Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.
JAMA Otolaryngol Head Neck Surg. 2019 Apr 1;145(4):328-337. doi: 10.1001/jamaoto.2018.4504.
Thirty-day readmission rates have been suggested as a marker for quality of care. By investigating the factors associated with readmissions in all otolaryngology subspecialties we provide data relevant for the development of risk stratification systems to improve outcomes.
To establish the association of surgical and hospital volume and patient characteristics with 30-day readmission rates to guide the development of otolaryngology-specific risk stratification models.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study including adult patients who underwent inpatient otolaryngology surgery in New York State between 1995 and 2015 was conducted using the Statewide Planning and Research Cooperative System (SPARCS). Regression techniques were used to describe relationships of patient-level factors, hospital, and surgeon volume to 30-day readmission rates in New York State.
The main outcome measures were patient-, surgeon-, and hospital-level risk factors for readmission. Secondary outcome measures were rate of readmissions by subspecialty procedure and by diagnosis on readmission.
We identified 254 257 cases of otolaryngology surgery (147 065 women [58%], mean [SD] age 50 [17] years). The 30-day readmission rate was 6%. In a multivariable model, odds ratios (ORs) identified Medicaid insurance (OR, 1.46; 99% CI, 1.36-1.57), Medicare insurance (OR, 1.32; 99% CI, 1.24-1.42), bottom quartile income (OR, 1.08; 99% CI, 1.01-1.15), patient comorbidities measured by the Charlson Comorbidity Index (CCI) (CCI >1; OR, 2.31; 99% CI, 2.16-2.47), length of stay (LOS) (LOS >10 days; OR, 2.29; 99% CI, 2.00-2.45), rhinology (OR, 1.37; 99% CI, 1.24-1.51), laryngology (OR, 1.98; 99% CI, 1.62-2.43), and head and neck cancer (OR, 1.27; 99% CI, 1.17-1.37) procedures as readmission predictors. High-volume surgeons were protective of 30-day readmission (OR, 0.67; 99% CI, 0.635-0.708) relative to low volume. Hospital volume was not significantly associated to readmissions. The most common causes of readmission included wound- (2682 patients, 18%), respiratory- (1776 patients, 12%), cardiovascular- (1210 patients, 8%), and volume- (1089 patients, 7%) related disorders.
This study evaluated the combined effects of patient-, surgeon-, and hospital-level factors on 30-day readmission after otolaryngology surgery. Socioeconomic factors, patient comorbidities, surgeon volumes, and procedure were significantly associated with 30-day readmission. Though the cause of 30-day readmission is multifactorial, a large portion is driven by socioeconomic factors. Addressing these disparities at the system level is necessary to address the described readmission disparities. The development of risk-stratification models based on patient-, procedure-, and surgeon-level factors may help facilitate resource distribution.
30 天再入院率被认为是衡量医疗质量的一个指标。通过调查耳鼻喉科所有亚专科相关的再入院因素，我们提供了与开发风险分层系统相关的数据，以改善结果。
确定手术和医院量以及患者特征与 30 天再入院率的关系，以指导耳鼻喉科特定的风险分层模型的开发。
设计、地点和参与者：本研究使用纽约州全州规划和研究合作系统（SPARCS）进行了一项回顾性队列研究，纳入了在 1995 年至 2015 年期间在纽约州接受住院耳鼻喉科手术的成年患者。回归技术用于描述患者水平因素、医院和外科医生数量与纽约州 30 天再入院率之间的关系。
主要的观察指标是患者、外科医生和医院水平的再入院风险因素。次要结果是按亚专科手术和再入院诊断的再入院率。
我们确定了 254257 例耳鼻喉科手术（147065 例女性[58%]，平均[SD]年龄 50[17]岁）。30 天再入院率为 6%。在多变量模型中，比值比（ORs）确定了医疗补助保险（OR，1.46；99%CI，1.36-1.57）、医疗保险（OR，1.32；99%CI，1.24-1.42）、收入最低四分之一（OR，1.08；99%CI，1.01-1.15）、Charlson 合并症指数（CCI）测量的患者合并症（CCI>1；OR，2.31；99%CI，2.16-2.47）、住院时间（LOS）（LOS>10 天；OR，2.29；99%CI，2.00-2.45）、鼻科学（OR，1.37；99%CI，1.24-1.51）、喉科学（OR，1.98；99%CI，1.62-2.43）和头颈部癌症（OR，1.27；99%CI，1.17-1.37）程序作为再入院预测因子。高容量外科医生相对于低容量外科医生（OR，0.67；99%CI，0.635-0.708）对 30 天再入院的保护作用。医院量与再入院无显著相关性。再入院的最常见原因包括伤口（2682 例，18%）、呼吸（1776 例，12%）、心血管（1210 例，8%）和容量（1089 例，7%）相关疾病。
本研究评估了患者、外科医生和医院水平因素对耳鼻喉科手术后 30 天再入院的综合影响。社会经济因素、患者合并症、外科医生数量和手术与 30 天再入院显著相关。尽管 30 天再入院的原因是多因素的，但很大一部分是由社会经济因素驱动的。为了解决所描述的再入院差异，有必要在系统层面上解决这些差异。基于患者、程序和外科医生水平因素开发风险分层模型可能有助于促进资源分配。
