Defining Rates and Risk Factors for Readmissions Following Emergency General Surgery | Emergency Medicine | JAMA Surgery | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Kocher  RP, Adashi  EY.  Hospital readmissions and the Affordable Care Act: paying for coordinated quality care.  JAMA. 2011;306(16):1794-1795.PubMedGoogle ScholarCrossref
Joynt  KE, Jha  AK.  Thirty-day readmissions: truth and consequences.  N Engl J Med. 2012;366(15):1366-1369.PubMedGoogle ScholarCrossref
Jencks  SF, Williams  MV, Coleman  EA.  Rehospitalizations among patients in the Medicare fee-for-service program.  N Engl J Med. 2009;360(14):1418-1428.PubMedGoogle ScholarCrossref
Dharmarajan  K, Hsieh  AF, Lin  Z,  et al.  Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia.  JAMA. 2013;309(4):355-363.PubMedGoogle ScholarCrossref
Sørensen  LT, Malaki  A, Wille-Jørgensen  P,  et al.  Risk factors for mortality and postoperative complications after gastrointestinal surgery.  J Gastrointest Surg. 2007;11(7):903-910.PubMedGoogle ScholarCrossref
Gawande  AA, Studdert  DM, Orav  EJ, Brennan  TA, Zinner  MJ.  Risk factors for retained instruments and sponges after surgery.  N Engl J Med. 2003;348(3):229-235.PubMedGoogle ScholarCrossref
Kwan  TL, Lai  F, Lam  CM,  et al.  Population-based information on emergency colorectal surgery and evaluation on effect of operative volume on mortality.  World J Surg. 2008;32(9):2077-2082.PubMedGoogle ScholarCrossref
Havens  JM, Peetz  AB, Do  WS,  et al.  The excess morbidity and mortality of emergency general surgery.  J Trauma Acute Care Surg. 2015;78(2):306-311.PubMedGoogle ScholarCrossref
Patel  SS, Patel  MS, Goldfarb  M,  et al.  Elective versus emergency surgery for ulcerative colitis: a National Surgical Quality Improvement Program analysis.  Am J Surg. 2013;205(3):333-337.PubMedGoogle ScholarCrossref
Kassin  MT, Owen  RM, Perez  SD,  et al.  Risk factors for 30-day hospital readmission among general surgery patients.  J Am Coll Surg. 2012;215(3):322-330.PubMedGoogle ScholarCrossref
Morris  MS, Deierhoi  RJ, Richman  JS, Altom  LK, Hawn  MT.  The relationship between timing of surgical complications and hospital readmission.  JAMA Surg. 2014;149(4):348-354.PubMedGoogle ScholarCrossref
Glance  LG, Kellermann  AL, Osler  TM,  et al.  Hospital readmission after noncardiac surgery: the role of major complications.  JAMA Surg. 2014;149(5):439-445.PubMedGoogle ScholarCrossref
Schwartz  DA, Hui  X, Schneider  EB,  et al.  Worse outcomes among uninsured general surgery patients: does the need for an emergency operation explain these disparities? [published correction appears in Surgery. 2014;156(5):1288].  Surgery. 2014;156(2):345-351.PubMedGoogle ScholarCrossref
Tsai  TC, Orav  EJ, Joynt  KE.  Disparities in surgical 30-day readmission rates for Medicare beneficiaries by race and site of care.  Ann Surg. 2014;259(6):1086-1090.PubMedGoogle ScholarCrossref
Hendren  S, Morris  AM, Zhang  W, Dimick  J.  Early discharge and hospital readmission after colectomy for cancer.  Dis Colon Rectum. 2011;54(11):1362-1367.PubMedGoogle ScholarCrossref
Tsai  TC, Joynt  KE, Orav  EJ, Gawande  AA, Jha  AK.  Variation in surgical-readmission rates and quality of hospital care.  N Engl J Med. 2013;369(12):1134-1142.PubMedGoogle ScholarCrossref
Kiran  RP, Delaney  CP, Senagore  AJ, Steel  M, Garafalo  T, Fazio  VW.  Outcomes and prediction of hospital readmission after intestinal surgery.  J Am Coll Surg. 2004;198(6):877-883.PubMedGoogle ScholarCrossref
O’Brien  DP, Senagore  A, Merlino  J, Brady  K, Delaney  C.  Predictors and outcome of readmission after laparoscopic intestinal surgery.  World J Surg. 2007;31(12):2430-2435.PubMedGoogle ScholarCrossref
Azimuddin  K, Rosen  L, Reed  JF  III, Stasik  JJ, Riether  RD, Khubchandani  IT.  Readmissions after colorectal surgery cannot be predicted.  Dis Colon Rectum. 2001;44(7):942-946.PubMedGoogle ScholarCrossref
Schneider  EB, Hyder  O, Brooke  BS,  et al.  Patient readmission and mortality after colorectal surgery for colon cancer: impact of length of stay relative to other clinical factors.  J Am Coll Surg. 2012;214(4):390-398.PubMedGoogle ScholarCrossref
