The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
Predictors of Readmission After Outpatient Otolaryngologic Surgery Umang Jain, BA; Rakesh K. Chandra, MD; Stephanie S. Smith, MD; Matthew Pilecki, BA; John Y. S. Kim, MD Objectives/Hypothesis: Hospital readmissions increase costs to hospitals and patients. There is a paucity of data on benchmark rates of readmission for otolaryngological surgery. Understanding the risk factors that increase readmission rates may help enhance patient education and set system-wide expectations. We aimed to provide benchmark data on causes and predictors of readmission following outpatient otolaryngological surgery. Study Design: This study is a retrospective analysis of the 2011 National Surgical Quality Improvement Program (NSQIP) dataset. Methods: NSQIP was reviewed for outpatients with “Otolaryngology (ENT)” as their recorded surgical specialty. Readmission was tracked through the “Unplanned Readmission” variable. Patient characteristics and outcomes were compared using chi-square analysis and student t tests for categorical and continuous variables, respectively. Multivariate regression analysis investigated predictors of readmission. Results: A total of 6,788 outpatient otolaryngological surgery patients were isolated. The unplanned readmission rate was 2.01%. Multivariate regression analysis revealed superficial surgical site infection (odds ratio [OR] 2.672, confidence interval [CI] 1.133-6.304, P 5.025) and work relative value units (RVU) (OR .972, CI .944–1, P 5.049) to be significant predictors of readmission. Conclusion: Outpatient otolaryngological surgery has an associated 2.01% unplanned readmission rate. Superficial surgical site infection and work RVUs proved to be significant positive and negative risk factors, respectively, for readmission. These findings will help to benchmark outpatient readmission rates and manage patient and hospital system expectations. Key Words: unplanned readmissions, NSQIP. Level of Evidence: 2c. Laryngoscope, 124:1783–1788, 2014
INTRODUCTION Unplanned hospital readmissions have become a topic of particular interest in the United States due to their proven contribution to high health care costs.1 A recent MedPAC Medicare analysis revealed that readmissions make up 17.6% of Medicare costs—or $15 billion in expenditures annually—of which $12 billion are potentially preventable.2 Increased costs due to preventable readmissions seem to expand beyond Medicare’s coverage as well. As such, the healthcare system has adopted readmissions as a quality measure, with increased rates reflecting suboptimal healthcare, in order to make a more efficient and cost-effective sys-
From the Division of Surgery, Northwestern University (U.J., M.P., Illinois; and the Department of Otolaryngology–Head & Neck Surgery (R.K.C., S.S.S.), Feinberg School of Medicine, Chicago, Illinois. Editor’s Note: This Manuscript was accepted for publication November 19, 2013. The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein. They have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to John Y.S. Kim, MD, Division of Surgery, Northwestern University, Feinberg School of Medicine, 675 North St. Clair Street, Galter Suite 19-250, Chicago, IL 60611. E-mail: [email protected] J.Y.S.K.),
DOI: 10.1002/lary.24533
Laryngoscope 124: August 2014
tem.3 The health and financial benefits of readmission reduction have prompted payers and policymakers to reform sectors of healthcare that are expensive and offer opportunities for quality improvement. The Obama Administration targeted these lowperforming sectors through the Affordable Care Act’s Hospital Readmissions Reduction Program (HRRP).4 The HRRP targets hospital readmissions as a cost-andquality measure and enacts penalties for hospitals that display above average hospital readmission rates.4 Although the HRRP currently only focuses on certain medical conditions, its development should raise awareness regarding readmissions in surgical fields as well. Seventy percent of surgical Medicare patients readmitted within 30 days were readmitted with a medical diagnosis—not a surgical one—of which 90% were unplanned.5 Unplanned readmissions certainly factor into higher medical bills. In order to prevent future occurrences, the causes of these readmissions should be explored. There is a paucity of data on hospital readmission rates following outpatient otolaryngological surgery; therefore, we sought to provide benchmark rates and outline significant causes for unplanned readmission following outpatient otolaryngological surgery. Although large outcomes databases have traditionally provided detailed and generalizable surgical data, readmissions data has only recently been tracked. Thus, using the National Surgical Quality Improvement Program (NSQIP) database, which represents over 400
