Objective: To find out the 30-day readmission rate for different surgical procedures and determine the causes for readmissions. Study Design: An audit report. Place and duration of study: Department of Surgery, The Aga Khan University Hospital, Karachi, in the calendar year 2014. Methodology: Records were retrospectively reviewed for 30-day readmission rate and their cause in general surgical patients who underwent a general surgical procedure at The Aga Khan University Hospital, Karachi, in the year 2014. Results: Out of 217 (6.4%) readmissions in 3,387 patients, more than 50% unplanned readmissions were avoidable. The highest readmission rate was after placement of feeding tubes (28.5%). Conclusion: More than half of the readmissions could have been prevented by proper patient/attendant education, good communication and provision of nursing services to these patients beyond the hospital

Abdullah, Umme Hani

Chawla, Tabish

Sultan, Rizwan

English

eCommons@AKU

eCommons@AKUSection of General Surgery Department of SurgeryApril 201830-day readmission rate and its causes in generalsurgical patientsRizwan SultanAga Khan University, Rizwan.sultan@aku.eduUmme Hani AbdullahAga Khan UniversityTabish ChawlaAga Khan University, tabish.chawla@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_genRecommended CitationSultan, R., Abdullah, U., Chawla, T. (2018). 30-day readmission rate and its causes in general surgical patients. Journal of the College ofPhysicians and Surgeons--Pakistan, 28(4), 314-316.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_gen/60314 Journal of the College of Physicians and Surgeons Pakistan 2018, Vol. 28 (4): 314-316INTRODUCTIONWhether planned or unplanned, readmission in ahospital is an additional financial, social and psychologicalburden to both patient as well as family. It is also aquality indicator for hospital in NHS, and contributes to"star" status for a hospital. From 2003 to 2004, 19.5% ofall medicare beneficiaries, who were discharged from ahospital, were readmitted within 30 days, leading to acost of $17.4 billion.1 It was estimated that a singlereadmission after pancreatic resection costs an averageof $16,000 or more.1 Readmission problem is different insurgical patients compared with medical patients.2,3 Aftera surgical procedure, majority (70.5%) of readmissionsare due to medical conditions and are unavoidable.Among the medicare beneficiaries undergoing majorbowel surgery, 16.6% were readmitted for gastro-intestinal problems, and 6.4% were readmitted with apostoperative infection.4In developing countries like Pakistan, where there is amarked shortage of nursing care outside hospitals,5 riskof readmission with minor ailments increasessignificantly.6 Similarly, readmission rate seems alsorelated to the education of the caretakers about thedisease.7,8 Besides cost of treatment, avoidablereadmissions also burdens emergency departments ofhospitals with preventable admissions.9 Data regardingcost of readmissions after a surgical procedure is notavailable from Pakistan or South Asia.Knowledge of causes of readmissions is important to beable to avoid the avoidable causes; and rate ofreadmission is important for preoperative counselling ofpatients and their families to decrease the anxiety andfrustration associated with readmissions.The objective of this study was to review all generalsurgical procedures performed in the year 2014 to findout procedure specific 30-day readmission rate andcauses of these readmissions.METHODOLOGYExemption from Ethical Review Committee of The AgaKhan University was taken prior to the start of study(3973-sur-ERC-15). The audit included all patientsundergoing general surgical procedures in the year 2014at Aga Khan Hospital, Karachi. The patients who leftagainst medical advice or died during the index hospitaladmission were excluded from the study.The investigators reviewed computer records of allpatients for 30-day readmissions. Medical records of thepatients with readmissions within 30 days of theirdischarge were then reviewed for cause of readmission;and details of the