HHS Public Access Author manuscript Author Manuscript
JAMA Facial Plast Surg. Author manuscript; available in PMC 2017 September 17. Published in final edited form as: JAMA Facial Plast Surg. 2016 December 01; 18(6): 420–428. doi:10.1001/jamafacial.2016.0539.
Thirty-Day Hospital Revisit Rates and Factors Associated With Revisits in Patients Undergoing Septorhinoplasty
Author Manuscript
Emily Spataro, MD, Gregory H. Branham, MD, Dorina Kallogjeri, MD, MPH, Jay F. Piccirillo, MD, and Shaun C. Desai, MD Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri (Spataro, Kallogjeri, Piccirillo); Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri (Branham); Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland (Desai)
Abstract IMPORTANCE—Estimates of the 30-day hospital revisit rate following septorhinoplasty and the risk factors associated with revisits are unknown in the current literature. Surgical 30-day readmission rates are important to establish, as they are increasingly used as a quality care metric and can incur future financial penalties from third-party payers and government agencies.
Author Manuscript
OBJECTIVE—To determine the rate of 30-day hospital revisits following septorhinoplasty and the risk factors associated with revisits. DESIGN, SETTING, AND PARTICIPANTS—A retrospective cohort analysis was conducted of 175 842 patients undergoing septorhinoplasty between January 1, 2005, and December 31, 2009, using data from the Healthcare Cost and Utilization Project state inpatient database, state ambulatory surgery database, and state emergency department database from California, Florida, and New York. Information on revisits for these patients was collected from the 3 databases between January 1, 2005, and December 31, 2012. Data analysis was conducted from September 1, 2014, to May 1, 2015.
Author Manuscript
Corresponding Author: Shaun C. Desai, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology– Head and Neck Surgery, Johns Hopkins University School of Medicine, 6420 Rockledge Dr, Ste 4920, Bethesda, MD 20817, ([email protected]). Author Contributions: Drs Spataro and Kallogjeri had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Spataro, Branham, Piccirillo, Desai. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Spataro, Desai. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Spataro, Kallogjeri, Piccirillo. Obtained funding: Desai. Adminstrative, technical, or material support: Branham, Desai. Study supervision: Branham, Piccirillo, Desai. Conflict of Interest Disclosures: None reported.
Spataro et al.
Page 2
Author Manuscript
MAIN OUTCOMES AND MEASURES—Hospital revisits within 30 days after an index septorhinoplasty and the primary diagnosis at the time of the revisit were the main outcome measures. The revisit rate was calculated within subgroups of patients based on different demographic and clinical characteristics. A multivariable model was then used to determine independent risk factors for the occurrence of a hospital revisit within 30 days of the septorhinoplasty procedure.
Author Manuscript
RESULTS—In total, 11 456 of 175 842 patients (6.5%) who underwent septorhinoplasty procedures revisited the hospital within 30 days of the procedure. Most of these revisits (6353 [55.5%]) were to the emergency department. The most common primary diagnosis was bleeding or epistaxis, occurring in 2150 patients (1.2%). Multivariable logistic regression showed that patients aged 41 to 65 years (adjusted odds ratio [aOR], 1.09; 99% CI, 1.02–1.16) or older than 65 years (aOR, 1.23; 99% CI, 1.06–1.43) had an increased revisit rate, as did black patients (aOR, 1.39; 99% CI, 1.16–1.66); those with Medicare (aOR, 1.55; 99% CI, 1.32–1.81) and Medicaid (aOR, 1.63; 99% CI, 1.33–2.01); those with diagnoses of autoimmune disorders or immunodeficiency (aOR, 2.69; 99% CI, 1.20–6.03), coagulopathy (aOR, 2.06; 99% CI, 1.33– 3.20), anxiety (aOR, 1.79; 99% CI, 1.55–2.07), and alcohol use (aOR, 1.70; 99% CI, 1.35–2.14); and those who had a conchal cartilage graft (aOR, 2.01; 99% CI, 1.29–3.14). CONCLUSIONS AND RELEVANCE—The study results suggest that patients with more medical comorbidities and lower socioeconomic status most commonly returned to the emergency department for surgical complications, such as bleeding or epistaxis, in the 30-day period after the procedure. These data provide valuable preoperative counseling information for patients and physicians. In addition, this study provides data to third-party payers or government agencies in which postprocedure readmissions in the 30-day period are used as a quality care metric affecting reimbursements and financial penalties.