Jain et al.: Readmission After Outpatient Otolaryngologic Surgery
1783
TABLE I. Readmission Rates Categorized by CPT Code and Ranked by Number of Readmission Occurrences (Procedures with n > 50). Procedure
CPT
n
Readmission Rate
Thyroidectomy, total or subtotal for malignancy; with limited neck dissection
60252
54
7.41%
Cervical lymphadenectomy (modified radical neck dissection)
38724
89
5.62%
Uvulopalatopharyngoplasty
42145
293
3.41%
Tonsillectomy and adenoidectomy; age 12 years or older
42821
422
3.08%
Glossectomy; less than one-half tongue
41120
66
(COPD), bleeding disorder, hypertension requiring medication, and work relative value units (RVU). Medical complications documented by NSQIP include deep vein thrombosis (DVT), pulmonary embolism, unplanned reintubation, ventilator dependence (> 48 hours), renal insufficiency, acute renal failure, coma, stroke, cardiac arrest, myocardial infarction, peripheral nerve injury, pneumonia, urinary tract infection, bleeding requiring transfusion, sepsis, and septic shock. Additionally, surgical complications recorded by NSQIP include superficial, deep, and organ/space surgical site infection (SSI), as well as prosthesis failure.
Statistical Analysis
3.03%
CPT 5current procedural terminology.
hospitals across the United States, we sought to investigate readmissions after outpatient otolaryngological surgery.
MATERIALS AND METHODS A retrospective analysis was performed on data collected from the 2011 NSQIP participant use files. The data collection methods for NSQIP have been previously described in detail.6–8 Briefly, 240 variables, including patient demographics, comorbidities, preoperative laboratory values, perioperative details, and 30-day risk-adjusted postoperative outcomes were prospectively collected for each patient. To ensure accuracy, certified nurse reviewers are rigorously trained to collect patient information according to standardized definitions and the data is regularly audited. Deidentified patient information is freely available to all institutional members who comply with the ACS-NSQIP Data Use Agreement. The Data Use Agreement implements the protections afforded by the Health Insurance Portability and Accountability Act of 1996 and the ACS-NSQIP Hospital Participation Agreement. Patients undergoing outpatient otolaryngological surgery were identified using the “Surgical Specialty” and “Inpatient/ Outpatient” variables. Patients with no gender information were excluded. A total of 6,788 outpatient otolaryngological surgery patients were identified.
The five procedures (categorized by current procedural terminology [CPT] code and only considering those with n > 50) with the highest readmissions rates were found: 1) thyroidectomy, total or subtotal for malignancy, with limited neck dissection; 2) cervical lymphadenectomy (modified radical neck dissection); 3) uvulopalatopharyngoplasty; 4) tonsillectomy and adenoidectomy; and 5) glossectomy, less than one-half tongue. (Table I) Closed procedures (n 5 2,127) included all tonsillectomy, adenoidectomy, laryngoscopy, and nasal sinus endoscopy CPT codes. Open procedures (n 5 2151) included all thyroidectomy, neck dissection, lymph node dissection, and salivary gland excision CPT codes. Open/contaminated procedures (n 5 18) included all CPT codes for laryngectomy, mandibulectomy, composite resection, and craniofacial resection. Readmission rates for outpatient cardiac, general, gynecological, neurological, orthopedic, plastic, thoracic, urologic, and vascular surgical procedures were also found from the NSQIP database. (Fig. 1). Patient demographics and risk factors (Table II), as well as postoperative outcomes (Table III), were calculated through frequency analysis. History of COPD, superficial surgical site infection, work RVUs, American Society of Anesthesiology (ASA) Class 3-5, obesity, and gender were found to be significant in bivariate screen analysis (n 10, P
Rhinological and Otological Society, Inc.