readmission were recorded on a pre-designed proforma. The variables recorded were thecause of readmission, median days between dischargeand readmission, whether readmission was planned orunplanned/avoidable or unavoidable, requirement ofintervention in readmission, and eventual outcome.Data was entered in SPSS 19. Continuous variables likeage, length of stay, and time between primary dischargeto readmission were measured by using mean +/- SD orAUDIT30-Day Readmission Rate and its Causesin General Surgical PatientsRizwan Sultan1, Umme Hani Abdullah2 and Tabish Chawla1ABSTRACTObjective: To find out the 30-day readmission rate for different surgical procedures and determine the causes forreadmissions.Study Design: An audit report.Place and Duration of Study: Department of Surgery, The Aga Khan University Hospital, Karachi, in the calendar year 2014.Methodology: Records were retrospectively reviewed for 30-day readmission rate and their cause in general surgicalpatients who underwent a general surgical procedure at The Aga Khan University Hospital, Karachi, in the year 2014.Results: Out of 217 (6.4%) readmissions in 3,387 patients, more than 50% unplanned readmissions were avoidable.The highest readmission rate was after placement of feeding tubes (28.5%).Conclusion: More than half of the readmissions could have been prevented by proper patient/attendant education, goodcommunication and provision of nursing services to these patients beyond the hospital.Key Words: Surgery patients.   Readmission rate.   Causes of readmission.   Tertiary care centre.1 Department of Surgery, The Aga Khan University Hospital,Karachi.2 Medical Student, The Aga Khan University Hospital, Karachi.Correspondence: Dr. Rizwan Sultan, Fellow Trauma andSurgery, Department of Surgery, The Aga Khan UniversityHospital, Stadium Road, Karachi.E-mail: imrizwan12@yahoo.comReceived: November 29, 2016;   Accepted: January 10, 2018.medians with IQR. The categorical variables weredescribed in frequency with percentages. Comparisonbetween the two groups was done using Chi-squaretest. P-value of <0.05 was considered significant.RESULTSThe total number of procedures performed in the year2014 in the Department of General Surgery at Aga KhanUniversity Hospital, Karachi, was 3,428 (Table I). Meanage was 46.94 +15.9 years. Nineteen hundred and fifty-four (57%) patients were male. Median LOS (length ofstay) was 2 days (IQR 1-4). Three thousand (87.5%)procedures were performed under general anesthesia.Two thousand, seven hundred and fifty-one (80%)procedures were done after admitting patient in thehospital; 2,451 (71.5%) cases were electively plannedbefore the day of surgery. There were 41 deaths amongthese patients (mortality rate 1.1%), rest of 3,387 patientswere discharged from hospital. Out of these, 209(6.17%) patients were readmitted within 30 days of theirdischarge. Eight patients required more than onereadmission within 30 days making, a total of 217readmissions (6.4%).Out of 217 admissions, 32 admissions were planned atthe time of discharge and were not avoidable (Table II).Rest of 185 readmissions were unplanned. Ninety-fourunplanned admissions were due to minor issues likeincreased ileostomy output, postoperative pain, nausea,vomiting, urinary retention or surgical wound relatedissues. These were managed in emergency room anddid not require any further interventions; while 91patients were admitted in the hospital and 15 requiredanother intervention for a postoperative complication.Seventy-six patients had a medical issue like electrolyteimbalance, kidney injury or pneumonia, which did notrequire any intervention. Out of 15 patients requiringsurgical intervention in the readmission, there was nomortality; but out of 76 who were conservatively treated,there were four mortalities.Procedure-wise readmission rate (Table II) showed thatthe patients operated for placement of feeding tubes hadhighest 30-day readmission rate of 28.57%. After majorabdominal surgeries like Whipples procedure and IvorLewis Esophagectomy, the 30-day readmission rate was21.74% and 14.28%, respectively. Stoma