Background
Methods
Study design and aims
Aim | Methods |
---|---|
1 Evaluate contribution of patient, procedure, postoperative and systems factors following major surgery (with minimum 2-day stay) to develop and validate a readmission risk prediction model. Classify reasons for readmissions and related processes of care. | Acquire and merge retrospective data from the VA Surgical Quality Improvement Program for all assessed surgeries between October 1, 2007 and September 30, 2014 |
Investigate predictors of 30-day unplanned readmission following surgery using logistic regression | |
Develop a risk prediction tool for 30-day unplanned readmission following surgery | |
Determine readmission reason categories from primary ICD9 diagnosis codes | |
Report findings to National Surgery Office Advisory Board | |
2 Assess potential patient factors not currently collected by VASQIP for association with readmission | Develop and pilot a prospective survey to assess patient psychosocial factors at discharge |
Recruit 800 surgical patients from four (4) VA sites distributed across the nation | |
Administer prospective survey prior to discharge and follow patients for 30 days post-discharge to assess readmission | |
Assess the association between psychosocial factors not currently assessed in administrative data and 30-day unplanned readmission in the prospective cohort | |
Further explore predictors of 30-day unplanned readmission following surgery using psychosocial factors | |
3 Rank reasons for readmission based on Aim 1 and Aim 2 and assess for potential preventability and appropriateness for classification as a measure of surgical quality. | Develop Delphi process form using readmission reasons defined in Aim 1 |
Convene Delphi panel participants | |
Rank readmission reasons as (1) potentially preventable and (2) appropriate measures of surgical quality | |
Report findings to National Surgery Office Advisory Board |
Cohort
Data source: VASQIP
Component | Variable | Data Source |
---|---|---|
Pre-Admission | ||
Demographics | Sex, Race/Ethnicity | CDW Patient Tables |
Age | CDW Vital Status Files | |
Comorbidities | Functional Status, DNR Status | VASQIP |
History of: Angina, Congestive Heart Failure, Cerebrovascular Accident, Peripheral Vascular Disease, Cardiac Surgery, Pre-operative Coma, Impaired Sensorium, Ascites, Esophageal Varices, Bleeding Disorders, Disseminated Cancer, Steroid Use, RBC Transfusion, Wound Infection, Weight Loss, Pneumonia, Ventilator Dependence, Dialysis, Acute Renal Failure | ||
Social/Behavioral | BMI, >2 Drinks/Day in the 2 Weeks Before Admission, Pack-Years Smoking | VASQIP |
Marital Status | CDW Patient Table | |
Pre-Admission Inpatient and ER Utilization | CDW Inpatient and Outpatient Tables | |
Preoperative Labs & Vitals | Albumin, Bicarbonate, Bilirubin, BUN, Calcium, Chloride, Serum Creatinine, Creatinine eGFR, Glucose, Hematocrit, Hemoglobin, INR, Potassium, Sodium, WBC | MCA Laboratory |
Systolic & Diastolic Blood Pressure, Pain, Pulse, Pulse Oximetry, Respiration Rate, Temperature | CDW Vital Signs | |
Hospital Factors | Index Hospitalization Facility | VASQIP |
Operative | ||
Complexity | Urgent/Emergent status, Inpatient/Outpatient status, Operative Time, Intraoperative RBC transfusion, Wound Classification, work RVU | VASQIP |
Other | Year of Surgery, ASA classification, Anesthesia technique | VASQIP |
Post-Operative | ||
Postoperative Labs & Vitals | Albumin, Bicarbonate, Bilirubin, BUN, Calcium, Chloride, Serum Creatinine, Creatinine eGFR, Glucose, Hematocrit, Hemoglobin, INR, Potassium, Sodium, WBC | MCA Laboratory |
Systolic & Diastolic Blood Pressure, Pain, Pulse, Pulse Oximetry, Respiration Rate, Temperature | CDW Vital Signs | |
