Leicestershire surgical readmissions survey

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Abscess. Extensive ischiorectal abscess, required multiple procedures. Poss. 4. F. 84 y. 2. LRI. Constipation. Constipation, abdo pain and fractured tibia. Non. 5.
Journal of Clinical Excellence (2002) 4: 33± 41

# 2002 Radcli¡ e Medical Press

Original articles

Leicestershire surgical readmissions survey Christopher Sutton FRCS Specialist Registrar in General Surgery, Department of Surgery, University Hospitals of Leicester NHS Trust, Leicester Royal InŽrmary, Leicester, UK

Leslie Marshall MB ChB Thomas Lloyd MRCS Guiseppe Garcea MRCS Clinical Research Fellows

David Berry MD FRCS Michael Kelly MChir FRCS MRCP Consultant Surgeons Department of Surgery, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Leicester, UK

ABSTRACT Introduction The aim of this study was to determine the pattern of surgical readmissions, and stratify the episodes as ‘preventable’, ‘possibly preventable’ and ‘non-preventable’, by comparing actual diagnoses extracted from casenotes and data coded by Leicestershire Health Authority. Methods A six-month retrospective casenotes’ review of consecutive surgical readmissions to the University Hospitals of Leicester and peripheral district generals was carried out by two independent clinicians. Results 435 patient episodes involving 384 patients were analysed (representing 94% casenote retrieval). The correlation between the two observers was good (Spearman 0.994). In total, 69% of readmissions were ‘real’ (patients readmitted in an

Introduction In 1965 the concept of using readmission rates as an index of the quality of medical care received by patients in hospital was introduced.1 With the advent of medical record linkage, patients within a given district have a common medical record number, so allowing readmissions to be accurately documented. 2–4 It is widely accepted that many readmissions represent a failure of best or ideal care.4–9 However, although controversy exists about the validity of using readmission rates to compare

unplanned fashion) but, of these, only 2% were judged as ‘preventable’ and 14% ‘possibly preventable’. Thirty-one percent of readmissions were not ‘real’: one-third were elective, planned readmissions and two-thirds involved a completely new pathology. Conclusions The number of completely preventable surgical readmissions was minuscule (2%). A further 14%, possibly preventable readmissions might beneŽ t from targeted aftercare. A total of 31% of patient episodes were incorrectly assigned as surgical readmissions, re ecting errors in data coding and transfer. Keywords: coding, medical record linkage, surgical readmissions

individual consultants, specialties and even as an outcome indicator of hospital performance, they have been recommended for use as a tool for medical audit and for broad inter health district comparisons.4,10 In the United States unplanned readmissions have been identiŽ ed as a major component of healthcare expenditure. Readmissions can in some states account for half of all hospital inpatients and up to 60% of all hospital costs.11–13 Therefore, any strategy that can e¡ectively reduce readmission rates whilst improving quality of care could have major Ž nancial implications. There have been many attempts to

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C Sutton, L Marshall, T Lloyd et al.

identify those patients that are most at risk of an unplanned readmission. The aims of this study were twofold. Firstly, to attempt to stratify all the readmissions and establish (where possible) those that were preventable, nonpreventable or possibly preventable. Secondly, to attempt to identify any improvements that could be made to reduce the number of readmissions.