formation inlower GI surgery was associated with readmission rateof 15.7% at the time of primary procedure and anadditional 10.5% readmission rate after stoma closure;while lower GI surgery without stoma was associatedReadmission rate and its causes in general surgical patientsTable I: Details of patients (n=3,428) who underwent general surgicalprocedures at AKUH in the year 2014.Variables FrequencyMean age 46.94 +15.9 yearsGenderMales 1954 (57%)Females 1474 (43%)Median LOS 2 days (IQR 1-4)Median length of surgery 60 minutes (IQR 35-92)Type of anesthesiaGA 3000 (87.5%)LA 299 (8.8%)Regional (spinal, caudal, epidural) 113 (3.3%)MAC (monitored anesthesia care) 16 (0.5%)Nature of admissionInpatient 2718 (79.3%)Day care 710 (20.7%)Nature of procedureElective 2451 (71.5%)Emergency 759 (22.1%)Add on 218 (6.4%)OutcomeMortality 41 (1.2%)Alive 3387 (98.8%)Table II: Details of 30-day readmissions.Variables FrequencyNumber of patients followed for 30-day re-admissions 3387Total re-admissions 217 (6.4%)Planned re-admissions 32 (14.9%)Duration between primary discharge and re-admission (median) 15 days(IQR 3-23)Unplanned re-admissions 185 (85.1%)Unplanned unavoidable re-admissions 91 (49%)Duration between primary discharge and re-admission (median) 8 days(IQR 3-17)Unplanned avoidable re-admissions 94 (51%)Duration between primary discharge and re-admission (median) 3 days(IQR 1-7)Second intervention required 15 (0.44%)Mortality 4 (0.12%)Table III: Procedure-wise readmission rate.Procedure Total Readmission No Procedure patients readmission specific readmissionrateHernia 326 25 301 7.67%Wound debridement andamputations 173 14 159 8.1%Skin and subcutaneous tissues 490 20 470 4.08%Anal and perianal procedures 374 17 357 4.54%Diagnostic lap 47 6 41 12.76%Endoscopic procedures 40 2 38 5%Appendectomy 167 10 157 5.99%Cholecystectomy 1033 37 996 3.58%Splenectomy 14 1 13 7.14%Feeding tubes 63 18 45 28.57%Bile duct and liver 32 1 31 3.125%Gastric procedures 60 3 57 5%Whipple 23 5 18 21.74%Two-stage esophagectomy 21 3 18 14.28%Abdominal mass 19 3 16 15.79%Pancreatic procedures 6 0 6 0%Lower GI surgery with stoma 140 22 118 15.71%Lower GI surgery without stoma 95 6 89 6.32%Stoma closure 86 9 77 10.5%Other Laparotomy 178 15 163 8.43%Total 3387 217 3170 6.40%Journal of the College of Physicians and Surgeons Pakistan 2018, Vol. 28 (4): 314-316 315Rizwan Sultan, Umme Hani Abdullah and Tabish Chawla316 Journal of the College of Physicians and Surgeons Pakistan 2018, Vol. 28 (4): 314-316with readmission rate of 6.32%. This difference betweenthe two groups was statistically significant (p=0.029).DISCUSSIONThis study showed that 30-day readmission rate afterdischarge was 6.4% in general surgery department ofthe Aga Khan University Hospital, Karachi. More than50% of unplanned admissions were for minor issues andwere avoidable with good communication and educationat discharge and better involvement of nursing staffoutside the hospital (home healthcare). It would havehelped in reduction of overall cost of the treatment aswell as burden on the Emergency Department of thehospital.The highest readmission rate was associated withplacement of feeding tubes. There are two reasons forthese readmissions. Most of these patients withmalignancy were planned for chemotherapy and someare elderly people with multiple comorbids requiringreadmission due to medical issues. Every 5th and7th patient gets readmitted after major abdominalprocedures like Whipples procedure and Ivor LewisEsophagectomy. Another interesting finding was,readmission rate in lower GI surgery patient with stoma,which was 2.5 times the readmission rate in patientswithout stoma. The patients with stoma had to bearanother 10.5% readmission rate at the time of stomareversal surgery.There is very little data on readmission rate and itscauses after discharge from surgery department. In2007, Dayo et al. suggested that the readmissionscannot be predicted on the basis of age, comorbidities,psychiatric illness and number of drugs on discharge.10In 2011, Atul Gawande suggested that if we target thepatients who are at high