Factors Associated With Emergency Department Visits and Hospital Admissions After Invasive Outpatient Procedures in the Veterans Health Administration | Emergency Medicine | JAMA Surgery | JAMA Network
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Table 1.  Patient Outcomes After Invasive Outpatient Procedures Across Veterans Health Administration Specialty Clinics
Patient Outcomes After Invasive Outpatient Procedures Across Veterans Health Administration Specialty Clinics
Table 2.  Logistic Regression Results Predicting 0- to 14-Day ED Visits or 1- to 14-Day Hospital Admissions After Invasive Outpatient Procedures by Veterans Health Administration Specialty Clinica
Logistic Regression Results Predicting 0- to 14-Day ED Visits or 1- to 14-Day Hospital Admissions After Invasive Outpatient Procedures by Veterans Health Administration Specialty Clinica
1.
Neily  J, Mills  PD, Eldridge  N,  et al.  Incorrect surgical procedures within and outside of the operating room.  Arch Surg. 2009;144(11):1028-1034.PubMedGoogle ScholarCrossref
2.
Khuri  SF, Daley  J, Henderson  W,  et al; National VA Surgical Quality Improvement Program.  The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care.  Ann Surg. 1998;228(4):491-507.PubMedGoogle ScholarCrossref
3.
Mull  HJ, Rosen  AK, Charns  MP, Itani  KMF, Rivard  PE.  Identifying risks and opportunities in outpatient surgical patient safety: a qualitative analysis of Veterans Health Administration staff perceptions  [published online November 4, 2017].  J Patient Saf. 2017. doi:10.1097/PTS.0000000000000311PubMedGoogle Scholar
4.
Mull  HJ, Rosen  AK, Rivard  PE, Itani  KMF.  Defining outpatient surgery: perspectives of surgical staff in the Veterans Health Administration.  Am Surg. 2016;82(11):1142-1145.Google Scholar
5.
VA National Surgery Office (NSO). Surgical Services Homepage. 2015. https://www.va.gov/health/surgery/. Accessed March 19, 2018.
6.
Centers for Medicare & Medicaid Services.  2016 Measure Updates and Specifications Report: Hospital Visits After Hospital Outpatient Surgery Measure (Risk-Standardized Hospital Visits Within 7 Days After Hospital Outpatient Surgery Measure), Version 1.1. Washington, DC: Centers for Medicare & Medicaid Services; 2016.
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    Research Letter
    August 2018

    Factors Associated With Emergency Department Visits and Hospital Admissions After Invasive Outpatient Procedures in the Veterans Health Administration

    Author Affiliations
    • 1Center for Healthcare Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
    • 2Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
    • 3Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, North Carolina
    • 4Division of Gastroenterology, Department of Medicine, Duke University, Durham, North Carolina
    • 5Durham VA Medical Center, Durham, North Carolina
    • 6Department of Radiology, Duke University, Durham, North Carolina
    • 7Division of Cardiology, Department of Medicine, VA Eastern Colorado Health Care System, Denver, Colorado
    • 8Department of Cardiology, University of Colorado School of Medicine, Aurora
    • 9Department of Urology, New York University School of Medicine, New York
    • 10Department of Urology, VA New York Harbor, New York
    • 11Division of Podiatry, Department of Surgery, VA Boston Healthcare System, Boston, Massachusetts
    • 12Department of Medicine, Section of Infectious Diseases, VA Boston Healthcare System, Boston, Massachusetts
    • 13Harvard Medical School, Boston, Massachusetts
    JAMA Surg. 2018;153(8):774-776. doi:10.1001/jamasurg.2018.0874

    Outpatient surgical care and invasive medical procedures are increasing. Prior research from the Veterans Health Administration (VHA) found that wrong-side or wrong-site adverse events were more common in the outpatient setting than the inpatient setting when the procedure was performed outside the operating room.1 Both inpatient and outpatient operating room–based surgical procedures are evaluated by the National Surgical Quality Improvement Program2; however, non–operating room outpatient invasive procedures are not assessed. To address this gap and inform future research, we measured the prevalence of postprocedure emergency department (ED) visits and admissions and explored the association of these outcomes with relevant patient, procedure, and facility factors.3

    Methods

    The VHA Corporate Data Warehouse fiscal years 2012 to 2015 outpatient and procedure files were used to identify cases by Current Procedural Terminology code and outpatient setting for 5 high-volume subspecialties: urology, podiatry, cardiology (invasive and electrophysiologic procedures), interventional radiology, and gastroenterology. Only elective invasive procedures, defined as requiring general, monitored, or regional anesthesia, incision, device implantation, injection, or endoscopic entry of a sterile site, performed in facilities that treat more than 50 cases per year were retained.4 Patient demographics, including self-reported race/ethnicity and sex, comorbidities, 30-day prior visits and hospitalizations, number of procedures, procedural relative value unit, and facility’s geographic region, were extracted from the Corporate Data Warehouse. The surgical complexity rating of each facility was obtained from the VHA National Surgery Office.5 The Boston Veterans Affairs Healthcare System institutional review board approved the study and waived informed consent (data remained identifiable).

