Causes of hospital readmissions within 7 days from the neurosurgical service of a quaternary referral hospital

INTRODUCTION

Several recent studies suggest that the average cost of general medical readmission was $2200,[10] which is dwarfed by published costs of neurosurgical readmissions, which can range between $30,000 and $90,000.[1,4,5,10] Overall, expenditures associated with 30-day readmissions totaled to $41 billion in 2011,[1] which grew to $50.7 billion in 2013.[3,9] Following the passage of the Affordable Care Act and the establishment of the Hospital Readmissions Reduction Program (HRRP), financial penalties aimed at reducing costs associated with unplanned readmissions were developed and took effect in 2015. Capable of withholding as much as 3% of Medicare reimbursements, the HRRP withheld, on average, 0.71% of Medicare reimbursements, affecting 83% of hospitals evaluated [Figure 1].[3,6]

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Figure 1:: Outlines trend in neurosurgical publications on readmission as it correlates with the creation of the Hospital Readmissions Reduction Program through the Affordable Healthcare Act.

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In addition, concerning is the fact that other surgical specialties have witnessed a decline in readmission rates over time, whereas reductions in readmissions for neurological surgery have plateaued and, in some cases, even increased.[10] Recent systematic reviews suggest that 30-day readmission rates for spinal pathologies vary between 4.2% and 7.4%[2] and are generally lower than rates for cranial pathologies, which vary between 14% and 24%.[5] These rates are lower than the rate of readmission for Medicare patients across the board (17.8%); however, the costs associated with neurosurgical readmissions are proportionally greater in comparison to all Medicare patients.

Beyond just their financial burden, evidence suggests that neurosurgical readmissions are associated with significant morbidities, reductions in quality of life, and increased mortality¹⁰. Understanding financial and labor costs associated with 30-day readmissions in neurological surgery have resulted in a significant increase in the surveillance of such readmissions. However, the controversy surrounding the use of these rates by HPPR to penalize hospitals has also invited scrutiny of 30-day readmission rates in neurological surgery as a health-care quality metric.[7,8,11]

To the best of our knowledge, the present observational study of 7-day readmissions in neurological surgery is the first of its kind. Three goals were identified at its outset: (1) to identify and better characterize a poorly understood population of patients being readmitted from a neurological surgery service, (2) to decrease the overall readmission rate of all discharged patients from our neurological service, and (3) to guide future efforts to identify the causal mechanisms underlying 7-day readmissions in neurological surgery.

MATERIALS AND METHODS

RESULTS

Between July 2017 and June 2019, 5274 patient discharges were performed. During this time, 258 patients (4.9%) were readmitted within 7 days (55.0% men; mean age 60 years) [Table 1]. General postoperative complications and direct surgical complications accounted for a little over a third of readmissions (15.1 and 18.9%, respectively), altered mental status/seizure resulted in 17.0% of readmissions, unrelated readmissions (18.0%), and scheduled surgeries (13%). Surgical site infections and postoperative pain-related readmissions accounted for nearly a fifth of readmissions (9.7% and 9.3%, respectively, Table 2).

Table 1:: Demographic characteristics of readmitted patients (n=258).

Table 2:: Reason for readmission (n=258).

Two-hundred thirty patients out of 258 who were readmitted either underwent cranial (57%) or spinal (32.5%) surgery with miscellaneous procedures accounting for the remaining 11% [Table 1]. Patients readmitted for general postoperative complications were largely represented by individuals who underwent a cranial operation [23/39 patients, Table 3]. In addition, patients readmitted within 7 days for complications that directly arose from the neurosurgical intervention were from the cranial operation cohort in a significant amount of the cases [33/47, Table 3]. A large portion of readmissions due to seizure or altered mental status (34/43, 79% cranial) occurred in patients with cranial pathologies; similarly, more than half of miscellaneous readmissions (27/47, 57% cranial) occurred in patients who exhibited cranial pathologies. Conversely, patients who underwent spinal surgical intervention were readmitted more often for postoperative pain (17/24, 71% spinal) and surgical site infections (14/25, 56 % spinal). Finally, patients readmitted for elective or scheduled surgical procedures were cranial patients (14/33, 42% spinal).