Author Manuscript Author Manuscript
Estimates of the 30-day hospital revisit rate following septorhinoplasty and the risk factors associated with revisits are unknown in the current literature. Septorhinoplasty is generally performed as an elective outpatient procedure owing to the expectation of low rates of surgical complications and need for admission in the perioperative period. Surgical 30-day readmission rates are important to establish, as they are increasingly used as a quality care metric and can incur future financial penalties.1 The Hospital Readmissions Reduction Program, established through the Affordable Care Act in 2012, is a program requiring the Centers for Medicare and Medicaid Services to reduce payments to hospitals with excessive 30-day readmissions.1 Initially, only medical conditions were monitored, including acute myocardial infarction, heart failure, and pneumonia. These conditions have since expanded to include surgical procedures, such as total hip and knee arthroplasty as well as coronary artery bypass surgery. Because many surgical procedures are elective, there is an opportunity to identify patient risk factors associated with a higher rate of hospital revisits and intervene to improve these factors before surgery to reduce revisit rates.2 Several publications about general and orthopedic surgical procedures identified procedural and patient risk factors associated with increased readmission rates,2–5 as have publications focusing on otolaryngology procedures.6–10 The consensus among surgical data is that postsurgical complications are most greatly associated with increased risk of readmission following surgery, but JAMA Facial Plast Surg. Author manuscript; available in PMC 2017 September 17.
Spataro et al.
Page 3
Author Manuscript
socioeconomic factors and patient comorbidities also have a significant effect.2–10 However, data on the 30-day revisit rate specifically relating to facial plastic surgical procedures, including septorhinoplasty, are still lacking.
Author Manuscript
The first objective of this study was to evaluate the 30-day hospital revisit rate and the primary diagnosis at the time of revisit for a large cohort of patients undergoing septorhinoplasty, covering all practices (multisurgeon) and institutions. The second objective was to evaluate patient and procedure characteristics associated with increased rates of 30day hospital revisits. Identification of factors associated with hospital revisits allows for better optimization and preparation of patients and physicians before this elective procedure to reduce 30-day revisit rates and provides normative data to third-party payers. This study uses the same databases that we analyzed to determine septorhinoplasty revision surgery rates,11 which are large all-payer state databases through the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality, currently comprising the largest collection of longitudinal hospital care data in the United States.12
Methods Study Design This study is a secondary data analysis of a cohort of patients who underwent septorhinoplasty between January 1, 2005, and December 31, 2009, in California, Florida, and New York. Information on revisits for these patients was collected from the 3 databases between January 1, 2005, and December 31, 2012. The institutional review board of Washington University in St Louis School of Medicine waived approval of this study as well as the need for informed consent.
Author Manuscript
Data Sources
Author Manuscript
The Healthcare Cost and Utilization Project is a group of health care databases and related software tools and products developed through a federal, state, and industry partnership and sponsored by the Agency for Healthcare Research and Quality. This study uses the following 3 Healthcare Cost and Utilization Project databases: the state ambulatory surgery databases (SASD),13 the state inpatient databases (SID),12 and the state emergency department database (SEDD)14 from California, Florida, and New York. These statewide databases contain information from discharge records for all patients regardless of age or payer (Medicare, Medicaid, private insurance, and no insurance). Records from ambulatory surgery visits at hospitals and freestanding ambulatory surgical centers are provided through the SASD. Discharge records of inpatient hospital visits are provided through the SID. Records from emergency department visits are provided through the SEDD. Individual patients are linked and tracked across all 3 databases with an encrypted patientlevel identifier. An encrypted variable for admission date, together with the length of stay, was used to calculate the period between visits for each patient while keeping exact dates encrypted to protect patient confidentiality.12–14
JAMA Facial Plast Surg. Author manuscript; available in PMC 2017 September 17.
