The goal of this study was to examine the reasons for early readmissions within 30 days of discharge to a major academic neurosurgical service.
A database of readmissions within 30 days of discharge between April 2009 and September 2010 was retrospectively reviewed. Clinical and administrative variables associated with readmission were examined, including age, sex, race, days between discharge and readmission, and insurance type. The readmissions were then assigned independently by 2 neurosurgeons into 1 of 3 categories: scheduled, adverse event, and unrelated. The adverse event readmissions were further subcategorized into patients readmitted although best practices were followed, those readmitted due to progression of their underlying disease, and those readmitted for preventable causes. These variables were compared descriptively.
A total of 348 patients with 407 readmissions were identified, comprising 11.5% of the total 3552 admissions. The median age of readmitted patients was 55 years (range 16–96 years) and patients older than 65 years totaled 31%. There were 216 readmissions (53% of 407) for management of an adverse event that was classified as either preventable (149 patients; 37%) or unpreventable (67 patients; 16%). There were 113 patients (28%) who met readmission criteria but who were having an electively scheduled neurosurgical procedure. Progression of disease (48 patients; 12%) and treatment unrelated to primary admission (30 patients; 7%) were additional causes for readmission. There was no significant difference in the proportion of early readmissions by payer status when comparing privately insured patients and those with public or no insurance (p = 0.09).
The majority of early readmissions within 30 days of discharge to the neurosurgical service were not preventable. Many of these readmissions were for adverse events that occurred even though best practices were followed, or for progression of the natural history of the neurosurgical disease requiring expected but unpredictably timed subsequent treatment. Judicious care often requires readmission to prevent further morbidity or death in neurosurgical patients, and penalties for readmission will not change these patient care obligations.
Abbreviations used in this paper:CMS = Centers for Medicare and Medicaid Services; SDH = subdural hematoma; SSI = surgical site infection; VTE = venous thromboembolism.
AsherAMcGirtMSperoffTGottesmanJCraigK: The National Neurosurgery Quality and Outcomes Database (N2QOD) Project Objectives and Data Collection Guidelines V1.0 January 5 2012(http://www.neuropoint.org/pdf/N2QOD%20data%20management%20and%20Project%20Objectives%20January%202012%20V%201.0.pdf) [Accessed April 1 2013]
Centers for Medicare and Medicaid Services: U.S. Department of Health and Human Services Medicare Hospital Value-Based Purchasing Plan Development Issues Paper 1st Public Listening Session January 17 2007BaltimoreCenter for Medicare and Medicaid Services2007. (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/downloads/hospital_VBP_plan_issues_paper.pdf) [Accessed April 1 2013]
DickinsonLDMillerLDPatelCPGuptaSK: Enoxaparin increases the incidence of postoperative intracranial hemorrhage when initiated preoperatively for deep venous thrombosis prophylaxis in patients with brain tumors. Neurosurgery43:1074–10811998
KasperEKGerstenblithGHefterGVan AndenEBrinkerJAThiemannDR: A randomized trial of the efficacy of multidisciplinary care in heart failure outpatients at high risk of hospital readmission. J Am Coll Cardiol39:471–4802002
KeenanPSNormandSLLinZDryeEEBhatKRRossJS: An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure. Circ Cardiovasc Qual Outcomes1:29–372008
KharkarSShuckJKapoorSBatraSWilliamsMARigamontiD: Radionuclide shunt patency study for evaluation of suspected ventriculoperitoneal shunt malfunction in adults with normal pressure hydrocephalus. Neurosurgery64:909–9182009
KimmelstielCLevineDPerryKPatelARSadaniantzAGorhamN: Randomized, controlled evaluation of short- and long-term benefits of heart failure disease management within a diverse provider network: the SPAN-CHF trial. Circulation110:1450–14552004
KnollBMWrightDEllingsonLKraemerLPatireRKuskowskiMA: Reduction of inappropriate urinary catheter use at a Veterans Affairs hospital through a multifaceted quality improvement project. Clin Infect Dis52:1283–12902011
OngMKMangioneCMRomanoPSZhouQAuerbachADChunA: Looking forward, looking back: assessing variations in hospital resource use and outcomes for elderly patients with heart failure. Circ Cardiovasc Qual Outcomes2:548–5572009
TabbalSDRevillaFJMinkJWSchneider-GibsonPWernleARde ErausquinGA: Safety and efficacy of subthalamic nucleus deep brain stimulation performed with limited intraoperative mapping for treatment of Parkinson's disease. Neurosurgery61:3 Suppl119–1292007