Pre-Discharge Complications | Cardiac Arrest, Myocardial Infarction, Coma, Cerebral Vascular Accident, Wound Disruption, Failure to Wean, Peripheral Nerve Injury, Acute Renal Failure, Organ/Space SSI, RBC Transfusion, DVT/Thrombophlebitis, Pneumonia, Pulmonary Embolism, Reintubation, Progressive Renal Insufficiency, Sepsis, Superficial Infection, Urinary Tract Infection, Deep Wound Infection | VASQIP |
ICU Utilization | ICU visits during the index hospitalization | CDW Inpatient Tables |
Other Postoperative | Postoperative Length of Stay, Number of Surgeries during Index Hospitalization | VASQIP |
Discharge Destination | CDW Inpatient Tables | |
Post-Discharge | ||
Discharge Characteristics | Care Coordination, Caregiver Accessibility, | CTM-15 |
Discharge Destination, Functional Status at Discharge, Transportation | Discharge, Readmission, and Follow-Up Interviews | |
Discharge Complexity | Medications, Wound Care Instructions, Mobility | Discharge Interview |
Patient Characteristics at Discharge | General Health | VR-12 |
Cognitive Function | SBT | |
Pain at Discharge | Visual Analogue Scale | |
Post-Discharge Clinic Utilization | VA Clinic Stops in the 30-days post-discharge | CDW Outpatient Tables |
Post-Discharge Complications | Cardiac Arrest, Myocardial Infarction, Coma, Cerebral Vascular Accident, Wound Disruption, Peripheral Nerve Injury, Acute Renal Failure, Organ/Space SSI, RBC Transfusion, DVT/Thrombophlebitis, Pneumonia, Pulmonary Embolism, Reintubation, Progressive Renal Insufficiency, Sepsis, Superficial Infection, Urinary Tract Infection, Deep Wound Infection | VASQIP |
Medical Chart Abstraction | ||
Other | Changes in: Care Coordination, Caregiver Accessibility, Transportation, Medications | Follow-up Interview |
Pain at Follow-Up/Readmission | Visual Analogue Scale | |
Outcome | ||
Inpatient Readmission | Inpatient Admission within 30-days Following Index Hospitalization Discharge | CDW Inpatient Tables |
Readmission Interview | ||
Unplanned ER Admission | ER utilization within 30-days Following Index Hospitalization Discharge | CDW Outpatient Tables |
Readmission Interview |
VA administrative data
Total Surgeries | Total Readmissions | Readmissions within 30-days of Discharge | ||||||||
---|---|---|---|---|---|---|---|---|---|---|
VA-Only | CMS-Onlya
| VA & CMSa
| ||||||||
N
| (%) |
N
| (%) |
N
| (%) |
N
| (%) |
N
| (%) | |
All Surgeries | 22,648 | 3367 | (14.9) | 3231 | (14.3) | 88 | (0.4) | 48 | (0.2) | |
No CMS Coverage | 16,918 | (74.7) | 2285 | (13.5) | 2285 | (13.5) | 0 | (0.0) | 0 | (0.0) |
With CMS Coverage | 5730 | (25.3) | 1082 | (18.9) | 946 | (16.5) | 88 | (1.5) | 48 | (0.8) |
Survey data
RUG-ADL Assessment | The Resource Utilization Group – Activities of Daily Living Assessment measures functional status at discharge, readmission and at 30-day follow-up. This four-item validated questionnaire assesses a patient’s independence with mobility, toileting, transfer and eating [39]. |
Pain | The National Institutes of Health Numeric Rating Pain Scale assesses pain intensity at the time of discharge, readmission and 30-day follow-up [40]. |
Pain Meds | Total dose of pain medication administered 24 h (7 am-7 am) before discharge |
Perceived Stress Scale | Cohen’s Perceived Stress Scale (PSS) is a 10-item scale that quantifies patient’s stress. The PSS has been shown to correlate with health behavior and health services utilization [41]. |
CES-D4 | The Center for Epidemiologic Studies Depression Screen, 4-item version, assesses psychological distress at the time of discharge. The CES-D4 has been shown to be have a positive predictive value of 85% for depression in an older adult population [31]. |
MoCA | The Montreal Cognitive Assessment is a validated tool to assess a patient’s cognitive function. This tool has a positive predictive value of 89% for mild cognitive impairment (90% sensitivity; 87% specificity) when compared to clinical criteria supported by psychometric measures [42]. |