Methods A consecutive series of all surgical readmissions from February to August 2000 inclusive (deŽ ned as the next, unplanned emergency admission of a patient into one of the study hospitals within 28 days of discharge from the initial (index) admission) was generated using a Ko« rner case record linkage from Leicestershire Health Authority and the index admissions comprising both elective and emergency cases. This allowed identiŽ cation of all patients who are treated in one of the three teaching hospitals; GlenŽ eld General Hospital (GGH), Leicester General Hospital (LGH), Leicester Royal InŽ rmary (LRI) – currently the University Hospitals of Leicester NHS Trust – along with all the peripheral hospitals in Leicestershire and Rutland. Patients not included are those from other health authorities. The data generated by Leicestershire Health Authority included the age and sex of the patient, index hospital, index diagnoses and procedure, readmission hospital, specialty, diagnoses and procedure. A proforma was generated to compare the accuracy of the data compiled by the Leicestershire Health Authority and that contained in the patients’ clinical notes. A detailed, retrospective medical casenote review was undertaken independently by two researchers (CS and LM) for the completion of the proforma. This involved reviewing every detail of the patient’s episode as documented, including the history, examination, observations, investigations and their results, nursing documentation and subsequent management decisions. Readmissions were broadly classiŽ ed into true and potentially false readmissions, using the data compiled on the proforma. A true readmission was any patient readmitted within 28 days of discharge with a problem related to some aspect of their index admission. All true readmissions were then subdivided into relevant categories. Potentially false readmissions included arranged admissions, coding errors, new medical, surgical, gynaecological, orthopaedic and urological problems not previously diagnosed anywhere in the patients’ casenotes (for

example a patient who had undergone a hernia repair and was readmitted following an assault). Any patient with a chronic medical, surgical or urological problem that was stable and asymptomatic during their index admission but then resulted in their readmission were included in the potentially false readmission group (for example a patient with known ischaemic heart disease that was asymptomatic during his index admission subsequently readmitted with angina). All readmissions were judged to be preventable, non-preventable and possibly preventable. Any uncertainty as to the category of the readmission was presented to and adjudicated by a senior consultant surgeon (MK). Two separate databases were constructed containing the same Ž elds by each researcher. The information was then compared and correlated using a kappa score. Statistical analysis was performed using SPSS version 8. Any discrepancies were discussed with two senior consultant surgeons before allocation to a deŽ nite category.

Results There were 435 readmissions involving 384 patients aged between 10 and 93 years (mean age 57 years, median age 61 years) and of similar gender distribution (male n = 187, female n = 197); all were assessed by two independent researchers. Casenote retrieval was possible for 94%; the remaining 6% were unobtainable due to continuing clinical outpatient use during the study period and ongoing complaints procedures. Kappa scores of 0.933 for non-surgical readmissions, 0.905 for surgical readmissions, 1.0 for preventable readmissions, 0.701 for non-preventable readmissions and 0.401 for possibly preventable readmissions were obtained between the researchers.

Non-index admission-related surgical readmissions In total, 32% of patient episodes classed as surgical readmissions according to health authority data (n = 138), detailed in Table 1, were categorised by the researchers as not true readmissions. Therefore, the issue of preventability could not be applied. Planned admissions and coding errors accounted for 10% (n = 45) of cases incorrectly listed as readmissions. Patient episodes unrelated in nature to the index admission accounted for the remaining 22%. This category comprised new medical and surgical conditions, for example, trauma injury resulting in fracture in a patient originally admitted with appendicitis, and exacerbations of chronic

Table 1 Not true surgical readmissions Reason for readmission

Readmissions n

Patients n

GGH

LGH

LRI

Peripheral hospital

Male

Female

Age range

Mean age

Living alone n

Preventable

Non-preventable

Possibly preventable

33

33

5

5

22

1

19

14

24–90

61

8

n/a

n/a

n/a

2 Coding error

12

11

0

2

9

1

7

5

19–73

41

1

n/a

n/a

n/a

3 New problem: medical

39

39

12

4

22

1

18

21

22–87

64

6

0

39

0

4 New problem: surgical

9

9

1

2

6

0

1

8

27–86

55

1

0

9

0

5 New problem: orthopaedic

5

5

0

2

3

0

2

3

30–92

56

3

0

5

0

6 New problem: urological

5

5

3

0

2

0

5

0

49–86

65

1

0

5

0

7 New problem: gynaecological

1

1

1

0

0

0

0

1

32

32

0

0

1

0

8 Underlying medical problem

28

28

2

8

18

0

15

13

36–86

67

5

0

28

0

9 Underlying surgical problem

5

5

2

1

2

0

1

4

28–32

49

2

0

5

0

10 Underlying urological problem

1

1

1

0

0

0

1

0

81

81

0

0

1

0

138

137

27

24

84

3

69

69

19–92

57

27

0

93

0

Total

GGH = GlenŽ eld General Hospital, LGH = Leicester General Hospital, LRI = Leicester Royal InŽ rmary