Spataro et al.
Page 4
Study Population
Author Manuscript
Patients 13 years or older who underwent septorhinoplasty at an outpatient surgery center from January 1, 2005, through December 31, 2009, in California, Florida, and New York were identified in the SASD using Current Procedural Terminology codes for primary and secondary septorhinoplasty (30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, and 30520).
Author Manuscript
The index septorhinoplasty procedure was defined as the first septorhinoplasty surgery for each patient in the SASD between January 1, 2005, and December 31, 2009. In addition, patients were required to be residents of the state in which the procedure was performed to limit loss to follow-up. Identified cases in the SASD were then linked by encrypted patient identifier to hospitalizations in the SID and emergency department encounters in the SEDD to obtain information on 30-day hospital revisit rates contained within these databases. A 30day hospital revisit was defined as a revisit to an ambulatory surgery center, emergency department, or inpatient hospital admission within 30 days of the index procedure. Outcome Measures The primary outcome measure was a hospital revisit within 30 days after an index septorhinoplasty procedure. The time between the index procedure and hospital revisit in each of the 3 databases was recorded. These data were then used to calculate the 30-day revisit rate. Primary diagnosis at the time of revisit was also recorded.
Author Manuscript
The secondary analysis examined the association between patient and procedure characteristics and a 30-day hospital revisit. Demographic data were defined at the time of the index procedure. Age was divided into 4 groups: 13 to 18 years, 19 to 40 years, 41 to 65 years, and older than 65 years. Race/ethnicity was categorized as white, black, Hispanic, Asian or Pacific Islander, or other. Primary expected payer was divided into 5 groups: Medicaid, Medicare, private insurance, self-pay, or other. Patient location was categorized as large metropolitan (≥1 million residents), small metropolitan (65
12 644
1398 (11.1)
2.05 (1.81–2.31)
Male
99 255
6600 (6.6)
1 [Reference]
Female
69 717
4570 (6.6)
0.99 (0.91–1.07)
White
116 241
7838 (6.7)
1 [Reference]
Black
4147
390 (9.4)
1.43 (1.21–1.69)
17 898
1369 (7.6)
1.15 (0.98–1.34)
Asian or Pacific Islander
4545
238 (5.2)
0.76 (0.61–0.95)
Other
8392
473 (5.6)
0.83 (0.64–1.07)
Medicare
16 537
1908 (11.5)
2.05 (1.79–2.34)
Medicaid
7128
708 (9.9)
1.73 (1.35–2.22)
131 993
7896 (6.0)
12 323
416 (3.4)
0.55 (0.42–0.72)
7772
524 (6.7)
1.14 (0.87–1.48)
Large metropolitan
125 678
7739 (6.2)
1 [Reference]
Small metropolitan
Characteristic Total
Unadjusted Odds Ratio (99% CI)
State
Age, y
Author Manuscript
Sexa
Raceb
Hispanic
Author Manuscript
Insurancec
Private insurance Self-pay Other
1 [Reference]
Patient locationd
Author Manuscript
41 892
3031 (7.2)
1.90 (1.03–1.37)
Micropolitan
5892
488 (8.3)
1.38 (1.08–1.75)
Not metropolitan or micopolitan
2364
198 (8.4)
1.39 (1.05–1.84)
0 to 25th
16 420
1289 (7.9)
f
26th to 50th
25 987
1759 (6.8)
f
51st to 75th
26 878
1747 (6.5)
f
76th to 100th
30 940
1581 (5.1)
f
Median household income, percentilee
JAMA Facial Plast Surg. Author manuscript; available in PMC 2017 September 17.
Spataro et al.
Page 16
Patients, No.