Martin  RC, Brown  R, Puffer  L,  et al.  Readmission rates after abdominal surgery: the role of surgeon, primary caregiver, home health, and subacute rehab.  Ann Surg. 2011;254(4):591-597.PubMedGoogle ScholarCrossref
Merkow  RP, Ju  MH, Chung  JW,  et al.  Underlying reasons associated with hospital readmission following surgery in the United States.  JAMA. 2015;313(5):483-495.PubMedGoogle ScholarCrossref
Healthcare Cost and Utilization Project (HCUP).  HCUP databases. Published 2015. Accessed March 2, 2015.
Shafi  S, Aboutanos  MB, Agarwal  S  Jr,  et al; AAST Committee on Severity Assessment and Patient Outcomes.  Emergency general surgery: definition and estimated burden of disease.  J Trauma Acute Care Surg. 2013;74(4):1092-1097.PubMedGoogle ScholarCrossref
Healthcare Cost and Utilization Project (HCUP).  HCUP central distributor SID description of data elements: all states. Published 2008. Accessed March 2, 2015.
Stagg  V.  CHARLSON: Stata module to calculate Charlson index of comorbidity. Chestnut Hill, MA: Statistical Software Components; 2006.
Charlson  ME, Pompei  P, Ales  KL, MacKenzie  CR.  A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.  J Chronic Dis. 1987;40(5):373-383.PubMedGoogle ScholarCrossref
Dawes  AJ, Sacks  GD, Russell  MM,  et al.  Preventable readmissions to surgical services: lessons learned and targets for improvement.  J Am Coll Surg. 2014;219(3):382-389.PubMedGoogle ScholarCrossref
Joynt  KE, Jha  AK.  Who has higher readmission rates for heart failure, and why? Implications for efforts to improve care using financial incentives.  Circ Cardiovasc Qual Outcomes. 2011;4(1):53-59.PubMedGoogle ScholarCrossref
Joynt  KE, Jha  AK.  Characteristics of hospitals receiving penalties under the Hospital Readmissions Reduction Program.  JAMA. 2013;309(4):342-343.PubMedGoogle ScholarCrossref
Wang  TS, Yen  TW.  Readmission after thyroidectomy and parathyroidectomy: what can we learn from NSQIP?  Surgery. 2014;156(6):1419-1422.PubMedGoogle ScholarCrossref
Lucas  DJ, Sweeney  JF, Pawlik  TM.  The timing of complications impacts risk of readmission after hepatopancreatobiliary surgery.  Surgery. 2014;155(5):945-953.PubMedGoogle ScholarCrossref
Kim  BD, Smith  TR, Lim  S, Cybulski  GR, Kim  JY.  Predictors of unplanned readmission in patients undergoing lumbar decompression: multi-institutional analysis of 7016 patients.  J Neurosurg Spine. 2014;20(6):606-616.PubMedGoogle ScholarCrossref
Lawson  EH, Hall  BL, Louie  R,  et al.  Association between occurrence of a postoperative complication and readmission: implications for quality improvement and cost savings.  Ann Surg. 2013;258(1):10-18.PubMedGoogle ScholarCrossref
Lawson  EH, Hall  BL, Louie  R, Zingmond  DS, Ko  CY.  Identification of modifiable factors for reducing readmission after colectomy: a national analysis.  Surgery. 2014;155(5):754-766.PubMedGoogle ScholarCrossref
Anderson  GF, Steinberg  EP.  Hospital readmissions in the Medicare population.  N Engl J Med. 1984;311(21):1349-1353.PubMedGoogle ScholarCrossref
Neumayer  L.  How do (and why should) I use the National Surgical Quality Improvement Program?  Am J Surg. 2009;198(5)(suppl):S36-S40.PubMedGoogle ScholarCrossref
Hall  BL, Hamilton  BH, Richards  K, Bilimoria  KY, Cohen  ME, Ko  CY.  Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals.  Ann Surg. 2009;250(3):363-376.PubMedGoogle Scholar
Atkinson  G, Giovanis  T.  Conceptual errors in the CMS refusal to make socioeconomic adjustments in readmission and other quality measures.  J Ambul Care Manage. 2014;37(3):269-272.PubMedGoogle ScholarCrossref
Gonzalez  AA, Shih  T, Dimick  JB, Ghaferi  AA.  Using same-hospital readmission rates to estimate all-hospital readmission rates.  J Am Coll Surg. 2014;219(4):656-663.PubMedGoogle ScholarCrossref
Tsai  TC, Orav  EJ, Jha  AK.  Care fragmentation in the postdischarge period: surgical readmissions, distance of travel, and postoperative mortality.  JAMA Surg. 2015;150(1):59-64.PubMedGoogle ScholarCrossref
Muthuvel  G, Tevis  SE, Liepert  AE, Agarwal  SK, Kennedy  GD.  A composite index for predicting readmission following emergency general surgery.  J Trauma Acute Care Surg. 2014;76(6):1467-1472.PubMedGoogle ScholarCrossref
Original Investigation
April 2016

