Rehospitalization to primary versus different facilities following abdominal aortic aneurysm repair

Abstract

Objective Reducing readmissions represents a unique opportunity to improve care and reduce health care costs and is the focus of major payers. A large number of surgical patients are readmitted to hospitals other than where the primary surgery was performed, resulting in clinical decisions that do not incorporate the primary surgeon and potentially alter outcomes. This study characterizes readmission to primary versus different hospitals after abdominal aortic aneurysm (AAA) repair and examines the implications with regard to mortality and cost. Methods Patients who underwent open or endovascular aneurysm repair (EVAR) for AAA were identified from the CMS Chronic Conditions Warehouse (CCW), a random 5% national sample of Medicare beneficiaries from 2005-2009. Outcomes for patients who underwent AAA repair and were readmitted within 30 days of initial discharge were compared based on readmission location (primary vs. different hospital). Results 885 patients underwent AAA repair and were readmitted within 30 days. 626 (70.7%) returned to the primary facility, and 259 (29.3%) returned to a different facility. Greater distance from patient residence to the primary hospital was the strongest predictor of readmission to a different facility. Patients living 50-100 miles from the primary hospital were more likely to be readmitted to a different hospital compared to patients living <10 miles away (OR = 8.50, P <.001). Patients with diagnoses directly related to the surgery (e.g. wound infection) were more likely to be readmitted to the primary hospital whereas medical diagnoses (e.g. pneumonia and congestive heart failure) were more likely to be treated at a different hospital. There was no statistically significant difference in mortality between patients readmitted to a different or the primary hospital. Median total 30-day payments were significantly lower at different versus primary hospitals ($11,978, primary vs. $11,168, different, P = .04). Conclusion Readmission to a different facility after AAA repair is common and occurs more frequently than for the overall Medicare population. Patients travelling a greater distance for AAA repair are more likely to return to different versus the primary hospital when further care is required. For AAA repair, quality healthcare may be achieved at marginally lower cost and with greater patient convenience for selected readmissions at hospitals other than where the initial procedure was performed.

Fragmentation of Care after Surgical Discharge: Non-Index Readmission after Major Cancer Surgery

“…Our finding that rural residence of patients predicted non-index readmissions is in line with previous reports that rural patients bear greater burden to travel to the index hospital, 26 which in turn leads to higher non-index readmissions. 16,18 Our data also showed that hospitals in Los Angeles or the Bay Area saw more index admission than readmission, indicating that some patients of non-index readmissions likely traveled to Los Angeles or the Bay Area from other parts of California for the index surgery. On the other hand, in contrast to a previous report that concluded Medicare surgical patients were diverted to non-index hospitals for readmissions for primarily nonmedical reasons, 36 our findings that emergency readmission, extensive procedures, and comorbidity were all associated with non-index readmissions suggest non-index readmissions might be caused, at least in part, by severe and urgent complications.…”

“…14–16,18,25,37 Our study suggests that although non-index readmission is associated with higher in-hospital mortality, this increase might be attributable to varying clinical conditions leading to readmissions at different locations. Similarly, a hospital-level analysis from New York state also found that although the aggregate 30-day mortality rate was higher at non-index hospitals than index hospitals after radical cystectomy, this elevation was mitigated by adjustment of covariates, including severity of illness and risk of mortality, which both captured all patient refined diagnosis-related group and diagnoses at readmission.…”

Association of Patient-Reported Readiness for Discharge and Hospital Consumer Assessment of Health Care Providers and Systems Patient Satisfaction Scores: A Retrospective Analysis

“…Depending on the patient population examined, readmission to nonindex hospitals ranges from 22% to 47% of total readmissions. 21-23 Our readmission rate in both groups is therefore likely to be underestimated. In a large surgical patient population at our facility where all readmissions were captured by primary patient contact, the total readmission rate was 10.2% 24 compared to 14.5% seen in this study.…”

Thirty-day readmission and mortality among Medicare beneficiaries discharged to skilled nursing facilities after vascular surgery

“…In-hospital, postoperative complications defined in Greenblatt et al (2012) include cardiac complications, device failure, hemorrhage, neurological complication, respiratory complication, renal complication, venous thromboembolism, reoperation, and wound complication or surgical site infection; this definition avoids the accidental inclusion of comorbid/chronic conditions by using only those ICD-9 codes with the 99× prefix and/or an “acute” descriptor (as opposed to “chronic”). 19, 20 …”