Table 3:: Readmission reason by index procedure type (n=258).

Approximately 66% of patients discharged following inpatient hospitalizations on the neurological surgery service were discharged to home [Figure 2]. All patients ultimately readmitted for postoperative pain or scheduled surgeries had been initially discharged home. However, <½ of patients readmitted for treatment of infections had been initially discharged home. This cohort was more likely to have been discharged to an inpatient rehabilitation facility or a skilled nursing facility. Nearly a third of patients readmitted for complications from the direct neurosurgical intervention were originally discharged to an inpatient rehabilitation facility; the remaining were discharged home.

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Figure 2:: Original disposition of patients after their index procedure. Outlined is the total number of patients sent to the respective destinations and percentages out of the total readmission population of 258.

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DISCUSSION

The aim of this retrospective study was to better understand the reasons that patients were readmitted to the neurological surgery service of a large quaternary referral hospital within 7 days of readmission. The 7-day all-cause readmission rate was nearly 5%. Many interesting points of discussion were revealed from this investigation. It was noted that 57% of readmissions within 7-days resulted from patients who underwent a cranial procedure; the remaining cohorts represented spinal (32%) and miscellaneous interventions (11%). Classically, a significant amount of outpatient resources, both from orthopedic and neurosurgical spine services, have been made possible for outpatient postoperative spine care, that is, home care, wound care nurses, and same-day mid-level providers’ clinics. These types of initiatives have helped to lower spine surgery-related readmissions. However, there are relatively fewer resources available to cranial patients. Furthermore, not many rehabilitation facilities skilled nursing homes or outpatient nurses feel equipped to temporize even the smallest of cranial complications; therefore, these patients are readmitted more often for a higher level of support provided in the inpatient setting.

General postoperative complications and direct surgical complications accounted for a little over a third of readmissions (15.1 and 18.9%, respectively). General postoperative complications included readmission for diagnoses such as but not limited to urinary tract infections, pneumonia, pulmonary embolism, and/or deep venous thromboses. Diagnosis of CSF leaks, hardware misplacement, or shunt failures was considered to direct results of neurosurgical care. Unlike other studies of readmissions in neurological surgery,[7,8,11] it was not within the bounds of the present study to characterize these diagnoses as “avoidable” or “unavoidable.” The authors found that the establishment of this sort of dichotomy introduced unnecessary subjectivity into a retrospective analysis chiefly designed to better understand an acutely vulnerable patient population. It stands to reason that a neurological surgery service has the greatest capacity to reduce the rates of readmissions from care modalities that they directly control. Therefore, these results may initiate initiatives which develop better- standardized discharge protocols in order to recognize and ultimately rectify perioperative errors before discharge so that neurosurgical patients, specifically those with cranial pathologies, can be spared readmissions.

Somewhat surprising, 7-day readmissions related to postoperative pain (9.3%) and infection (9.7%) proved to have the lowest incidence among readmitted patients. However, subgroup analyses showed that a patient who underwent spine surgery was a significant proportion in each of the categories. As previous data in the literature have soon, this result is likely from a subset of patients who are narcotic dependent and have significant comorbid conditions which predispose them to surgical site infection, that is, obesity and diabetes mellitus. Furthermore, readmissions for planned elective surgeries and those which are unrelated to neurosurgical care (e.g., patient displeased with rehabilitation or skilled nursing facility) accounted for 13% and 18%, respectively. This information provides an opportunity for more insightful means for institutions to scrutinize such readmission into a separate category that does not get lumped into the cohort, for which hospitals may be penalized.

There are several limitations to this study. These results are a reflection of our hospital’s unique neurosurgical service line that may not compare directly to other hospitals, patient populations, and geographic locations. Our future goals are to increase the sample size and generalizability by collaborating with other large neurosurgical institutions for a multi-center database to increase the investigational rigor of the study.

CONCLUSION

The 7-day readmission rate for the UPMC-PUH neurosurgery service was 5%. Fifty-seven percent of all readmitted patients underwent a cranial intervention in comparison to 32% who had spine procedures. The majority of readmissions were related to direct perioperative complications. Therefore, focal efforts to decrease specific postoperative complications should translate into a reduction in 7- and subsequently 30- day unplanned readmissions.