Annals of Surgery Journal Club

Interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in Annals of Surgery selected by a monthly guest expert who will review an article each month, offer questions and respond to reader's comments.

Tuesday, November 5, 2013

November, 2013 Journal Club
Moderator: Dr. Matthew M. Hutter
by Lawson, Elise H.; Hall, Bruce Lee; Louie, Rachel; Ettner, Susan L.; Zingmond, David S.; Han, Lein; Rapp, Michael; Ko, Clifford Y published in Annals of Surgery 258: 10-18, 2013.

Summary: Reducing readmissions is a major focus for payers and policymakers who by extension are making this a primary focus for the leadership at our hospitals, and for us the surgeons. Though readmission rates are certainly an imperfect metric for the quality of surgical care, there are many good reasons to focus on readmissions:  they are a marker for some level of harm for our patients, they decrease the patient’s experience and perception of care delivered, and they are costly. Readmissions can be related to complications, and/or coordination of care, and both are reasonable things upon which to improve. 

In this study, the authors use a clever linkage of NSQIP and Medicare (MedPAR) data and thoughtful statistical analyses, to examine the impact of surgical complications on readmission rates, and costs of care. Specifically, by examining 90,932 patients from 214 hospitals with data in the ACS- NSQIP that could be linked to Medicare data, they show that readmitted patients were 3.4 times more likely to have had an ACS-NSQIP postoperative complication compared to non-readmitted patients (53% vs. 16%).  Further analyses demonstrate that a modest 5% relative reduction in complication rates for the 20 procedures with the highest number of readmissions could result in prevention of 2,092 readmissions per year and a savings to Medicare of $31 million per year.

From a practical, boots on the grounds standpoint, this makes sense.  Having worked doggedly at our hospital to reduce readmission rates, we initially addressed some of the low hanging fruit of “placing patients in observation” rather than “readmitting” them, and worked on the often preventable issues with regards to the breakdown of coordination of outpatient care.  However, after those issues were addressed, we know find that reducing complication rates would be the best way to reduce readmissions.  And that is exactly what this paper demonstrates in a thoughtful manner.


1.        Are readmission rates a reasonable metric for quality?  If not, what would be better?


2.       Do you feel that this journal article helps you to focus your Quality Improvement efforts for reducing readmissions?  How could you use these results to reduce readmissions at your hospital?


3.       Do you have any comments on the methodology and style of this paper?  Are the analyses performed and the results displayed in a way that is most effective?  What did you like? What was not helpful and how could you improve on it?


4.       What other important studies would you design using this powerful linkage of ACS-NSQIP and Medicare data?


Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.