• Hospital readmissions after surgery

    Yesterday I wrote about a study of emergency department visits within 30 days of a surgical procedure. Last night NEJM published a study, by Thomas Tsai and colleagues, on 30-day hospital readmissons after surgery. This surgery focus is motivated by the fact that the Medicare program is considering including imposing penalties on hospitals with high surgical readmission rates.

    The investigators examined 2009-2010 Medicare data for patients who had received one of the following surgical procedures: coronary-artery bypass grafting (CABG), pulmonary lobectomy, endovascular repair of abdominal aortic aneurysm, open repair of abdominal aortic aneurysm, colectomy, and hip replacement.

    The paper is packed with findings. In brief, from the abstract:

    The median risk-adjusted composite readmission rate at 30 days was 13.1% (interquartile range, 9.9 to 17.1). In a multivariate model adjusting for hospital characteristics, we found that hospitals in the highest quartile for surgical volume had a significantly lower composite readmission rate than hospitals in the lowest quartile (12.7% vs. 16.8%, P<0.001), and hospitals with the lowest surgical mortality rates had a significantly lower readmission rate than hospitals with the highest mortality rates (13.3% vs. 14.2%, P<0.001). High adherence to reported surgical process measures was only marginally associated with reduced readmission rates (highest quartile vs. lowest quartile, 13.1% vs. 13.6%; P=0.02).

    So, hospitals with higher volume, lower mortality rates, and better surgical process measures (all traditional indicators of quality) had lower readmission rates. With respect to the volume findings, here’s a pretty picture:

    As readers might recall, hospital readmission rates for heart attacks, heart failure, and pneumonia are not as strongly aligned with mortality rates and other measures of quality. So, why the difference for surgical readmission rates? Tsai et al. explain:

    The reasons that bring surgical patients back to the hospital soon after discharge are probably different from those that bring medical patients back. Whereas medical patients may come back because of poor social support at home, inability to access primary care, or general poor health, surgical patients are more likely to return as a consequence of complications arising from the surgery.

    In other words, surgical readmission rates more closely measure hospital (surgical) quality, as opposed to the nature of care beyond hospital walls. That being the case, it makes sense that they’d be more highly correlated with other measures of hospital (surgical) quality.


    • I attempted to find in paper any correlation not just between mortality and readmit, volume and readmit, but with all three.

      Do hospitals performing in the top quintile or decile connect all the dots on the quality and outcomes front?


    • Really need to lay LOS data over that. With an effort to decrease LOS some pt’s get DC’d too early and end up back on a unit. Many orgnizations that struggle with the right balance.

    • Lurking in these findings are serious issues of regulatory policy and health access. Imagine that all patients fall into two groups: residents of large cities where hospitals get lots of volume for surgical procedures X, Y, and Z, and residents of rural areas, towns, and small cities where procedures X, Y, and Z don’t happen very often simply because the service area has fewer people. Nor will these hospitals be able to attract top surgeons or build top surgical teams. This study shows that any readmission penalties will fall heavily on the latter group. But should it? It is not the hospital’s fault that it was dealt a bad hand in terms of opportunity to get really proficient on high volume. And while I am a great fan of medical “tourism” to centers of excellence, not everybody is physically, emotionally, or financially able to face that challenge. Meanwhile, the penalties may tip some hospitals under, depriving area residents of all convenient or close hospital access, including emergency care. I don’t have a strong view on the “right” answer, but it seems clear that high penalties on high readmission rates will not have only positive consequences, or even necessarily be effective in improving surgical and hospital performance in many facilities.

    • There’s also a large of large numbers problem. Note that the low volum hospitals have both the highest and lowest rates. That suggests that high volume hospitals are benefitting from averaging larger numbers.

    • Note a I have not read the paper. My university login system has been down this morning, so I can’t get it.