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The Fifth Vital Sign: Postoperative Pain Predicts 30-day Readmissions and Subsequent Emergency Department Visits.

ABSTRACT: OBJECTIVE:We hypothesized that inpatient postoperative pain trajectories are associated with 30-day inpatient readmission and emergency department (ED) visits. BACKGROUND:Surgical readmissions have few known modifiable predictors. Pain experienced by patients may reflect surgical complications and/or inadequate or difficult symptom management. METHODS:National Veterans Affairs Surgical Quality Improvement data on inpatient general, vascular, and orthopedic surgery from 2008 to 2014 were merged with laboratory, vital sign, health care utilization, and postoperative complications data. Six distinct postoperative inpatient patient-reported pain trajectories were identified: (1) persistently low, (2) mild, (3) moderate or (4) high trajectories, and (5) mild-to-low or (6) moderate-to-low trajectories based on postoperative pain scores. Regression models estimated the association between pain trajectories and postdischarge utilization while controlling for important patient and clinical variables. RESULTS:Our sample included 211,231 surgeries-45.4% orthopedics, 37.0% general, and 17.6% vascular. Overall, the 30-day unplanned readmission rate was 10.8%, and 30-day ED utilization rate was 14.2%. Patients in the high pain trajectories had the highest rates of postdischarge readmissions and ED visits (14.4% and 16.3%, respectively, P < 0.001). In multivariable models, compared with the persistently low pain trajectory, there was a dose-dependent increase in postdischarge ED visits and readmission for pain-related diagnoses, but not postdischarge complications (? trend P < 0.001). CONCLUSIONS:Postoperative pain trajectories identify populations at risk for 30-day readmissions and ED visits, and do not seem to be mediated by postdischarge complications. Addressing pain control expectations before discharge may help reduce surgical readmissions in high pain categories.

SUBMITTER: Hernandez-Boussard T

PROVIDER: S-EPMC6530481 | biostudies-literature | 2017 Sep

REPOSITORIES: biostudies-literature

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The Fifth Vital Sign: Postoperative Pain Predicts 30-day Readmissions and Subsequent Emergency Department Visits.

Hernandez-Boussard Tina T Graham Laura A LA Desai Karishma K Wahl Tyler S TS Aucoin Elise E Richman Joshua S JS Morris Melanie S MS Itani Kamal M KM Telford Gordon L GL Hawn Mary T MT

Annals of surgery 20170901 3

<h4>Objective</h4>We hypothesized that inpatient postoperative pain trajectories are associated with 30-day inpatient readmission and emergency department (ED) visits.<h4>Background</h4>Surgical readmissions have few known modifiable predictors. Pain experienced by patients may reflect surgical complications and/or inadequate or difficult symptom management.<h4>Methods</h4>National Veterans Affairs Surgical Quality Improvement data on inpatient general, vascular, and orthopedic surgery from 2008 ...[more]

PMID: 28657940

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Project description:ObjectiveTo assess the association of Private, Medicare, and Medicaid/Uninsured insurance type with 30-day Emergency Department visits/Observation Stays (EDOS), readmissions, and costs in a safety-net hospital (SNH) serving diverse socioeconomic status patients.Summary background dataMedicare's Hospital Readmission Reduction Program (HRRP) disproportionately penalizes SNHs.MethodsThis retrospective cohort study used inpatient National Surgical Quality Improvement Program (2013-2019) data merged with cost data. Frailty, expanded Operative Stress Score, case status, and insurance type were used to predict odds of EDOS and readmissions, as well as index hospitalization costs.ResultsThe cohort had 1,477 Private; 1,164 Medicare; and 3,488 Medicaid/Uninsured cases with a patient mean age 52.1 years [SD=14.7] and 46.8% of the cases were performed on male patients. Medicaid/Uninsured (aOR=2.69, CI=2.38-3.05, P<.001) and Medicare (aOR=1.32, CI=1.11-1.56, P=.001) had increased odds of urgent/emergent surgeries and complications versus Private patients. Despite having similar frailty distributions, Medicaid/Uninsured compared to Private patients had higher odds of EDOS (aOR=1.71, CI=1.39-2.11, P<.001), and readmissions (aOR=1.35, CI=1.11-1.65, P=.004), after adjusting for frailty, OSS, and case status, while Medicare patients had similar odds of EDOS and readmissions versus Private. Hospitalization variable cost %change was increased for Medicare (12.5%) and Medicaid/Uninsured (5.9%), but Medicaid/Uninsured was similar to Private after adjusting for urgent/emergent cases.ConclusionsIncreased rates and odds of urgent/emergent cases in Medicaid/Uninsured patients drive increased odds of complications and index hospitalization costs versus Private. SNHs care for higher cost populations while receiving lower reimbursements and are further penalized by the unintended consequences of HRRP. Increasing access to care, especially for Medicaid/Uninsured patients, could reduce urgent/emergent surgeries resulting in fewer complications, EDOS/readmissions, and costs.

Project description:BackgroundAs an effort to reduce hospital readmissions, early follow-up visits were recommended by the Society of Hospital Medicine. However, published literature on the effect of follow-up visits is limited with mixed conclusions. Our goal here is to fully explore the relationship between follow-up visits and the all-cause non-elective 30-day readmission rate (RR) after adjusting for confounders.Methods and resultsTo conduct this retrospective observational study, we extracted data for 55,378 adult inpatients from Advocate Health Care, a large, multi-hospital system serving a diverse population in a major metropolitan area. These patients were discharged to Home or Home with Home Health services between June 1, 2013 and April 30, 2015. Our findings from time-dependent Cox proportional hazard models showed that follow-up visits were significantly associated with a reduced RR (adjusted hazard ratio: 0.86; 95% CI: 0.82-0.91), but in a complicated way because the interaction between follow-up visits and a readmission risk score was significant with p-value < 0.001. Our analysis using logistic models on an adjusted data set confirmed the above findings with the following additional results. First, time matter. Follow-up visits within 2 days were associated with the greatest reduction in RR (adjusted odds ratio: 0.72; 95% CI: 0.63-0.83). Visits beyond 2 days were also associated with a reduction in RR, but the strength of the effect decreased as the time between discharge and follow-up visit increased. Second, the strength of such association varied for patients with different readmission risk scores. Patients with a risk score of 0.113, high but not extremely high risk, had the greatest reduction in RR from follow-up visits. Patients with an extremely high risk score (> 0.334) saw no RR reduction from follow-up visits. Third, a patient was much more likely to have a 2-day follow-up visit if that visit was scheduled before the patient was discharged from the hospital (30% versus < 5%).ConclusionsFollow-up visits are associated with a reduction in readmission risk. The timing of follow-up visits can be important: beyond two days, the earlier, the better. The effect of follow-up visits is more significant for patients with a high but not extremely high risk of readmission.

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The Fifth Vital Sign: Postoperative Pain Predicts 30-day Readmissions and Subsequent Emergency Department Visits.

Publications

The Fifth Vital Sign: Postoperative Pain Predicts 30-day Readmissions and Subsequent Emergency Department Visits.

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