Leicestershire surgical readmissions survey

1 Arranged

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C Sutton, L Marshall, T Lloyd et al.

underlying disease that were asymptomatic during the index admission, such as one patient with a chronic urological complaint that was readmitted as his long-term catheter became blocked.

Multiple readmissions Thirty-one patients had true multiple readmissions (n = 72), accounting for 17% of attendance. Eightynine percent (n = 64) were categorised as nonpreventable readmissions. Preventable and possibly preventable readmissions (n = 2 and n = 6 respectively), all detailed in Table 2, accounted for 11% of multiple readmissions.

True readmissions Of all the readmission episodes, 52% (n = 227) were categorised as true readmissions by the researchers. These are detailed in Table 3, but can be broadly summarised as cases of reoccurring surgical pathology, for example, recurrent abscesses (n = 10), gallstone disease (n = 10), in ammatory bowel disease (n = 2), peptic ulcer disease (n = 10); surgical complications (n = 103) such as post-operative bleeding (n = 26), minor wound infections (n = 29), intestinal obstruction secondary to adhesions (n = 11), post-operative pain (n = 22), urological complications (n = 8), thrombo-embolic complications and trauma (n = 7); malignancy (n = 20); underlying ‘medical’ pathology symptomatic on index admission but appropriately managed (n = 13) and unplanned social problems having had adequate support on discharge (n = 3).

Preventable surgical readmissions All surgical readmissions considered to be preventable are listed in Table 4. As summarised in the table, six out of seven readmissions involved females aged 70 and above. The recurring theme throughout this group appears to be lack of communication amongst individual teams.

Discussion In view of ever-increasing expectations to deliver cost-e¡ ective, high-quality patient care over the shortest possible duration of inpatient stay, hospital readmission rates have been used with increasing frequency over the past two decades as indicators of outcome of inpatient care, to identify areas of practice which may be improved and patient factors which may predispose to early hospital readmis-

sion.4,12 Readmission rates are a useful means of auditing local, speciŽ c practices; however, as already suggested by some authors, readmission rates must be interpreted with much caution if they are to be used to compare interspecialty and district-wide quality performance, due to questionable reliability resulting from di¡ erences in data collection and di¡erences in case-mix.4,8 Most studies have analysed readmission patterns within medical specialties, most notably, within care of the elderly. Various factors, broadly categorised into patient particulars (demographics and nature of illness: patient age, chronic disability and unavoidable relapse, compliance, social support) and medical practice (discharge planning, continuity of care in the community/outpatient departments) have been identiŽ ed as potential causes of early readmission. 4,9 Although little documentation can be found in the literature which speciŽ cally addresses surgical readmission rates, patterns in comparison to medical readmission have been noted: early peaks, namely within a few days of discharge, are noted in surgery, whereas medical readmissions gradually increase reaching a peak late in the readmission period (28 days). 4 In our study, which speciŽ cally addresses readmission patterns in general surgery, 5% of all readmissions were due to post-procedural pain, 4% post-operative and 1% post-angioplasty. Two percent of readmissions were patients receiving medication for peptic ulcer disease. These groups of patients appear to need additional education and support. Therefore, an increasing role for clinical nurse specialists within the district could be proposed, to provide patients with additional information regarding the procedures undertaken and actively following up their progress in the community, with telephone calls and or home visits. This strategy has been successfully employed for patients with congestive cardiac failure, resulting in a signiŽ cant decrease in hospital readmissions. 14 Ten patients were readmitted with minor wound infections following hernia repair. Only two had received antibiotic prophylaxis and the remaining eight accounted for 3% of readmissions. Unfortunately, there is unlikely to be a clear scientiŽ c answer to this question, as two large studies have produced contradictory results.15,16 Adhesions accounted for 3% of all readmissions (n = 11) and 91% of people with intestinal obstruction due to adhesions had undergone abdominal or pelvic surgery. This Ž gure is in close agreement with the Ž ndings of Ellis et al., who concluded that adhesions are responsible for 5.7% of all readmissions over a ten-year period, the majority of which occur within the Ž rst postoperative year.17

