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Early Primary Care Provider Follow-up and Readmission After High-Risk Surgery

Benjamin S. Brooke, MD, PhD1; David H. Stone, MD2; Jack L. Cronenwett, MD2; Brian Nolan, MD, MS2,3; Randall R. DeMartino, MD, MS2; Todd A. MacKenzie, PhD3; David C. Goodman, MD, MS3; Philip P. Goodney, MD, MS2,3
[+] Author Affiliations
1Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City
2Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
3The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
JAMA Surg. 2014;149(8):821-828. doi:10.1001/jamasurg.2014.157.
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Importance  Follow-up with a primary care provider (PCP) in addition to the surgical team is routinely recommended to patients discharged after major surgery despite no clear evidence that it improves outcomes.

Objective  To test whether PCP follow-up is associated with lower 30-day readmission rates after open thoracic aortic aneurysm (TAA) repair and ventral hernia repair (VHR), surgical procedures known to have a high and low risk of readmission, respectively.

Design, Setting, and Participants  In a cohort of Medicare beneficiaries discharged to home after open TAA repair (n = 12 679) and VHR (n = 52 807) between 2003 to 2010, we compared 30-day readmission rates between patients seen and not seen by a PCP within 30 days of discharge and across tertiles of regional primary care use. We stratified our analysis by the presence of complications during the surgical (index) admission.

Main Outcomes and Measures  Thirty-day readmission rate.

Results  Overall, 2619 patients (20.6%) undergoing open TAA repair and 4927 patients (9.3%) undergoing VHR were readmitted within 30 days after surgery. Complications occurred in 4649 patients (36.6%) undergoing open TAA repair and 4528 patients (8.6%) undergoing VHR during their surgical admission. Early follow-up with a PCP significantly reduced the risk of readmission among open TAA patients who experienced perioperative complications, from 35.0% (without follow-up) to 20.4% (with follow-up) (P < .001). However, PCP follow-up made no significant difference in patients whose hospital course was uncomplicated (19.4% with follow-up vs 21.9% without follow-up; P = .31). In comparison, early follow-up with a PCP after VHR did not reduce the risk of readmission, regardless of complications. In adjusted regional analyses, undergoing open TAA repair in regions with high compared with low primary care use was associated with an 18% lower likelihood of 30-day readmission (odds ratio, 0.82; 95% CI, 0.71-0.96; P = .02), whereas no significant difference was found among patients after VHR.

Conclusions and Relevance  Follow-up with a PCP after high-risk surgery (eg, open TAA repair), especially among patients with complications, is associated with a lower risk of hospital readmission. Patients undergoing lower-risk surgery (eg, VHR) do not receive the same benefit from early PCP follow-up. Identifying high-risk surgical patients who will benefit from PCP integration during care transitions may offer a low-cost solution toward limiting readmissions.

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Figure 1.
Selection of Patient Cohort Undergoing Open Thoracic Aortic Aneurysm (TAA) Repair and Ventral Hernia Repair (VHR)

Data set linkage to determine primary care provider (PCP) utilization shown. HRR indicates hospital referral region; PC, primary care.

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Figure 2.
Thirty-Day Readmission Rates Following Open Thoracic Aortic Aneurysm (TAA) Repair and Ventral Hernia Repair

Early primary care provider (PCP) follow-up significantly reduced 30-day readmission following open TAA repair if a postoperative complication occurred. In comparison, early PCP follow-up was not associated with a significant difference in readmission rates among patients undergoing ventral hernia repair, whether or not a complication occurred.

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Figure 3.
Thirty-Day Readmission Rates Among Patients at Low, Moderate, and High Risk for Readmission Following Open Thoracic Aortic Aneurysm Repair

Patients determined to be at the highest risk for readmission following open thoracic aortic aneurysm repair achieved the greatest benefit from having their procedure performed in a region with high primary care use.

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