    Outcomes included 0- to 14-day visits to a VHA ED and 1- to 14-day VHA admissions; we excluded observational stays and same-day admissions. The association between outcomes and patient, procedure, and facility characteristics for each specialty was assessed with logistic regression using SAS statistical software, version 9.2 (SAS Institute Inc). We controlled for temporal factors and facility-level fixed effects.

    Results

    There were 988 476 invasive outpatient procedures performed in 109 hospital outpatient departments, 23 ambulatory surgical centers, and 113 nonsurgical VHA facilities. Most cases were treated by specialists in gastroenterology (32%), urology (25%), and podiatry (25%). Incidence of 0- to 14-day postprocedure ED visits ranged from 1.3% (podiatry) to 3.4% (interventional radiology); 1- to 14-day postprocedure admissions ranged from 0.6% (podiatry) to 1.6% (interventional radiology) (Table 1). Higher rates of health care use in the 30 days before the procedure were associated with postprocedure use across all specialties (Table 2). Within each specialty, unmarried status, race, age, procedural relative value unit, and overall procedural complexity were significant indicators of postprocedural use outcomes.

    Discussion

    Improving patient outcomes after outpatient procedures is important to health care practitioners and policy makers.6 Although procedures that do not require an inpatient or operating room stay are assumed to present fewer risks, these results demonstrate that postprocedure ED visits and admissions are not rare. Underlying disease severity may contribute to increases in postprocedure use; higher rates of visits and admissions in the prior month were significant indicators. Of importance, when preprocedural use was accounted for, racial/ethnic and age disparities were observed. We did not assess whether 1- to 14-day admissions were planned or preventable, which may explain the higher admission rates for certain specialties (eg, interventional radiology and cancer treatments). However, because ED visits and admissions that occurred outside the VHA were not captured in this data set, these findings are likely to be an underestimate of the true rate of postprocedure outcomes. More work is needed to confirm these results in a nonveteran sample; however, our findings have significant population health relevance because the VHA is the largest US health care system.

    These findings suggest that although invasive outpatient procedures are not routinely included in patient safety or quality measurement, they account for a significant burden of postprocedure care. Improving surveillance of invasive procedures may lead to quality improvement initiatives that can benefit patients while potentially reducing ED visits and admissions.

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    Article Information

    Accepted for Publication: February 10, 2018.

    Corresponding Author: Hillary J. Mull, PhD, MPP, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S Huntington Ave (Mail Code 152M), Boston, MA 02130 (hillary.mull@va.gov).

    Published Online: May 2, 2018. doi:10.1001/jamasurg.2018.0874

    Author Contributions: Dr Mull had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Study concept and design: Mull, Gupta, Valle, Branch-Elliman.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Mull, Gupta, Branch-Elliman.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Mull, Gupta.

    Obtained funding: Mull.

    Administrative, technical, or material support: Gupta, Makarov, Silverman.

    Study supervision: Mull, Gupta, Makarov.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This research was supported by grants CDA 13-270 (Dr Mull), CDA 12-157 (Dr Makarov), and CDA 14-158 (Dr Gellad) from the Veterans Affairs Health Services Research and Development Service. Dr Branch-Elliman is supported by a VISN-1 Career Development Award and American Heart Association Institute for Precision Cardiovascular Medicine Award 17IG33630052.

    Role of the Funder/Sponsor: The funding sources 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 opinions expressed are those of the authors and not necessarily those of the US Department of Veterans Affairs.

    References
    1.
    Neily  J, Mills  PD, Eldridge  N,  et al.  Incorrect surgical procedures within and outside of the operating room.  Arch Surg. 2009;144(11):1028-1034.PubMedGoogle ScholarCrossref
    2.
    Khuri  SF, Daley  J, Henderson  W,  et al; National VA Surgical Quality Improvement Program.  The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care.  Ann Surg. 1998;228(4):491-507.PubMedGoogle ScholarCrossref
    3.
    Mull  HJ, Rosen  AK, Charns  MP, Itani  KMF, Rivard  PE.  Identifying risks and opportunities in outpatient surgical patient safety: a qualitative analysis of Veterans Health Administration staff perceptions  [published online November 4, 2017].  J Patient Saf. 2017. doi:10.1097/PTS.0000000000000311PubMedGoogle Scholar
    4.
    Mull  HJ, Rosen  AK, Rivard  PE, Itani  KMF.  Defining outpatient surgery: perspectives of surgical staff in the Veterans Health Administration.  Am Surg. 2016;82(11):1142-1145.Google Scholar
    5.
    VA National Surgery Office (NSO). Surgical Services Homepage. 2015. https://www.va.gov/health/surgery/. Accessed March 19, 2018.
    6.
    Centers for Medicare & Medicaid Services.  2016 Measure Updates and Specifications Report: Hospital Visits After Hospital Outpatient Surgery Measure (Risk-Standardized Hospital Visits Within 7 Days After Hospital Outpatient Surgery Measure), Version 1.1. Washington, DC: Centers for Medicare & Medicaid Services; 2016.
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