Unplanned hospital readmission

see Unplanned hospital readmission after cranial neurosurgery.

see Unplanned hospital readmission after cervical spine fusion surgery.

Hospital readmission is a key surgical quality metric associated with financial penalties and higher healthcare costs.

Reducing the rate of early hospital readmission, particularly those occurring within 30 days of discharge, is a priority in current US healthcare reform. Thirty-day readmission is associated with increased patient morbidity, as well as a significant economic burden ^{1) 2) 3)}.

As a result, 30-day readmission rates are increasingly being used as a surrogate metric for both the quality and value of care ⁴⁾ and hospitals with higher readmission rates are subject to reimbursement penalties from the Centers for Medicare and Medicaid Services ^{5) 6)}.

Among Medicare patients, the overall rate of readmission within 30 days of hospital discharge is nearly 20%, and there is an associated annual cost of more than $24 billion when one includes those treated in Veterans Administration hospitals as well ^{7) 8) 9) 10)}. ¹¹⁾.

Many readmissions may be preventable and occur at predictable time intervals. The causes and timing of readmission vary significantly across neurosurgical subgroups. Future studies should focus on detecting specific complications in select cohorts at predefined time points, which may allow for interventions to lower costs and reduce patient morbidity ¹²⁾.

To identify deficiencies leading to readmissions to the University of Florida Neurosurgery Service by using the Institute for Healthcare Improvement STate Action on Avoidable Rehospitalizations Readmissions diagnostic tool and to report the opinions of patients, their families, and health care providers.

A retrospective review of hospital admission and discharge data was conducted. All patients who met eligibility criteria and who were discharged from the neurosurgery service between January 1 and March 31, 2012, and readmitted within 30 days after discharge (n=74; 66 patients; 7 multiple readmissions) were included. A chart review revealed potential precipitating factors. Health care providers, patients, and family members were also interviewed. Median values and frequencies were used to summarize the data.

The 30-day readmission rate on the neurosurgery service was 14%. Problems associated with wound care accounted for 24% of readmissions, neurologic conditions accounted for 50%, and other medical conditions accounted for 26%. Patients and providers agreed on the medical diagnoses resulting in readmission, but providers also often named “patient noncompliance” as a factor leading to readmission, whereas patients often thought they either were “sent home too early” or had a “general decline with no improvement.”

Systematic patterns and common themes associated with patient readmissions were identified for a neurosurgical service. These findings are now being used to implement changes in discharge planning ¹³⁾.

LACE Index for Readmission

An analysis of the present 30-day readmission rate in the spine literature is needed to aid the development of policies to decrease the frequency of readmissions. The authors examine 2 questions: 1) What is the 30-day readmission rate as reported in the spine literature? 2) What study factors impact the rate of 30-day readmissions?

A study was registered with Prospera (CRD42014015319), and 4 electronic databases (PubMed, Cochrane Library, Web of Science, and Google Scholar) were searched for articles. A systematic review and meta-analysis was performed to assess the current 30-day readmission rate in spine surgery. Thirteen studies met inclusion criteria. The readmission rate as well as data source, time from enrollment, sample size, demographics, procedure type and spine level, risk factors for readmission, and causes of readmission were extrapolated from each study.

The pooled 30-day readmission rate was 5.5% (95% CI 4.2%-7.4%). Studies from single institutions reported the highest 30-day readmission rate at 6.6% (95% CI 3.8%-11.1%), while multicenter studies reported the lowest at 4.7% (95% CI 2.3%-9.7%). Time from enrollment had no statistically significant effect on the 30-day readmission rate. Studies including all spinal levels had a higher 30-day readmission rate (6.1%, 95% CI 4.1%-8.9%) than exclusively lumbar studies (4.6%, 95% CI 2.5%-8.2%); however, the difference between the 2 rates was not statistically significant (p = 0.43). The most frequently reported risk factors associated with an increased odds of 30-day readmission on multivariate analysis were an American Society of Anesthesiology score of 4+, operative duration, and Medicare/Medicaid insurance. The most common cause of readmission was wound complication (39.3%).

The 30-day readmission rate following spinal surgery is between 4.2% and 7.4%. The range, rather than the exact result, should be considered given the significant heterogeneity among studies, which indicates that there are factors such as demographics, procedure types, and individual institutional factors that are important and affect this outcome variable. The pooled analysis of risk factors and causes of readmission is limited by the lack of reporting in most of the spine literature ¹⁴⁾.

Most readmissions after aneurysmal subarachnoid hemorrhage (SAH) relate to late consequences of hemorrhage, such as hydrocephalus, or medical complications secondary to severe neurological injury. Although a minority of readmissions may potentially be avoided with closer medical follow-up in the transitional care environment, readmission after SAH is an insensitive and likely inappropriate hospital performance metric ¹⁵⁾.

Predictors of SSI and hospital readmission differ in the USA, Denmark and Japan, suggesting that risk stratification models may need to be population specific or adjusted. Some differences in measured parameters exist in the 3 databases analyzed, however, patient and procedure selection also appear to differ and may limit the ability to directly pool data from different regions. Therefore, risk stratification models developed in one country may not be directly applicable to other countries ¹⁶⁾.