Caregiver Accessibility | |
Transportation | Patient access to transportation and burden of transportation (number of post-operative visits and travel distance). |
CTM-15, adapted | The Care Transition Measure is a 15-item scale that addresses the hospital’s efforts at care coordination at discharge. The survey also assesses patient self-efficacy in implementing the discharge plan. The tool was designed as a post-discharge, recall assessment [45]. We will adapt the tool: a) to assess these items on the day of discharge; b) to assess patient self-efficacy with wound, indwelling device, new ostomy or durable medical equipment, as applicable; and c) to assess patient understanding of whom and when to contact regarding warning signs or symptoms that may arise. |
Institute for Healthcare Improvement Readmission Tool | This tool was developed by IHI as part of a conceptual roadmap to reduce avoidable re-hospitalizations by intervening at the system level. The tool will be adapted for surveying patients at readmission [46]. |
Brief Survey of Post-operative Care | Queries patient on unplanned emergency visit or readmission at an outside hospital; keeping post-operative appointments; difficulty getting medications filled (costs) and refilled (especially pain medication); receipt of home health or durable medical equipment. |
Study outcomes
Analysis plan
Model building for Aim 1
Pre-Admission Model | Discharge Model | Enhanced Model | |
---|---|---|---|
Variables | |||
Pre-Admission | |||
Patient Factors | X | X | X |
# Pre-index admissions | X | X | X |
Age | X | X | X |
ASA class | X | X | X |
Co-morbid conditions | X | X | X |
Do Not Resuscitate status | X | X | X |
Functional status | X | X | X |
Gender | X | X | X |
Lab values | X | X | X |
Marital status | X | X | X |
Pain score | X | X | X |
Race | X | X | X |
Smoking/Alcohol status | X | X | X |
Procedure Factors | X | X | X |
Fiscal Year | X | X | X |
Indication for surgery | X | X | X |
Operation complexity | X | X | X |
Procedure type | X | X | X |
Hospital Factors | X | X | X |
Facility (or VISN) | X | X | X |
Post-Operative/Pre-Discharge | |||
Surgical Complications | X | X | |
Hospital Acquired Infections | X | X | |
Emergent/Elective | X | X | |
Lab values | X | X | |
Length of Stay | X | X | |
Pain Score | X | X | |
Procedure Characteristics | X | X | |
Vital Signs at Discharge | X | X | |
Post-Discharge | |||
Care Coordination at Discharge | X | ||
Caregiver Accessibility | X | ||
Cognitive Function | X | ||
Depression/Mood | X | ||
Discharge Complexity | X | ||
Discharge Destination | X | ||
Functional Status at Discharge | X | ||
Healthcare Utilization | X | ||
Perceived Stress | X | ||
Post-Discharge Complications | X | ||
Transportation | X |
Risk prediction tool
Development of readmission reason categories
ICD-9 Category | Code | Description |
N
| (%) |
---|---|---|---|---|
Injury and poisoning | 998.59 | Other postoperative infection | 214 | (18.4) |
Injury and poisoning | 099.74 | Digestive system complications | 116 | (10.0) |
Endocrine, nutritional, and metabolic | 276.51 | Dehydration | 60 | (5.2) |
Digestive system | 560.9 | Unspecified intestinal obstruction | 58 | (5.0) |
Genitourinary system | 584.9 | Acute kidney failure, unspecified | 53 | (4.6) |
Injury and poisoning | 998.32 | Disruption of external operation wound | 43 | (3.7) |
Digestive system | 567.22 | Peritoneal abscess | 41 | (3.5) |
Genitourinary system | 599.0 | Urinary tract infection | 38 | (3.3) |
Infectious and parasitic diseases | 084.5 | Clostridium difficile | 33 | (2.8) |
Injury and poisoning | 998.31 | Disruption of internal wound | 21 | (1.8) |