Postsurgery Complications and Readmissions Common, Costly

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Minimizing Postoperative Complications May Require Different Strategies

I’d like to congratulate Dr. Lawson on an excellent presentation and a well-deserved award. Clearly, reducing postoperative morbidity will decrease costs by decreasing lengths of stay and decreasing resource utilization.

When I was in training it was thought that central line–associated bloodstream infections and complications of central lines couldn’t be prevented in some cases. We’ve clearly shown that that is not the case, and with very simple measures we’ve been able to almost eliminate central line infections.

But colon surgery involves complex procedures. How often can we identify individual- or system-level error and correct it in systematic fashion to improve outcomes?

Dr. Taylor S. Riall

I suspect that all complications are not equally associated with readmission. Identifying those that do increase readmission risk will help us increase our observation of those patients postoperatively and our perceived risk for those patients.

I was surprised that carotid endarterectomy was one of the top three procedures on the list. It makes me think that there’s an interaction between the procedure type and complications in terms of readmission. For example, I think complications would be far more predictive of readmission for something like colectomy than something like carotid endarterectomy. My suspicion is that the majority of readmissions after carotid endarterectomy were related to patients’ preoperative comorbidities. If so, the approach to reducing readmissions might vary significantly depending on the procedure in question.

Finally, 47% of readmissions were not associated with postoperative complications. If we understood what was driving these readmissions, we might be able to prevent them and further decrease costs. For instance, does improved continuity of care decrease readmissions? If patients had primary care physicians, were they less likely to be readmitted? Or if they saw their primary care physicians within 2 weeks of discharge, were they less likely to be readmitted?

Dr. Taylor S. Riall, an ACS Fellow at the University of Texas Medical Branch, Galveston, made these remarks as the discussant after Dr. Lawson’s presentation.



SAN FRANCISCO – A majority of patients who are rehospitalized after surgery have a postoperative complication, most commonly after colectomy, lower extremity bypass, or carotid endarterectomy.

Reducing postoperative complications could reduce costs associated with readmissions by millions of dollars per year, a retrospective study of data on 90,932 patients from 214 hospitals suggests.

Investigators linked records from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the Medicare Provider Analysis and Review files for patients aged 65 years or older who underwent surgery in 2005-2008.

Dr. Elise H. Lawson

Within 30 days of surgery, 13% of patients were readmitted. A postoperative complication listed in the ACS-NSQIP registry was seen in 53% of readmitted patients compared with 16% of patients who did not need readmission, Dr. Elise H. Lawson and her associates reported at the annual clinical congress of the American College of Surgeons.

The study looked at 20 postoperative complications, including surgical site infections, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, coma, cardiac arrest requiring CPR, myocardial infarction, bleeding requiring transfusion, deep venous thrombosis, sepsis or septic shock, being on a ventilator for more than 48 hours, and an unplanned return to the OR, among others.

Colectomy was associated with the greatest number of readmissions, followed by lower extremity bypass and carotid endarterectomy. After colectomy, 27% of patients developed a complication, and 13.4% of all colectomy patients were readmitted within 30 days.

Readmission rates after colectomy were 28% for patients who developed postoperative complications and 8% for patients without complications, said Dr. Lawson of the University of California, Los Angeles. She won the College’s 2011 Excellence in Research Award for her study.

Hypothetically, if postoperative complications could be prevented after colectomy, the risk-adjusted probability of readmission within 30 days would be 8%, she said. The study adjusted for the effects of many other factors that influenced the risk of having a postoperative complication, including age, sex, body mass index, functional status, emergency procedures, smoking, renal failure, and diabetes.

Not only did patients with complications have more readmissions, but those readmissions were more expensive. The cost for readmission after colectomy was $13,400 for patients with a complication and $7,500 for those without complications.

It’s unrealistic to think that a hospital could prevent all postoperative complications, Dr. Lawson said. Reducing complications after colectomy by even 10% (to 24%) would lower the overall postcolectomy readmission rate from 13.4% to 12.8%, the investigators estimated. For the 108,820 colectomies performed each year in Medicare beneficiaries aged 65 years or older, a 10% reduction in postoperative complications would reduce costs from readmissions alone by $9.3 million per year, she said.

Reducing complications after colectomy by 30% (to 19%) would lower the postcolectomy readmission rate to 11.7% and save an estimated $28 million per year in readmission costs. Halving the postcolectomy complication rate (to 13.5%) would reduce the readmission rate to 10.6% and save an estimated $46 million per year in readmission costs.

Previous data suggest that 13% of surgical patients and 16% of medical patients are readmitted after discharge from hospitalization, accounting for an estimated $17 billion in Medicare costs. Medicare plans to reduce payments for readmissions starting in 2013.

The reasons that patients are readmitted are not well understood, which was one motivation for the study, Dr. Lawson said. Unplanned readmissions that are related to the initial surgery may be due to postoperative complications or exacerbations of a preoperative comorbidity. Unplanned readmissions also may be for reasons unrelated to the initial surgery, such as for trauma or falls. In other cases, readmission may be planned for chemotherapy or elective procedures. The study excluded patients who died before discharge or who were not discharged from the primary hospitalization.

Dr. Lawson said she has no relevant conflicts of interest.

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