Defining Rates and Risk Factors for Readmissions Following Emergency General Surgery

Author Affiliations
  • 1Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women’s Hospital, Boston, Massachusetts
  • 2Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
  • 3Division of General Surgery, Mayo Clinic College of Medicine, Phoenix, Arizona
JAMA Surg. 2016;151(4):330-336. doi:10.1001/jamasurg.2015.4056

Importance  Hospital readmission rates following surgery are increasingly being used as a marker of quality of care and are used in pay-for-performance metrics. To our knowledge, comprehensive data on readmissions to the initial hospital or a different hospital after emergency general surgery (EGS) procedures do not exist.

Objective  To define readmission rates and identify risk factors for readmission after common EGS procedures.

Design, Setting, and Participants  Patients undergoing EGS, as defined by the American Association for the Surgery of Trauma, were identified in the California State Inpatient Database (2007-2011) on January 15, 2015. Patients were 18 years and older. We identified the 5 most commonly performed EGS procedures in each of 11 EGS diagnosis groups. Patient demographics (sex, age, race/ethnicity, and insurance type) as well as Charlson Comorbidity Index score, length of stay, complications, and discharge disposition were collected. Factors associated with readmission were determined using multivariate logistic regression models analysis.

Main Outcomes and Measures  Thirty-day hospital readmission.

Results  Among 177 511 patients meeting inclusion criteria, 57.1% were white, 48.8% were privately insured, and most were 45 years and older (51.3%). Laparoscopic appendectomy (35.2%) and laparoscopic cholecystectomy (19.3%) were the most common procedures. The overall 30-day readmission rate was 5.91%. Readmission rates ranged from 4.1% (upper gastrointestinal) to 16.8% (cardiothoracic). Of readmitted patients, 16.8% were readmitted at a different hospital. Predictors of readmission included Charlson Comorbidity Index score of 2 or greater (adjusted odds ratio: 2.26 [95% CI, 2.14-2.39]), leaving against medical advice (adjusted odds ratio: 2.24 [95% CI, 1.89-2.66]), and public insurance (adusted odds ratio: 1.55 [95% CI, 1.47-1.64]). The most common reasons for readmission were surgical site infections (16.9%), gastrointestinal complications (11.3%), and pulmonary complications (3.6%).

Conclusions and Relevance  Readmission after EGS procedures is common and varies widely depending on patient factors and diagnosis categories. One in 5 readmitted patients will go to a different hospital, causing fragmentation of care and potentially obscuring the utility of readmission as a quality metric. Assisting socially vulnerable patients and reducing postoperative complications, including infections, are targets to reduce readmissions.