Surgical site infections (SSIs) are a costly twice-told tale, as surgeons and hospitals are penalized when they occur and again if the patient is readmitted.
“Because most readmissions were attributable to well-described postoperative complications, readmissions after surgery are mostly a proxy measure for post discharge complications and, in effect, penalizes hospitals twice for postoperative complications (i.e., other pay-for-performance programs include postoperative complications such as SSI),” researchers report in a recently published study.1
Another concern the authors have is that efforts to tackle the two largest reasons for readmission — infection and obstruction — have not been hugely successful. To penalize hospitals for conditions that have been intractable might be counterproductive “because performance targets without accepted courses of intervention might be more prone to unintended or ineffective behaviors and consequences,” the authors warn.
Karl Bilimoria, MD, MS, one of the authors of the study and a surgical oncologist at Northwestern Memorial Hospital in Chicago, wonders if readmission rates might be the wrong thing to focus on for surgical area quality indicators. The complications are not necessarily the direct result of poor care. In a sense, they are the result of the fact that any care was given, and to some degree, they will be extremely difficult to attack and perhaps impossible to completely eliminate.
“I do not think most surgeons would be surprised at this,” says Bilimoria. “But it is important for us to study the reasons why our patients come back to the hospital.”
The Centers for Medicare & Medicaid Services (CMS) requires hospitals to report information on readmissions for surgical patients who have had knee or hip replacement, but Bilimoria says other surgical procedures are going to follow. Getting a handle on the reasons behind complications for SSIs is vital given the financial penalties that likely will be involved. Still, surgeons bristle a bit at what they consider double jeopardy related to those penalties. Payers already penalize hospitals with SSIs. Now, if a patient comes back to the hospital because of one, it will be twice dinged: for the complication of the infection and the readmission. To a certain extent, the SSIs and other complications are out of surgeons’ and hospitals’ control once a patient has been discharged.
Gleaning data from the National Surgical Quality Improvement Program (NSQIP), the researchers looked at almost a half million cases from 2012 that included the following procedures:
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bariatric surgery;
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colectomy or proctectomy;
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hysterectomy;
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total hip or knee replacement;
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ventral hernia repair;
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lower extremity vascular bypass.
Of the cases, 5.7% resulted in a readmission, and just 2.3% of those patients returned to the hospital because of something that happened during their stay. The results for the various surgeries differed, with a low of 3.8% for hysterectomy and a high of almost 15% for lower extremity vascular bypass. SSI was the most common reason for return for all the surgeries except bariatric procedures, ranging from 18.8% for total hip or knee to 36.4% for lower extremity vascular bypass. For bariatric patients, ileus, or obstruction, was the most common cause of readmission, and it caused just under a quarter of the returns.
Patients with co-morbidities, those treated in academic hospitals, and those who were not discharged home were more likely to return to the hospital before 30 days were up.
Bilimoria says the last point highlights a problem and an opportunity. The problem is that care at skilled nursing facilities might not be what it needs to be to prevent complications after discharge that result in returns to the hospital, at least partly as a result of poor communication, he says. The opportunity is to improve communication with those facilities and help them improve care to benefit the patients, he adds.
Some of the other reasons for readmission can be more readily addressed. For example, bariatric patients had issues with vitamin deficiencies and colorectal surgical patients had issues with dehydration. Better patient education might address some of those issues. Another idea, says Bilimoria, is some sort of intermediate clinic for postsurgical patients after discharge that will more closely monitor them.
While praising the authors for offering such solutions, an accompanying editorial by nationally known patient safety advocate Lucian Leape, MD, said the level of harm would not be tolerated in nonmedical settings.2
“The extent of harm is sobering,” he notes. “Although many of these complications are expected by surgeons, to a nonmedical observer some of the rates seem substantial. ... These defect rates are far higher than are tolerated in any other industry.”
Translating numbers into patients, 5,565 patients acquired an SSI. “Reducing that number by half would reduce pain and suffering for more than 2,700 patients,” Leape states.
REFERENCES
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Merkow MD, Ju MH, Chung JW, et al. Underlying reasons associated with hospital readmission following surgery in the United States. JAMA 2015; 313:483-495.
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Leape L. Hospital readmissions following surgery: Turning complications into “treasures.” JAMA 2015; 313(5):467-468.
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