INDIAN WELLS, CALIF. – Unplanned, 30-day readmissions after hysterectomy for benign indications mainly occur because of surgical complications, regardless of approach, with the most common issue being surgical site infections.
Additionally, there is an increased vulnerability to readmission shortly after discharge, especially within the first 15 days.
Those are the key findings from an analysis of the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database participant user file for 2012 and 2013, presented by Dr. Courtney Penn at the annual scientific meeting of the Society of Gynecologic Surgeons.
Dr. Courtney Penn
“A seminal article in 2009 found that one in five Medicare patients are readmitted within 30 days, and unplanned readmissions account for 17% of total hospital payments from Medicare, or $17.4 billion annually,” said Dr. Penn, the lead study author and a resident in the department of obstetrics and gynecology at the University of Michigan, Ann Arbor. “Thus, addressing the problem of hospital readmissions is viewed as a golden opportunity to reduce healthcare costs and improve patient care quality. Despite this national focus on hospital readmissions, little is known about readmissions after hysterectomy.”
In an effort to characterize the most common reasons for unplanned 30-day readmissions following hysterectomy, and to characterize the timing of readmissions, the researchers retrospectively evaluated data from the ACS NSQIP database participant user file for 2012 and 2013. After using the International Classification of Diseases, Ninth Revision, Clinical Modification to identify common readmission diagnoses, they divided reasons for readmission into several categories: surgical site infection, surgical injury, non-infectious wound complications, gastrointestinal, genitourinary, venous thromboembolic, pain, medical, and “other” reasons. Results were stratified based on surgical approach.
Dr. Penn reported results from 40,580 patients who underwent hysterectomies at hospitals that participated in the ACS NSQIP. The overall, unadjusted readmission rate following hysterectomy was 2.8%, and was highest among those who underwent the procedure by abdominal approach (3.7%), followed by those who underwent the procedure by laparoscopic and vaginal approaches (2.6% vs. 2.1%, respectively).
After adjusting for potential confounding factors such as age, race, BMI, and operative time, readmissions were not significantly more likely when performed laparoscopically than with the vaginal approach. However, readmissions were significantly more likely when hysterectomy was performed via the open abdominal route, compared with the vaginal approach.
When categorizing reasons for reasons for readmission, traditional surgical complications, including surgical site infection, visceral entities, and non-infectious wound complications, were more common reasons for readmission than traditional medical complications, such as venous thromboembolism, myocardial infarction, and pulmonary edema. Slightly more than half of all readmissions (52%) were surgical in nature, compared with 9% that were attributable to traditional medical complications.
“This trend held true regardless of surgical approach, whether vaginal, laparoscopic, or abdominal,” Dr. Penn said.
Surgical site infections were the most common primary readmission diagnosis overall. “It was the underlying reason for readmission in approximately one-third of total readmissions,” she said. It was also the most common reason for readmission diagnosis for each surgical approach: 37% of abdominal, 28% of laparoscopic, and 33% of vaginal hysterectomy readmissions had a surgical site infection as the primary readmission diagnosis.
The researchers observed a few differences on reasons for readmission based on surgical approach. For example, surgical injury – such as hematoma and visceral injury – was higher after laparoscopic and vaginal hysterectomy, compared with that observed for abdominal cases (odds ratio, 2.4 and 2.8, respectively). Additionally, the proportion of readmissions related to gastrointestinal complications was higher after abdominal hysterectomies, compared with that observed among laparoscopic and vaginal cases (OR, 2.4 and 2.8, respectively).
For all surgical approaches, there was an increased likelihood of unplanned readmission within the first 15 days of discharge. In fact, 82% of all readmissions occurred within the first 15 days after discharge.
“We found that all major readmissions categories had a median time to readmission within the first 10 days after discharge, and the median time to readmission varied based on readmission diagnosis,” Dr. Penn said at the meeting, which was jointly sponsored by the American College of Surgeons. “Pain-related reasons for readmission had the shortest time to readmission, with a median of 3 days, and non-infectious wound complications had the longest time to readmission, with a median of 10 days.”
She acknowledged certain limitations of the study including the retrospective design, the database’s over-representation of urban and academic medical centers, as well the study’s reliance on one readmission diagnosis to capture the principal cause of readmission, “when the true reason for readmission may be multifactorial.”