Table 2 Reasons for multiple readmissions Patient number

Sex

Age

Living alone

Readmissions Index Surgical diagnosis n hospital (on index admission)

Reason for readmissions

Category

1

F

82

y

2

LRI

Diverticulitis

Longstanding COAD

Non

2

F

75

n

3

LGH

Rectal prolapse

Longstanding renal failure and diabetes

Non

3

M

37

n

2

GGH

Abscess

Extensive ischiorectal abscess, required multiple procedures

Poss

4

F

84

y

2

LRI

Constipation

Constipation, abdo pain and fractured tibia

Non

5

F

74

y

2

LGH

Incisional hernia

Small bowel obstruction, unstable angina

Non

6

F

45

n

2

LRI

Renal abscess

Drain to abscess site fell out twice

Non

7

F

86

n

3

LRI

Rectal cancer

Non-curative TART, bleed, AP resection, wound infection

Non

8

M

23

n

2

LRI

Ulcerative colitis

Anastomotic stricture, resection of pouch stricture, bleed

Non

9

M

80

y

2

LRI

Inguinal hernia

Retention and mesh infection following hernia repair

Poss

10

F

36

y

4

LRI

Crohns’ disease

Crohn’s disease, heart block, pacemaker

Non

11

M

70

y

2

LRI

Ulcerative colitis

Subphrenic abscess and COAD

Non

12

M

39

n

2

GGH

Circumcision

UTI, retention

Non

13

M

77

y

3

LGH

Ischaemic leg

Diabetes, wound infection, not coping at home

Non

14

F

80

y

3

LRI

Small bowel obstruction

Small bowel Ž stula: treatment with external drainage, collection

Non/y

15

M

63

y

2

LRI

Hydrocoele

Scrotal haematoma, retention, UTI

Non

16

F

21

n

2

GGH

NS Abdo pain

Injury to iliac artery, ischaemic leg

Non

17

F

33

n

2

LRI

Small bowel obstruction

Disseminated carcinoma of ovary

Non

18

M

76

n

2

GGH

Colonic polyp

Bleed post-polypectomy, retention

Non

19

M

53

n

2

LGH

Small bowel obstruction

Cerebral TB, thalassaemia, schistosomiasis, liver failure

Non

20

M

78

n

2

GGH

Gastrooesophageal re ux disease

Bronchopneumonia, not coping at home

Non

21

M

61

n

3

GGH

Cholecystitis

Cholecystitis

Poss

22

F

71

y

2

LRI

Closure ileostomy

Adhesion obstruction following procedure/phlebitis

Non/y

23

M

61

n

5

LRI

Hernia repair

Mesh infection, MRSA, removal of mesh

Poss

24

F

40

n

2

LRI

Laparoscopic cholecystectomy

Bile leak following procedure

Non

25

M

18

n

2

LRI

Crohn’s disease

Pelvic abscess following right hemicolectomy

Non

26

M

74

n

2

LRI

Gastric cancer

Small bowel obstruction following total gastrectomy

Non

27

M

47

n

2

LRI

Stabbing

Haemothorax following chest drain insertion

Poss

28

M

50

n

2

GGH

Ischaemic leg

Fem pop bypass, MRSA infection, wound breakdown

Poss

29

F

49

n

2

LRI

NS Abdo pain

NS abdo pain

Non

30

M

43

n

2

LRI

Oesophageal varices

Alcoholic liver disease, continuing alcoholic

Non

31

F

73

n

2

LGH

Gastrooesophageal re ux disease

Chronic schizophrenic, UTI

Non

Non = Non-preventable, Poss = Possibly preventable, y = Preventable GGH = GlenŽ eld General Hospital, LGH = Leicester General Hospital, LRI = Leicester Royal InŽ rmary

