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Original Investigation |

Hospital Readmission After Noncardiac Surgery:  The Role of Major Complications

Laurent G. Glance, MD1; Arthur L. Kellermann, MD, MPH2; Turner M. Osler, MD, MS3; Yue Li, PhD4; Dana B. Mukamel, PhD5; Stewart J. Lustik, MD1; Michael P. Eaton, MD1; Andrew W. Dick, PhD6
[+] Author Affiliations
1Department of Anesthesiology, University of Rochester School of Medicine, Rochester, New York
2F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
3Department of Surgery, University of Vermont College of Medicine, Burlington
4Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
5Center for Health Policy Research, Department of Medicine, University of California, Irvine
6RAND Health, RAND Corp, Boston, Massachusetts
JAMA Surg. 2014;149(5):439-445. doi:10.1001/jamasurg.2014.4.
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Importance  Hospital readmissions are believed to be an indicator of suboptimal care and are the focus of efforts by the Centers for Medicare and Medicaid Services to reduce health care cost and improve quality. Strategies to reduce surgical readmissions may be most effective if applied prospectively to patients who are at increased risk for readmission. Hospitals do not currently have the means to identify surgical patients who are at high risk for unplanned rehospitalizations.

Objective  To examine whether the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) predicted risk of major complications can be used to identify surgical patients at risk for rehospitalization.

Design, Setting, and Participants  Retrospective cohort study of 142 232 admissions in the ACS NSQIP registry for major noncardiac surgery.

Main Outcomes and Measures  The association between unplanned 30-day readmission and the ACS NSQIP predicted risk of major complications, controlling for severity of disease and surgical complexity.

Results  Of the 143 232 patients undergoing noncardiac surgery, 6.8% had unplanned 30-day readmissions. The rate of unplanned 30-day readmissions was 78.3% for patients with any postdischarge complication, compared with 12.3% for patients with only in-hospital complications and 4.8% for patients without any complications. Patients at very high risk for major complications (predicted risk of ACS NSQIP complication >10%) had 10-fold higher odds of readmission compared with patients at very low risk for complications (adjusted odds ratio = 10.35; 95% CI, 9.16-11.70), whereas patients at high (adjusted odds ratio = 6.57; 95% CI, 5.89-7.34) and moderate (adjusted odds ratio = 3.96; 95% CI, 3.57-4.39) risk of complications had 7- and 4-fold higher odds of readmission, respectively.

Conclusions and Relevance  Unplanned readmissions in surgical patients are common in patients experiencing postoperative complications and can be predicted using the ACS NSQIP risk of major complications. Prospective identification of high-risk patients, using the NSQIP complication risk index, may allow hospitals to reduce unplanned rehospitalizations.

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Figure 1.
Thirty-Day Unplanned Readmission Rates for Noncardiac Surgery by Inpatient and Outpatient Complications

Unadjusted 30-day unplanned readmission rates for patients, stratified by baseline severity of disease (American Society of Anesthesiologists [ASA] physical status) and occurrence of either in-hospital complication or postdischarge complication. A 30-day unplanned readmission is defined as any unplanned readmission occurring within 30 days of the surgical procedure. Patients who had both in-hospital and postdischarge complications were categorized as having postdischarge complications.

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Figure 2.
Thirty-Day Unplanned Readmission Rates for Noncardiac Surgery by American Society of Anesthesiologists (ASA) Physical Status and American College of Surgeons National Surgical Quality Improvement Program Risk of Complications

A, Unadjusted 30-day unplanned readmission rates for patients, stratified by baseline severity of disease (ASA physical status) and calculated risk of any major complication (provided by American College of Surgeons National Surgical Quality Improvement Program). B, Number of patients in each stratum.

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