Predictors of Readmission After Outpatient Otolaryngologic Surgery Umang Jain, BA; Rakesh K. Chandra, MD; Stephanie S. Smith, MD; Matthew Pilecki, BA; John Y. S. Kim, MD Objectives/Hypothesis: Hospital readmissions increase costs to hospitals and patients. There is a paucity of data on benchmark rates of readmission for otolaryngological surgery. Understanding the risk factors that increase readmission rates may help enhance patient education and set system-wide expectations. We aimed to provide benchmark data on causes and predictors of readmission following outpatient otolaryngological surgery. Study Design: This study is a retrospective analysis of the 2011 National Surgical Quality Improvement Program (NSQIP) dataset. Methods: NSQIP was reviewed for outpatients with “Otolaryngology (ENT)” as their recorded surgical specialty. Readmission was tracked through the “Unplanned Readmission” variable. Patient characteristics and outcomes were compared using chi-square analysis and student t tests for categorical and continuous variables, respectively. Multivariate regression analysis investigated predictors of readmission. Results: A total of 6,788 outpatient otolaryngological surgery patients were isolated. The unplanned readmission rate was 2.01%. Multivariate regression analysis revealed superficial surgical site infection (odds ratio [OR] 2.672, confidence interval [CI] 1.133-6.304, P 5.025) and work relative value units (RVU) (OR .972, CI .944–1, P 5.049) to be significant predictors of readmission. Conclusion: Outpatient otolaryngological surgery has an associated 2.01% unplanned readmission rate. Superficial surgical site infection and work RVUs proved to be significant positive and negative risk factors, respectively, for readmission. These findings will help to benchmark outpatient readmission rates and manage patient and hospital system expectations. Key Words: unplanned readmissions, NSQIP. Level of Evidence: 2c. Laryngoscope, 124:1783–1788, 2014
INTRODUCTION Unplanned hospital readmissions have become a topic of particular interest in the United States due to their proven contribution to high health care costs.1 A recent MedPAC Medicare analysis revealed that readmissions make up 17.6% of Medicare costs—or $15 billion in expenditures annually—of which $12 billion are potentially preventable.2 Increased costs due to preventable readmissions seem to expand beyond Medicare’s coverage as well. As such, the healthcare system has adopted readmissions as a quality measure, with increased rates reflecting suboptimal healthcare, in order to make a more efficient and cost-effective sys-
From the Division of Surgery, Northwestern University (U.J., M.P., Illinois; and the Department of Otolaryngology–Head & Neck Surgery (R.K.C., S.S.S.), Feinberg School of Medicine, Chicago, Illinois. Editor’s Note: This Manuscript was accepted for publication November 19, 2013. The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein. They have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to John Y.S. Kim, MD, Division of Surgery, Northwestern University, Feinberg School of Medicine, 675 North St. Clair Street, Galter Suite 19-250, Chicago, IL 60611. E-mail: [email protected] J.Y.S.K.),
DOI: 10.1002/lary.24533
Laryngoscope 124: August 2014
tem.3 The health and financial benefits of readmission reduction have prompted payers and policymakers to reform sectors of healthcare that are expensive and offer opportunities for quality improvement. The Obama Administration targeted these lowperforming sectors through the Affordable Care Act’s Hospital Readmissions Reduction Program (HRRP).4 The HRRP targets hospital readmissions as a cost-andquality measure and enacts penalties for hospitals that display above average hospital readmission rates.4 Although the HRRP currently only focuses on certain medical conditions, its development should raise awareness regarding readmissions in surgical fields as well. Seventy percent of surgical Medicare patients readmitted within 30 days were readmitted with a medical diagnosis—not a surgical one—of which 90% were unplanned.5 Unplanned readmissions certainly factor into higher medical bills. In order to prevent future occurrences, the causes of these readmissions should be explored. There is a paucity of data on hospital readmission rates following outpatient otolaryngological surgery; therefore, we sought to provide benchmark rates and outline significant causes for unplanned readmission following outpatient otolaryngological surgery. Although large outcomes databases have traditionally provided detailed and generalizable surgical data, readmissions data has only recently been tracked. Thus, using the National Surgical Quality Improvement Program (NSQIP) database, which represents over 400