Patients With Hospital Revisit, No. (%)
0
173 460
11 030 (6.4)
1
2379
425 (17.9)
2
JAMA Facial Plast Surg. Author manuscript; available in PMC 2017 September 17. Published in final edited form as: JAMA Facial Plast Surg. 2016 December 01; 18(6): 420–428. doi:10.1001/jamafacial.2016.0539.
Thirty-Day Hospital Revisit Rates and Factors Associated With Revisits in Patients Undergoing Septorhinoplasty
Author Manuscript
Emily Spataro, MD, Gregory H. Branham, MD, Dorina Kallogjeri, MD, MPH, Jay F. Piccirillo, MD, and Shaun C. Desai, MD Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri (Spataro, Kallogjeri, Piccirillo); Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri (Branham); Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland (Desai)
Abstract IMPORTANCE—Estimates of the 30-day hospital revisit rate following septorhinoplasty and the risk factors associated with revisits are unknown in the current literature. Surgical 30-day readmission rates are important to establish, as they are increasingly used as a quality care metric and can incur future financial penalties from third-party payers and government agencies.
Author Manuscript
OBJECTIVE—To determine the rate of 30-day hospital revisits following septorhinoplasty and the risk factors associated with revisits. DESIGN, SETTING, AND PARTICIPANTS—A retrospective cohort analysis was conducted of 175 842 patients undergoing septorhinoplasty between January 1, 2005, and December 31, 2009, using data from the Healthcare Cost and Utilization Project state inpatient database, state ambulatory surgery database, and state emergency department database from California, Florida, and New York. Information on revisits for these patients was collected from the 3 databases between January 1, 2005, and December 31, 2012. Data analysis was conducted from September 1, 2014, to May 1, 2015.
Author Manuscript
Corresponding Author: Shaun C. Desai, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology– Head and Neck Surgery, Johns Hopkins University School of Medicine, 6420 Rockledge Dr, Ste 4920, Bethesda, MD 20817, ([email protected]). Author Contributions: Drs Spataro and Kallogjeri had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Spataro, Branham, Piccirillo, Desai. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Spataro, Desai. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Spataro, Kallogjeri, Piccirillo. Obtained funding: Desai. Adminstrative, technical, or material support: Branham, Desai. Study supervision: Branham, Piccirillo, Desai. Conflict of Interest Disclosures: None reported.
Spataro et al.
Page 2
Author Manuscript
MAIN OUTCOMES AND MEASURES—Hospital revisits within 30 days after an index septorhinoplasty and the primary diagnosis at the time of the revisit were the main outcome measures. The revisit rate was calculated within subgroups of patients based on different demographic and clinical characteristics. A multivariable model was then used to determine independent risk factors for the occurrence of a hospital revisit within 30 days of the septorhinoplasty procedure.
Author Manuscript
RESULTS—In total, 11 456 of 175 842 patients (6.5%) who underwent septorhinoplasty procedures revisited the hospital within 30 days of the procedure. Most of these revisits (6353 [55.5%]) were to the emergency department. The most common primary diagnosis was bleeding or epistaxis, occurring in 2150 patients (1.2%). Multivariable logistic regression showed that patients aged 41 to 65 years (adjusted odds ratio [aOR], 1.09; 99% CI, 1.02–1.16) or older than 65 years (aOR, 1.23; 99% CI, 1.06–1.43) had an increased revisit rate, as did black patients (aOR, 1.39; 99% CI, 1.16–1.66); those with Medicare (aOR, 1.55; 99% CI, 1.32–1.81) and Medicaid (aOR, 1.63; 99% CI, 1.33–2.01); those with diagnoses of autoimmune disorders or immunodeficiency (aOR, 2.69; 99% CI, 1.20–6.03), coagulopathy (aOR, 2.06; 99% CI, 1.33– 3.20), anxiety (aOR, 1.79; 99% CI, 1.55–2.07), and alcohol use (aOR, 1.70; 99% CI, 1.35–2.14); and those who had a conchal cartilage graft (aOR, 2.01; 99% CI, 1.29–3.14). CONCLUSIONS AND RELEVANCE—The study results suggest that patients with more medical comorbidities and lower socioeconomic status most commonly returned to the emergency department for surgical complications, such as bleeding or epistaxis, in the 30-day period after the procedure. These data provide valuable preoperative counseling information for patients and physicians. In addition, this study provides data to third-party payers or government agencies in which postprocedure readmissions in the 30-day period are used as a quality care metric affecting reimbursements and financial penalties.
