By Christina Frangou

image Chicago—A new study found that one in three complications arising from major operations is diagnosed after the patient leaves the hospital, a finding that adds a new dimension to the health policy debate surrounding public reporting of complications and readmissions.

The study showed that significant numbers of postoperative complications occur after the patient is discharged and may account for longer, more difficult and more expensive recoveries, often requiring readmission to the hospital. As a result, hospitals and surgeons need to track and monitor postoperative complications closely, even when they occur after a patient is discharged from the hospital, said investigators.

“If hospitals only look at what happens during the index hospital stay, they’re missing a big part of the picture,” said study co-author Mary T. Hawn, MD, MPH, professor and chief of gastrointestinal (GI) surgery, University of Alabama at Birmingham, and a staff surgeon at Birmingham VA Medical Center.

Senior author Melanie S. Morris, MD, assistant professor of surgery at the University of Alabama at Birmingham and also a staff surgeon at the Birmingham VA, presented the findings at the 2012 Clinical Congress of the American College of Surgeons.

The investigators analyzed 59,464 surgical procedures performed at 112 VA hospitals in four surgical specialties—orthopedics, GI, vascular and gynecology—from 2005 to 2009.

Overall, one in seven cases (14.7%) resulted in a complication within 30 days of surgery. Of these, 32.15% were diagnosed after the patient was discharged from the hospital.

Surgical site infections (SSIs) accounted for 56% of the complications identified after patients were discharged. In turn, SSIs significantly increased the likelihood that a patient would require readmission to the hospital. Of the 1,775 patients who had a post-discharge SSI, 57.3% were readmitted. Only 19.4% of patients with an SSI diagnosed in the hospital later required readmission.

Readmissions add up to billions of health care dollars per year. A 2009 study in The New England Journal of Medicine found that nearly 20% of Medicare beneficiaries who had been discharged from the hospital were rehospitalized within 30 days, costing Medicare $17.4 billion annually in additional hospital bills (360:1418-1428).

To make a dent in SSI-related readmission rates, post-discharge SSIs need to be tracked and monitored, a move that should result in cost savings while improving the quality of care delivered to surgical patients, said investigators.

At the same time, hospitals and ambulatory surgical centers need to adhere to a standard for tracking and reporting post-discharge SSIs, said the authors. Otherwise, the hospitals that do a more thorough job of tracking and reporting these infections will appear to have higher infection rates.

“Public reporting of SSI rates is here but we need to ensure a level playing field so patients and payers have accurate data,” said Dr. Morris.

Factors associated with post-discharge SSI were shorter hospital length of stay (LOS; odds ratio [OR], 0.79; 95% confidence interval [CI], 0.77-0.81), non-GI procedures (OR, 5.18; 95% CI, 4.18-6.43), dependent functional status (OR, 1.62; 95% CI, 1.12-2.35) and American Society of Anesthesiologists physical status class (OR, 1.90; 95% CI, 1.46-2.49).

The study showed each type of surgery is associated with a distinct pattern of complications. Nearly one in five patients who underwent vascular procedures developed a complication and of these, 40% were diagnosed after discharge. Nearly half of the complications reported in vascular patients were SSIs (8.4%), followed by respiratory complications at 6.7%. Among patients who had GI procedures, 27% developed complications and 23% of these were diagnosed after patients were released from the hospital. Approximately 11% of these patients developed an SSI, making it the highest rate of SSIs among surgical specialties. However, GI surgery also had the lowest rate of complications that arose or were diagnosed after patients were released from the hospital.

image Orthopedic and gynecologic surgeries had overall complication rates of 7% and SSI rates hovering around 2%, but gynecology had a much higher rate of post-discharge complications at 81% versus 39.4% for orthopedic surgery. Dr. Morris attributed this variation to the typically shorter hospital LOS for gynecologic procedures, many of which have same-day discharge.

Investigators also studied whether pre- or post-discharge complications influenced readmission rates. Their work showed that postoperative complications were the most significant driver of readmissions, associated with a nearly fivefold increase (hazard ratio [HR], 4.81; 95% CI, 4.56-5.07). No other variable was nearly as predictive. A preoperative history of congestive heart failure, the second most potent factor influencing readmission, was associated with an approximately 40% increase (HR, 1.41; 95% CI, 1.18-1.69).

“We should be able to keep more of these patients from being readmitted now that we have begun to realize patients who have complications diagnosed during their index stay are very much at higher risk,” said Elizabeth C. Wick, MD, assistant professor of surgery, Johns Hopkins University, Baltimore.

The study comes at a time of increased public scrutiny of hospital readmission and complication rates. Mandatory reporting of complications by hospitals is now required and the Affordable Care Act requires hospitals to report readmission rates as a quality indicator. As of late this year, payments are linked to readmission rates as part of a broad strategic plan for quality care improvement.

With increasing pressure to track and report complications, it’s important that policymakers, physicians and researchers are capturing all the important data points, said investigators.

“In health care, we’re all focused on quality care,” said Dr. Morris. “It’s important to know we are actually capturing the data points that we are going to be held accountable for.”

John F. Sweeney, MD, chief of general and GI surgery at Emory University School of Medicine, Atlanta, said postoperative surgical complications and the resultant readmissions can and must be decreased. The nature of surgery itself lets surgeons and hospital staff prepare for complications, he pointed out.

Surgical patients differ from medical patients because the surgical procedure, in and of itself, places them at risk for readmission.

“That’s a planned event. And if we know what those high-risk operations are, what the high-risk complications are, we can begin to intervene preoperatively to minimize risks as much as possible. We can plan for the events that can happen after surgery and be ready if it does happen.”

Dr. Sweeney led a large study, published in the Journal of the American College of Surgeons in September (215:322-330), which came to similar conclusions as the VA study. In a retrospective review of 1,442 general surgery patients treated at hospitals enrolled in the American College of Surgeons National Surgical Quality Improvement Program, postoperative complications were the most significant independent risk factor leading to 30-day hospital readmissions. The more postoperative complications a patient experienced, the more likely the risk for readmission. And when a complication developed after the patient left the hospital, the risk for readmission was higher than among patients who experienced complications in the hospital.

“We need to do our best to minimize this as much as possible,” said Dr. Sweeney.

He said a “high sense of urgency” now surrounds the issue of readmissions. “It’s coming from two places: one, American health care costs are unsustainable and readmissions are a small part of that puzzle, and two, because of the enormous upset to patients who go through a big operation and only to end up back in the hospital.”

Experts say more research is needed to investigate the links among patient risk, complications and readmissions. For now, they recommend surgeons educate their patients about the risk for post-discharge complications, especially SSIs, and explain to patients how they should seek care early in the course of a complication.

“This education starts at the preoperative visit, continues during hospitalization, involves clear discharge instructions and ends with follow-up visits. This will enable patients to be active participants in their care,” said Dr. Morris.