Faculty Bibliography

BACKGROUND:Hospital readmissions are under intense scrutiny as a measure of health care quality. The Center for Medicare and Medicaid Services (CMS) has proposed using readmission rates as a benchmark for improving care, including targeting them as nonreimbursable events. Our study aim was to describe potentially preventable readmissions after surgery and to identify targets for improvement. STUDY DESIGN/METHODS:Patients discharged from a general surgery service over 8 consecutive quarters (Q4 2009 to Q3 2011) were selected. A working group of attending surgeons defined terms and created classification schemes. Thirty-day readmissions were identified and reviewed by a 2-physician team. Readmissions were categorized as preventable or unpreventable, and by target for future quality improvement intervention. RESULTS:Overall readmission rate was 8.3% (315 of 3,789). The most common indication for initial admission was elective general surgery. Among readmitted patients in our sample, 28% did not undergo an operation during their index admission. Only 21% (55 of 258) of readmissions were likely preventable based on medical record review. Of the preventable readmissions, 38% of patients were discharged within 24 hours and 60% within 48 hours. Dehydration occurred more frequently among preventable readmissions (p < 0.001). Infection accounted for more than one-third of all readmissions. Among preventable readmissions, targets for improvement included closer follow-up after discharge (49%), management in the outpatient setting (42%), and avoidance of premature discharge (9%). CONCLUSIONS:A minority of readmissions may potentially be preventable. Targets for reducing readmissions include addressing the clinical issues of infection and dehydration as well as improving discharge planning to limit both early and short readmissions. Policies aimed at penalizing reimbursements based on readmission rates should use clinical data to focus on inappropriate hospitalization in order to promote high quality patient care.

IMPORTANCE/OBJECTIVE:The Centers for Medicare & Medicaid Services has developed an all-cause readmission measure that uses administrative data to measure readmission rates and financially penalize hospitals with higher-than-expected readmission rates. OBJECTIVES/OBJECTIVE:To examine the accuracy of administrative codes in determining the cause of readmission as determined by medical record review, to evaluate the readmission measure's ability to accurately identify a readmission as planned, and to document the frequency of readmissions for reasons clinically unrelated to the original hospital stay. DESIGN, SETTING, AND PARTICIPANTS/METHODS:Retrospective review of all consecutive patients discharged from general surgery services at a tertiary care, university-affiliated teaching hospital during 8 consecutive quarters (quarter 4 [October through December] of 2009 through quarter 3 [July through September] of 2011). Clinical readmission diagnosis determined from direct medical record review was compared with the administrative diagnosis recorded in a claims database. The number of planned hospital readmissions defined by the readmission measure was compared with the number identified using clinical data. Readmissions unrelated to the original hospital stay were identified using clinical data. MAIN OUTCOMES AND MEASURES/METHODS:Discordance rate between administrative and clinical diagnoses for all hospital readmissions, discrepancy between planned readmissions defined by the readmission measure and identified by clinical medical record review, and fraction of hospital readmissions unrelated to the original hospital stay. RESULTS:Of the 315 hospital readmissions, the readmission diagnosis listed in the administrative claims data differed from the clinical diagnosis in 97 readmissions (30.8%). The readmission measure identified 15 readmissions (4.8%) as planned, whereas clinical data identified 43 readmissions (13.7%) as planned. Unrelated readmissions comprised 70 of the 258 unplanned readmissions (27.1%). CONCLUSIONS AND RELEVANCE/CONCLUSIONS:Administrative billing data, as used by the readmission measure, do not reliably describe the reason for readmission. The readmission measure accounts for less than half of the planned readmissions and does not account for the nearly one-third of readmissions unrelated to the original hospital stay. Implementation of this readmission measure may result in unwarranted financial penalties for hospitals.

BACKGROUND:Central line-associated bloodstream infections (CLABSIs) are a significant source of morbidity and mortality. This study sought to determine whether implementation of the Institute for Healthcare Improvement (IHI) Central Line Bundle would reduce the incidence of CLABSIs. METHODS:The IHI Central Line Bundle was implemented in a surgical intensive care unit. Patient demographics and the rate of CLABSIs per 1,000 catheter days were compared between the pre- and postintervention groups. Contemporaneous infection rates in an adjacent ICU were measured. RESULTS:Baseline demographics were similar between the pre- and postintervention groups. The rate of CLABSIs per catheter days decreased from 19/3,784 to 3/1,870 after implementation of the IHI Bundle (1.60 vs 5.02 CLABSIs per 1,000 catheter days; rate ratio .32 [.08 to .99, P < .05]). There was no significant change in CLABSIs in the control ICU. CONCLUSIONS:Implementation of the IHI Central Line Bundle reduced the incidence of CLABSIs in our SICU by 68%, preventing 12 CLABSIs, 2.5 deaths, and saving $198,600 annually.