Jain et al.: Readmission After Outpatient Otolaryngologic Surgery
1783
TABLE I. Readmission Rates Categorized by CPT Code and Ranked by Number of Readmission Occurrences (Procedures with n > 50). Procedure
CPT
n
Readmission Rate
Thyroidectomy, total or subtotal for malignancy; with limited neck dissection
60252
54
7.41%
Cervical lymphadenectomy (modified radical neck dissection)
38724
89
5.62%
Uvulopalatopharyngoplasty
42145
293
3.41%
Tonsillectomy and adenoidectomy; age 12 years or older
42821
422
3.08%
Glossectomy; less than one-half tongue
41120
66
(COPD), bleeding disorder, hypertension requiring medication, and work relative value units (RVU). Medical complications documented by NSQIP include deep vein thrombosis (DVT), pulmonary embolism, unplanned reintubation, ventilator dependence (> 48 hours), renal insufficiency, acute renal failure, coma, stroke, cardiac arrest, myocardial infarction, peripheral nerve injury, pneumonia, urinary tract infection, bleeding requiring transfusion, sepsis, and septic shock. Additionally, surgical complications recorded by NSQIP include superficial, deep, and organ/space surgical site infection (SSI), as well as prosthesis failure.
Statistical Analysis
3.03%
CPT 5current procedural terminology.
hospitals across the United States, we sought to investigate readmissions after outpatient otolaryngological surgery.
MATERIALS AND METHODS A retrospective analysis was performed on data collected from the 2011 NSQIP participant use files. The data collection methods for NSQIP have been previously described in detail.6–8 Briefly, 240 variables, including patient demographics, comorbidities, preoperative laboratory values, perioperative details, and 30-day risk-adjusted postoperative outcomes were prospectively collected for each patient. To ensure accuracy, certified nurse reviewers are rigorously trained to collect patient information according to standardized definitions and the data is regularly audited. Deidentified patient information is freely available to all institutional members who comply with the ACS-NSQIP Data Use Agreement. The Data Use Agreement implements the protections afforded by the Health Insurance Portability and Accountability Act of 1996 and the ACS-NSQIP Hospital Participation Agreement. Patients undergoing outpatient otolaryngological surgery were identified using the “Surgical Specialty” and “Inpatient/ Outpatient” variables. Patients with no gender information were excluded. A total of 6,788 outpatient otolaryngological surgery patients were identified.
The five procedures (categorized by current procedural terminology [CPT] code and only considering those with n > 50) with the highest readmissions rates were found: 1) thyroidectomy, total or subtotal for malignancy, with limited neck dissection; 2) cervical lymphadenectomy (modified radical neck dissection); 3) uvulopalatopharyngoplasty; 4) tonsillectomy and adenoidectomy; and 5) glossectomy, less than one-half tongue. (Table I) Closed procedures (n 5 2,127) included all tonsillectomy, adenoidectomy, laryngoscopy, and nasal sinus endoscopy CPT codes. Open procedures (n 5 2151) included all thyroidectomy, neck dissection, lymph node dissection, and salivary gland excision CPT codes. Open/contaminated procedures (n 5 18) included all CPT codes for laryngectomy, mandibulectomy, composite resection, and craniofacial resection. Readmission rates for outpatient cardiac, general, gynecological, neurological, orthopedic, plastic, thoracic, urologic, and vascular surgical procedures were also found from the NSQIP database. (Fig. 1). Patient demographics and risk factors (Table II), as well as postoperative outcomes (Table III), were calculated through frequency analysis. History of COPD, superficial surgical site infection, work RVUs, American Society of Anesthesiology (ASA) Class 3-5, obesity, and gender were found to be significant in bivariate screen analysis (n 10, P
