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Steiner CA, Maggard-Gibbons M, Raetzman SO, Barrett ML, Sacks GD, Owens PL. Return to Acute Care Following Ambulatory Surgery. JAMA. 2015;314(13):1397–1399. doi:10.1001/jama.2015.12210
Two-thirds of operations are performed on an outpatient basis, yet little research has assessed their quality.1-4 Our population-based study found that 30-day revisits for clinically significant surgical site infections following ambulatory operations accounted for less than 15% of all-cause revisits to inpatient or ambulatory surgery settings.5
The reasons for other revisits and their relationship to the index operation are unknown. This study determined the rates of all-cause, unplanned revisits (ie, not for routine medical care) within 30 days of ambulatory surgery and whether revisits were related to the operation.
We performed a retrospective analysis of 6 low- to moderate-risk ambulatory operations spanning a range of specialties and complexity. We used the 2010-2011 Healthcare Cost and Utilization Project (HCUP) State Ambulatory Surgery and Services Databases, State Inpatient Databases, and State Emergency Department Databases for 7 states with unique, encrypted patient numbers (representing approximately one-third of the US population), allowing linkage of the ambulatory operations with 30-day postoperative, unplanned acute care revisits.6
We identified index ambulatory operations performed in hospital-owned settings for adults with low surgical risk (single operation; no infection, cancer, or acute care in prior 30 days). We determined 30-day revisit rates per 1000 operations by setting (inpatient, ambulatory surgery, or emergency department [ED]). A patient with a revisit was counted once; priority was hierarchically assigned as inpatient, then ambulatory surgery, and then ED.
The reason for the revisit (based on first-listed diagnosis code) was categorized as a complication related to the operation or an unrelated condition. The categories were developed iteratively using a combination of prospective and empirical methods.
First, 2 of the authors (M.M-G. and G.D.S; who are surgeons) created categories a priori of known complications for each operation; revisit diagnosis codes were identified and assigned to these categories. Second, the 2 surgeons along with a third physician (C.A.S., who is an internist) reviewed the remaining revisits and empirically developed additional categories. To ensure face validity, the related complication categories were analyzed for consistency with procedures, and the unrelated conditions were reviewed to ensure that conditions were not miscategorized.
We further characterized related complications by reason for revisit and present the 2 most frequent types: operation specific and pain (abdominal and other). The Agency for Healthcare Research and Quality institutional review board waived the need for informed consent because data were deidentified.
There were 482 034 ambulatory operations and 45 760 all-cause 30-day revisits (94.9 per 1000 operations; Table 1). Most revisits were to the ED (58.7 per 1000), followed by inpatient and ambulatory surgery settings (27.0 and 9.2 per 1000, respectively). Revisit rates to the inpatient and ED settings were highest for transurethral prostatectomies (43.8 and 87.3 per 1000, respectively) and incisional/abdominal hernia repair (33.9 and 62.9 per 1000, respectively). Across all operations and settings, up to one-third of all revisits were for unrelated conditions (29.7 per 1000) and two-thirds were for complications related to the index operation (65.2 per 1000; Table 2).
Most inpatient and ED revisits were for complications related to the index operation (20.4 and 41.1 per 1000, respectively). This pattern was similar across all 6 types of operations. Revisits to all acute care settings for operation-specific complications varied across operations from 1.7 to 73.1 per 1000 and revisits for pain varied from 1.9 to 22.2 per 1000 (Table 2).
Acute care revisits following ambulatory operations in low-risk patients occurred with notable frequency across 6 diverse types of operations. A substantial proportion of revisits were to the ED and two-thirds were for complications related to the index operation.
Administrative data offer limited clinical detail and are susceptible to coding inaccuracies, and our categorization of reasons for revisits involved some subjectivity. However, we restricted revisits to the primary diagnosis code to avoid identifying chronic conditions as complications, an approach validated by HCUP. Other limitations include restriction to a limited number of operations and to low-risk patients.
Our results support using cause- or operation-specific (rather than all-cause) outcomes in quality improvement efforts and pay-for-performance initiatives. Considering the burden of revisits to patients and hospitals following ambulatory operations, our study highlights the importance of expanding health policy and clinical interventions to include ambulatory surgery and complications assessed in the ED.
Future work should determine associated risk factors and which complications are potentially preventable.
Corresponding Author: Claudia A. Steiner, MD, MPH, Agency for Healthcare Research and Quality, 540 Gaither Rd, Rockville, MD 20850 (firstname.lastname@example.org).
Author Contributions: Drs Steiner and Owens had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Steiner, Raetzman, Barrett, Sacks, Owens.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Steiner, Maggard-Gibbons, Raetzman, Barrett, Owens.
Critical revision of the manuscript for important intellectual content: Steiner, Raetzman, Barrett, Sacks, Owens.
Statistical analysis: Steiner, Maggard-Gibbons, Barrett, Owens.
Obtained funding: Steiner.
Administrative, technical, or material support: Steiner, Raetzman, Sacks, Owens.
Study supervision: Steiner, Owens.
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: This study was funded by the Agency for Healthcare Research and Quality (AHRQ) under a contract to Truven Health Analytics for developing and supporting the Healthcare Cost and Utilization Project (HCUP). Dr Sacks’ time was supported by the Robert Wood Johnson Clinical Scholars Program at the University of California, Los Angeles.
Role of the Funder/Sponsor: The AHRQ had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect those of AHRQ or the US Department of Health and Human Services.
Additional Contributions: We thank the following HCUP partner organizations that provided the data: California Office of Statewide Health Planning and Development, Florida Agency for Health Care Administration, Georgia Hospital Association, Missouri Hospital Industry Data Institute, Nebraska Hospital Association, New York State Department of Health, and Tennessee Hospital Association. In addition, we thank the following Truven Health Analytics staff members, who were compensated for their contributions: Minya Sheng, MS, for the statistical programming; Lauren Hughey, MPH, and Christine Walsh, BA, for reviewing data tables; and Linda Lee, PhD, for editorial assistance.
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