Author Manuscript Author Manuscript
Estimates of the 30-day hospital revisit rate following septorhinoplasty and the risk factors associated with revisits are unknown in the current literature. Septorhinoplasty is generally performed as an elective outpatient procedure owing to the expectation of low rates of surgical complications and need for admission in the perioperative period. Surgical 30-day readmission rates are important to establish, as they are increasingly used as a quality care metric and can incur future financial penalties.1 The Hospital Readmissions Reduction Program, established through the Affordable Care Act in 2012, is a program requiring the Centers for Medicare and Medicaid Services to reduce payments to hospitals with excessive 30-day readmissions.1 Initially, only medical conditions were monitored, including acute myocardial infarction, heart failure, and pneumonia. These conditions have since expanded to include surgical procedures, such as total hip and knee arthroplasty as well as coronary artery bypass surgery. Because many surgical procedures are elective, there is an opportunity to identify patient risk factors associated with a higher rate of hospital revisits and intervene to improve these factors before surgery to reduce revisit rates.2 Several publications about general and orthopedic surgical procedures identified procedural and patient risk factors associated with increased readmission rates,2–5 as have publications focusing on otolaryngology procedures.6–10 The consensus among surgical data is that postsurgical complications are most greatly associated with increased risk of readmission following surgery, but JAMA Facial Plast Surg. Author manuscript; available in PMC 2017 September 17.
Spataro et al.
Page 3
Author Manuscript
socioeconomic factors and patient comorbidities also have a significant effect.2–10 However, data on the 30-day revisit rate specifically relating to facial plastic surgical procedures, including septorhinoplasty, are still lacking.
Author Manuscript
The first objective of this study was to evaluate the 30-day hospital revisit rate and the primary diagnosis at the time of revisit for a large cohort of patients undergoing septorhinoplasty, covering all practices (multisurgeon) and institutions. The second objective was to evaluate patient and procedure characteristics associated with increased rates of 30day hospital revisits. Identification of factors associated with hospital revisits allows for better optimization and preparation of patients and physicians before this elective procedure to reduce 30-day revisit rates and provides normative data to third-party payers. This study uses the same databases that we analyzed to determine septorhinoplasty revision surgery rates,11 which are large all-payer state databases through the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality, currently comprising the largest collection of longitudinal hospital care data in the United States.12
Methods Study Design This study is a secondary data analysis of a cohort of patients who underwent septorhinoplasty between January 1, 2005, and December 31, 2009, in California, Florida, and New York. Information on revisits for these patients was collected from the 3 databases between January 1, 2005, and December 31, 2012. The institutional review board of Washington University in St Louis School of Medicine waived approval of this study as well as the need for informed consent.
Author Manuscript
Data Sources
Author Manuscript
The Healthcare Cost and Utilization Project is a group of health care databases and related software tools and products developed through a federal, state, and industry partnership and sponsored by the Agency for Healthcare Research and Quality. This study uses the following 3 Healthcare Cost and Utilization Project databases: the state ambulatory surgery databases (SASD),13 the state inpatient databases (SID),12 and the state emergency department database (SEDD)14 from California, Florida, and New York. These statewide databases contain information from discharge records for all patients regardless of age or payer (Medicare, Medicaid, private insurance, and no insurance). Records from ambulatory surgery visits at hospitals and freestanding ambulatory surgical centers are provided through the SASD. Discharge records of inpatient hospital visits are provided through the SID. Records from emergency department visits are provided through the SEDD. Individual patients are linked and tracked across all 3 databases with an encrypted patientlevel identifier. An encrypted variable for admission date, together with the length of stay, was used to calculate the period between visits for each patient while keeping exact dates encrypted to protect patient confidentiality.12–14
JAMA Facial Plast Surg. Author manuscript; available in PMC 2017 September 17.
