Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland.
JAMA Surg. 2015 Nov;150(11):1042-9. doi: 10.1001/jamasurg.2015.2215.
Readmission is a target area of quality improvement in surgery. While variation in readmission is common, to our knowledge, no study has specifically examined the underlying etiology of this variation among a variety of surgical procedures performed in a large academic medical center.
To quantify the variability in 30-day readmission attributable to patient, surgeon, and surgical subspecialty levels in patients undergoing a major surgical procedure.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of administrative claims data of patients discharged following a major surgical procedure at a tertiary care center between January 1, 2009, and, December 31, 2013. A total of 22,559 patients were included in this study and underwent a major surgical procedure performed by 56 surgeons practicing in 8 surgical subspecialties.
In-hospital morbidity, 30-day readmission, and proportional variation in 30-day readmission at patient, surgeon, and surgical subspecialty levels.
Among the 22,559 patients in this study, patient age, race/ethnicity, and payer type differed across surgical subspecialties. Preoperative comorbidity was common and noted in 65.1% of patients. Postoperative complications were noted in 21.6% of patients varying from 2.1% following breast, melanoma or endocrine surgery to 37.0% following cardiac surgery. The overall 30-day readmission was 13.2% (n = 2975). Readmission varied considerably across the 8 different surgical subspecialties, ranging from 24.8% following transplant surgery (n = 557) to 2.1% following breast, melanoma, or endocrine surgery (n = 32). After adjusting for patient- and surgeon-level variables, factors associated with readmission included African American race/ethnicity (odds ratio, 1.23; 95% CI, 1.11-1.36; P < .001), increasing comorbidity (Charlson Comorbidity Index score of 1: odds ratio, 1.16; 95% CI, 1.02-1.32; P = .02; and a Charlson Comorbidity Index score of ≥2 : odds ratio, 1.38; 95% CI, 1.24-1.53; P < .001), postoperative complication (odds ratio, 1.19; 95% CI, 1.08-1.32; P = .001), and an extended length of stay (odds ratio, 1.78; 95% CI, 1.61-1.96; P < .001). The majority of the variation in readmission was attributable to patient-related factors (82.8%) while surgical subspecialty accounted for 14.5% of the variability, and individual surgeon-level factors accounted for 2.8%.
Readmission occurred in more than 1 in 10 patients, with considerable variation across surgical subspecialties. Variation in readmission was overwhelmingly owing to patient-level factors while only a minority of the variation was attributable to factors at the surgical subspecialty and individual surgeon levels.
再入院是手术质量改进的一个目标领域。虽然再入院的差异很常见，但据我们所知，在一家大型学术医疗中心进行的各种外科手术中，没有研究专门研究这种差异的根本病因。
量化患者、外科医生和外科亚专业水平在接受主要手术的患者中 30 天再入院的可变性。
设计、设置和参与者：对 2009 年 1 月 1 日至 2013 年 12 月 31 日在三级护理中心接受主要手术的患者的行政索赔数据进行回顾性分析。共有 22559 名患者参与了这项研究，他们接受了 56 名在 8 个外科亚专业领域执业的外科医生进行的主要手术。
患者、外科医生和外科亚专业水平的住院发病率、30 天再入院率和 30 天再入院率的比例变化。
在这项研究的 22559 名患者中，患者年龄、种族/族裔和付款人类型在不同的外科亚专业之间存在差异。术前合并症很常见，在 65.1%的患者中均有记载。术后并发症在 21.6%的患者中出现，从乳房、黑色素瘤或内分泌手术的 2.1%到心脏手术的 37.0%不等。整体 30 天再入院率为 13.2%（n=2975）。8 种不同的外科亚专业之间的再入院率差异很大，从移植手术（n=557）的 24.8%到乳房、黑色素瘤或内分泌手术（n=32）的 2.1%。在调整患者和外科医生水平的变量后，与再入院相关的因素包括非裔美国人种族/族裔（优势比，1.23；95%置信区间，1.11-1.36；P<.001）、合并症增多（Charlson 合并症指数评分为 1：优势比，1.16；95%置信区间，1.02-1.32；P=0.02；Charlson 合并症指数评分为≥2：优势比，1.38；95%置信区间，1.24-1.53；P<.001）、术后并发症（优势比，1.19；95%置信区间，1.08-1.32；P=0.001）和延长住院时间（优势比，1.78；95%置信区间，1.61-1.96；P<.001）。再入院的大部分变异归因于患者相关因素（82.8%），而外科亚专业占 14.5%的变异，个别外科医生水平的因素占 2.8%。
超过 10%的患者再次入院，各外科亚专业之间存在较大差异。再入院的差异主要归因于患者水平的因素，而只有少数差异归因于外科亚专业和个别外科医生水平的因素。
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