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Table 3 True readmissions Incidence of GGH LGH LRI readmission

Peripheral Male Female hospitals

Age range

Mean age

Living alone

Preventable NonPossibly preventable preventable

1 Abscess

10

3

0

7

0

4

6

22–71

43

0

1

8

1

2 Cholecystitis

10

2

0

7

1

2

8

22–67

55

0

0

8

2

3 Complications

10

2

0

8

0

5

5

30–81

57

0

0

8

2

4 Crohn’s disease

2

2

0

0

0

2

0

17–38

28

0

0

2

0

5 Diverticular disease

7

5

0

2

0

4

3

63–92

77

4

0

6

1

6 Post-op bleeding

26

5

3

14

4

12

14

18–86

53

2

0

24

2

7 Infection

29

6

1

20

2

11

18

18–93

57

4

0

21

8

8 Malignancy

20

5

3

10

2

9

11

43–83

68

4

0

20

0

9 Underlying medical problem

13

2

3

8

0

7

6

44–82

67

5

0

12

1

10 NS abdo pain

13

7

2

4

0

0

13

17–82

38

1

0

13

0

11 Intestinal obstruction

11

1

2

9

0

8

3

36–87

62

1

0

10

1

12 Pain post-angioplasty

6

0

0

6

0

4

2

65–92

74

1

0

0

6

13 Phlebitis

2

0

0

2

0

2

0

64–75

73

0

0

0

2

14 Post-op pain

16

4

2

10

0

7

9

11–78

50

3

0

0

16

15 Peptic ulcer disease

10

2

2

4

2

6

5

20–85

51

2

0

10

0

16 Same problem

22

5

4

13

0

9

13

10–84

45

5

0

21

1

17 Social problems

3

3

0

0

0

0

3

67–92

81

2

0

3

0

18 Thromboembolic

2

0

0

1

1

1

1

54–88

71

1

0

2

0

19 Trauma

5

0

0

5

0

4

1

25–90

58

2

0

5

0

20 Urological

8

0

0

8

0

5

3

20–86

61

3

0

6

2

225

54

22

137

12

102

123

10–93

61

40

1

179

45

Totals

C Sutton, L Marshall, T Lloyd et al.

Reason for readmission

Leicestershire surgical readmissions survey

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Table 4 Preventable readmissions Case Age number

Sex

Diagnosis: Ž rst admission

Diagnosis: second admission

Comments

1

90

F

Head injury, loss of consciousness

Subdural haematoma

No CT scan of head on index admission

2

78

F

Subphrenic abscess secondary to diverticular disease

Subphrenic abscess and pleural e¡usion

USS demonstrated persisting collection at discharge

3

80

F

Small bowel obstruction, small bowel Ž stula

Small bowel Ž stula, intra-abdominal collection

Discharged despite swinging pyrexia (no further abdo imaging performed)

4

79

F

Forearm abscess

Abdominal adenocarcinoma, groin lymphadenopathy

Communication breakdown; lymphadenopathy diagnosed at index admission but not investigated

5

71

F

Reversal of ileostomy

Forearm phlebitis

Noted to have infection secondary to cannula, not discharged on antibiotics

6

70

F

Cholecystitis

Cholangiocarcinoma

Communication breakdown; worsening LFTs not noticed prior to discharge

7

32

F

Anal skin tags

Perianal abscess

Communication breakdown; perianal abscess diagnosed at index admission but not treated