risk for readmissions, we cancertainly decrease number of readmissions and savecost.11 These patients were labelled as "hot spots". In2012, Kassin et al. concluded that multiple comorbids,inpatient surgical procedures and need of admissionbefore surgery were risk factors for readmission.12Intraabdominal procedures were prone with morereadmission rate requiring more vigilance and attention.13Less educated family and poor socioeconomic back-ground are also found to be significantly associated withthe readmission rate.14 Similarly, stoma formation is alsoassociated with higher postoperative readmission rate.15To the best of authors' knowledge, this is a first studylooking at readmission rate and causes of readmissionsin Pakistan. Large number of patients, variety of surgicalprocedures, and utilization of computerized data forretrieval of readmissions were our advantages; while wecould have missed the patients not readmitted in thehospital. The authors have introduced concept ofhotline, in which a cellular phone carried by a registerednurse is given to the patient at discharge so that he/shecan contact her regarding any complaint at home todecrease the unplanned avoidable readmission rate.CONCLUSIONEffective communication using hotline, patient educationand use of home healthcare services can decreaseunplanned avoidable admission rate. In some high riskprocedures, the risk of readmission should be explainedto the patients preoperatively.REFERENCES1. Kent TS, Sachs TE, Callery MP, Vollmer CM. Readmissionafter major pancreatic resection: a necessary evil? J Am CollSurg 213:515-23.2. Khuri SF, Henderson WG, De Palma RG, Mosca C, Healey NA,Kumbhani DJ. Determinants of long-term survival after majorsurgery and the adverse effect of postoperative complications.Ann Surg. 2005; 242:326-43.3. Anderson GF, Steinberg EP. Hospital readmissions in themedicare population. N Engl J Med 1984; 311:1349-53.4. Jencks SF, Williams MV, Coleman EA. Rehospitalizationsamong patients in the medicare fee-for-service program.N Engl J Med 2009; 360:1418-28.5. Khowaja K. Healthcare systems and care delivery in Pakistan.J Nurs Adm 2009; 39:263-5.6. Hayden DM, Pinzon MCM, Francescatti AB, Edquist SC,Malczewski MR, Jolley JM, et al. Hospital readmission for fluidand electrolyte abnormalities following ileostomy construction:preventable or unpredictable? J Gastrointest Surg 2013; 17:298-303.7. Healy SJ, Black D, Harris C, Lorenz A, Dungan KM. Inpatientdiabetes education is associated with less frequent hospitalreadmission among patients with poor glycemic control.Diabetes Care 36:2960-7.8. Marcantonio ER, McKean S, Goldfinger M, Kleefield S,Yurkofsky M, Brennan TA. Factors associated with unplannedhospital readmission among patients 65 years of age and olderin a medicare managed care plan. Am J Med 1999; 107:13-7.9. Mahmoudi S, Taghipour HR, Javadzadeh HR, Ghane MR,Goodarzi H, Motamedi MHK. Hospital readmission through theemergency department. Trauma Mon 2016; 21:e35139.10. Adeyemo D, Radley S. Unplanned general surgical re-admissions - how many, which patients and why? Ann R CollSurg Engl 2007; 89:363-7.11. Gawande A. The hot spotters: can we lower medical costs bygiving the neediest patients better care? New Yorker 2011:40-51.12. Kassin MT, Owen RM, Perez SD, Leeds I, Cox JC, Schnier K,et al. Risk factors for 30-day hospital readmission amonggeneral surgery patients. J Am Coll Surg Sep; 215:322-30.13. Aust JB, Henderson W, Khuri S, Page CP. The impact ofoperative complexity on patient risk factors. Ann Surg 2005;241:1024-7.14. Hendren S, Morris AM, Zhang W, Dimick J. Early dischargeand hospital readmission after colectomy for cancer. Dis ColonRectum 2011; 54:1362-7.15. Guinier D, Mantion GA, Alves A. Risk factors of unplannedreadmission after colorectal surgery: a prospective, multicenterstudy. Dis Colon Rectum 2007; 50:1316-23.

30-day readmission rate and its causes in general surgical patients

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30-day readmission rate and its causes in general surgical patients

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