes for general pediatric neurosurgical procedures.…”

“…Pediatric neurosurgery had the highest morbidity and mortality rates of any pediatric surgical specialty in a beta phase report of the American College of Surgeons (ACS) National Surgical Quality Improvement Program–Pediatric (NSQIP-P) database, indicating a need to assess patient risk factors for complications, readmission, and other outcome measures in neurosurgery. 4 Previous studies have investigated return to system (readmission or reoperation) after pediatric neurosurgery at a single institution 9,21,26 and 30-day outcomes after pediatric shunt surgery; 20 to our knowledge, however, no study has used a national, multiinstitutional patient database with follow-up to analyze risk factors for readmission after any pediatric neurosurgical procedure. Identifying the baseline rate of readmission for common pediatric neurosurgical procedures is useful to provide a benchmark for quality improvement efforts.…”

Causes of 30-day readmission after neurosurgery of the spine

“…21,24 Other studies reporting on the neurosurgery of the spine show varying results as well. 5,6,25,31,32,36,38 Three studies investigated ASA physical status classification and found it to be significantly elevated in the readmitted group. 21,24,30 Previously, the increasing ASA score has been connected to increased mortality and worse outcomes for several surgical procedures by Wolters et al 39 Comorbid illnesses were also an effective predictor of readmission.…”