Acquired neonatal lung lesions including pneumatoceles, cystic bronchopulmonary dysplasia, and pulmonary interstitial emphysema can cause extrinsic mediastinal compression, which may impair pulmonary and cardiac function. Acquired lung lesions are typically managed medically. Here we report a case series of three extremely premature infants with acquired lung lesions. All three patients underwent aggressive medical management and ultimately required tube thoracostomies. These interventions were unsuccessful and emergency thoracotomies were performed in each case. Two infants with acquired pneumatoceles underwent unroofing of the cystic structure and primary repair of a bronchial defect. The third infant with pulmonary interstitial emphysema, arising from cystic bronchopulmonary dysplasia, required a middle lobectomy for severe and diffuse cystic disease. When medical management fails, tube thoracostomy can be attempted, leaving surgical intervention for refractory cases. Surgical options include oversewing a bronchial defect in the setting of a bronchopleural fistula or lung resection in cases of an isolated expanding lobe.

BACKGROUND:To evaluate the effect of operative timing on functional outcome in patients suffering spinal trauma, we conducted a retrospective analysis of the National Trauma Data Bank. By treating time to operation as a categorical variable and limiting our analysis to isolated spinal trauma, we hypothesized that time to operation would not be a predictor of functional outcome. METHODS:The National Trauma Data Bank was queried for all patients with isolated spinal trauma who underwent spinal fixation or decompression. Functional outcomes at the time of hospital discharge were measured using Functional Independent Motor Locomotion Score. Generalized ordered logistic model was used to determine the effect of time until operation on functional outcomes. Gender, age, injury severity, the level of trauma center, and the presence of spinal cord injury were included as covariates. RESULTS:Of the final sample of 1,848 patients (mean age 44.3 years), 78% were White and 71% male. Fifty-seven percent of patients had Injury Severity Score between 8 and 15, with the remainder having Injury Severity Score ≤8. Forty-five percent were treated at a Level I trauma center. Using generalized ordered logistic regression, time to operation was not a significant predictor of functional outcomes, whereas treatment at Level I trauma centers seemed to confer marginally better outcomes. CONCLUSIONS:In patients with isolated spinal trauma, time until spinal operation does not seem to be an important predictor of functional outcome at the time of hospital discharge. Operative timing, at the discretion of the surgeon, needs to consider the risks and benefits associated with delayed versus emergent operation.

BACKGROUND:Postacute care is an essential component of medical care aimed at returning trauma patients to their preinjury functional status. Rehabilitation services, skilled nursing facilities, and home care all play a role in facilitating the healing process. Access to such care may be limited based on insurance status, leaving the uninsured with limited resources to reach full recovery. We hypothesized that access to specialized postacute care is less available to patients who lack health insurance. METHODS:A retrospective cohort of trauma patients in the National Trauma Databank from 2002 to 2006 was assessed to determine whether insurance status was a predictor of discharge to a specialized postacute care facility (rehabilitation, skilled nursing facilities, and home health). Using multivariate logistic regression, we assessed the likelihood of discharge to such facilities on the basis of insurance status, controlling for patient demographics and injury severity. RESULTS:Adjusting for variation in age, race/ethicity, gender, and injury type and severity, uninsured patients had the lowest odds of being discharged to a skilled nursing facility (odds ratio [OR], 0.76; 95% confidence interval [CI] 0.73-0.80; p<0.001), home health (OR, 0.51; 95% CI 0.49-0.53; p<0.001), and rehabilitation (OR, 0.45; 95% CI 0.44-0.46; p<0.001). Uninsured patients had the highest odds, however, of being discharged directly home (OR, 1.32; 95% CI 1.30-1.34; p<0.001). CONCLUSION/CONCLUSIONS:Insurance status is an important predictor of hospital disposition and access to specialized posthospital care. Uninsured patients are less likely to have access to the full range of medical care available to ensure complete recovery from traumatic injuries.