Spataro et al.
Page 4
Study Population
Author Manuscript
Patients 13 years or older who underwent septorhinoplasty at an outpatient surgery center from January 1, 2005, through December 31, 2009, in California, Florida, and New York were identified in the SASD using Current Procedural Terminology codes for primary and secondary septorhinoplasty (30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, and 30520).
Author Manuscript
The index septorhinoplasty procedure was defined as the first septorhinoplasty surgery for each patient in the SASD between January 1, 2005, and December 31, 2009. In addition, patients were required to be residents of the state in which the procedure was performed to limit loss to follow-up. Identified cases in the SASD were then linked by encrypted patient identifier to hospitalizations in the SID and emergency department encounters in the SEDD to obtain information on 30-day hospital revisit rates contained within these databases. A 30day hospital revisit was defined as a revisit to an ambulatory surgery center, emergency department, or inpatient hospital admission within 30 days of the index procedure. Outcome Measures The primary outcome measure was a hospital revisit within 30 days after an index septorhinoplasty procedure. The time between the index procedure and hospital revisit in each of the 3 databases was recorded. These data were then used to calculate the 30-day revisit rate. Primary diagnosis at the time of revisit was also recorded.
Author Manuscript
The secondary analysis examined the association between patient and procedure characteristics and a 30-day hospital revisit. Demographic data were defined at the time of the index procedure. Age was divided into 4 groups: 13 to 18 years, 19 to 40 years, 41 to 65 years, and older than 65 years. Race/ethnicity was categorized as white, black, Hispanic, Asian or Pacific Islander, or other. Primary expected payer was divided into 5 groups: Medicaid, Medicare, private insurance, self-pay, or other. Patient location was categorized as large metropolitan (≥1 million residents), small metropolitan (65
12 644
1398 (11.1)
2.05 (1.81–2.31)
Male
99 255
6600 (6.6)
1 [Reference]
Female
69 717
4570 (6.6)
0.99 (0.91–1.07)
White
116 241
7838 (6.7)
1 [Reference]
Black
4147
390 (9.4)
1.43 (1.21–1.69)
17 898
1369 (7.6)
1.15 (0.98–1.34)
Asian or Pacific Islander
4545
238 (5.2)
0.76 (0.61–0.95)
Other
8392
473 (5.6)
0.83 (0.64–1.07)
Medicare
16 537
1908 (11.5)
2.05 (1.79–2.34)
Medicaid
7128
708 (9.9)
1.73 (1.35–2.22)
131 993
7896 (6.0)
12 323
416 (3.4)
0.55 (0.42–0.72)
7772
524 (6.7)
1.14 (0.87–1.48)
Large metropolitan
125 678
7739 (6.2)
1 [Reference]
Small metropolitan
Characteristic Total
Unadjusted Odds Ratio (99% CI)
State
Age, y
Author Manuscript
Sexa
Raceb
Hispanic
Author Manuscript
Insurancec
Private insurance Self-pay Other
1 [Reference]
Patient locationd
Author Manuscript
41 892
3031 (7.2)
1.90 (1.03–1.37)
Micropolitan
5892
488 (8.3)
1.38 (1.08–1.75)
Not metropolitan or micopolitan
2364
198 (8.4)
1.39 (1.05–1.84)
0 to 25th
16 420
1289 (7.9)
f
26th to 50th
25 987
1759 (6.8)
f
51st to 75th
26 878
1747 (6.5)
f
76th to 100th
30 940
1581 (5.1)
f
Median household income, percentilee
JAMA Facial Plast Surg. Author manuscript; available in PMC 2017 September 17.
Spataro et al.
Page 16
Patients, No.
Patients With Hospital Revisit, No. (%)
0
173 460
11 030 (6.4)
1
2379
425 (17.9)
2
