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 Inrmary, 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 bene 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 identi 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 nancial implications. There have been many attempts to
34
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 (de 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 identi cation of all patients who are treated in one of the three teaching hospitals; Glen eld General Hospital (GGH), Leicester General Hospital (LGH), Leicester Royal In 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 classi 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 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 de 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 = Glen eld General Hospital, LGH = Leicester General Hospital, LRI = Leicester Royal In rmary
Leicestershire surgical readmissions survey
1 Arranged
35
36
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, speci 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 identi ed as potential causes of early readmission. 4,9 Although little documentation can be found in the literature which speci 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 speci 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 signi 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 scienti 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 gure is in close agreement with the 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 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 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 = Glen eld General Hospital, LGH = Leicester General Hospital, LRI = Leicester Royal In rmary
38
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
39
Table 4 Preventable readmissions Case Age number
Sex
Diagnosis: 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 stula
Small bowel 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 identi ed in the study and classi 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 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 identi 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 speci cally related to general surgical readmissions, therefore risk factors have not been accurately assessed.
40
C Sutton, L Marshall, T Lloyd et al.
Our study speci cally examined the accuracy of health authority coding within the framework of surgical readmissions and has shown that miscoding had a relatively small but signi cant impact on the data generated. On initial inspection, it would appear that a signi 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 rstline miscoding: allimportant coding pre 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 pre 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 speci 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 rst to speci cally address patterns of general surgical readmissions. Real surgical readmissions constituted 69% of the total 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 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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inal and pelvic surgery: a retrospective cohort study. Lancet 353: 1476–80. Stewart S, Pearson S, Luke CG and Horowitz JD (1998) E¡ects of home-based intervention on unplanned readmissions and out of hospital deaths. Journal of the American Geriatric Society 46: 174–80. Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M and Pauly M (1994) Comprehensive discharge planning for the hospitalised elderly. Annals of Internal Medicine 120: 999–1006. Department of Health (2002) NHS Performance Indicators. Department of Health: London. Laurance J and Arthur C (2002) Waiting list demands
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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 In rmary, In rmary Square, Leicester LE1 5WW, UK. Tel: +44 (0)116 254 1414; fax: +44 (0)116 258 6083; email:
[email protected]. Accepted August 2002