Further to the above ‘true surgical readmissions’, another category of patients was identiŽ ed in the study and classiŽ ed as ‘potentially not true surgical readmissions’, accounting for 31% (n = 136) of the quoted readmission rate. Planned admissions and coding errors comprised 33% of this group; the remainder were presentations classed as readmissions on the database but in fact represented new problems that bore no relation to the original surgical complaint. For example, one patient underwent a haemorrhoidectomy and was readmitted three weeks later with a lacerated index Ž nger, events that are clearly unrelated. This group of patients may represent the previously documented low background level of readmissions that are associated with general surgical specialties.4 If it is accepted that this group of readmissions are new events and therefore new admissions, there are two options: to accept the

current situation, knowing that approximately 20% of surgical readmissions will be unrelated and nonpreventable, or to recategorise the episodes into new admissions. To reduce the above detailed number of readmissions, strategies (many already in place in emergency departments) must be devised in order to identify patients at high risk of readmission, to provide further education counselling and enable support by sta¡ such as clinical nurse practitioners.14,18,19 In order to introduce such schemes for surgical patients, those most at risk need to be identiŽ ed. Unfortunately, reasons for readmission are not consistent across all studies possibly due to variable case-mix and severity.5,9,13,18 In addition, there have not been any previous studies speciŽ cally related to general surgical readmissions, therefore risk factors have not been accurately assessed.

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C Sutton, L Marshall, T Lloyd et al.

Our study speciŽ cally examined the accuracy of health authority coding within the framework of surgical readmissions and has shown that miscoding had a relatively small but signiŽ cant impact on the data generated. On initial inspection, it would appear that a signiŽ cant number of major coding errors were committed. However, on further investigation, it became apparent that the source of error was the data transfer process from the hospitals to the health authority rather than Ž rstline miscoding: allimportant coding preŽ xes were not downloaded and so information retrieval from the central database was inaccurate. For example, the patient with ‘carcinoma of the colon’ simply coded as ‘colon’ was due to failure to transfer the preŽ x. In this study, 31% of the readmissions were not ‘real’ surgical readmissions. One-third were elective admissions for further treatment and two-thirds were due to completely new pathology that bore no relation to the original diagnosis. Therefore, coding errors and planned admissions accounted for an overreporting of surgical readmissions of 10%. The Department of Health recently published statistics in their NHS Performance Indicators report.20 This generated headlines in the national press such as ‘Waiting list demands mean more readmissions’.21 They analysed each healthcare trust and compared a number of performance indicators, including the readmission rates, not speciŽ cally taking into account the specialty. We have demonstrated that 32% of readmissions from the health authority data were not related to the original admission, therefore the accuracy of the data generated from such government reports must be questioned.

Conclusion This study, to our knowledge, is the Ž rst to speciŽ cally address patterns of general surgical readmissions. Real surgical readmissions constituted 69% of the total Ž gure cited by the local health authority, 2% of which were thought to be potentially avoidable. In total, 32% of readmissions were not genuine readmissions, one-third of cases having been arranged prior to discharge and two-thirds being attributable to completely new pathologies that bore no relation to the original diagnosis. Therefore, coding errors and planned admissions accounted for an overreporting of surgical readmissions of 10%.

Our Ž ndings would advocate greater communication between teams involved in patient care, an increased role for clinical nurse specialists to educate and support patients, and more intense primary care involvement in patient follow-up, to reduce the burden of readmission on both hospitals and patients. It also illustrates errors in collection and recording, which must question the accuracy of readmissions as a performance indicator.

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mean more readmissions. The Independent 20 February 2002.

ADDRESS FOR CORRESPONDENCE

Mr C Sutton, Department of Surgery, University Hospitals of Leicester NHS Trust, Leicester Royal InŽ rmary, InŽ rmary Square, Leicester LE1 5WW, UK. Tel: +44 (0)116 254 1414; fax: +44 (0)116 258 6083; email: [email protected]. Accepted August 2002