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Post-operative 30-day Readmission: Time to Focus on What Happens Outside the Hospital
Melanie S Morris*1, Laura Graham*1, Joshua Richman*1, Kamal M.F. Itani2, Amy Rosen*2, Hillary Mull*2, Sara Knight*1, Mary T Hawn3
1University of Alabama at Birmingham, Birmingham, AL;2Boston University, Boston, MA;3Stanford University, Palo Alto, CA

Introduction:
Assuming post-operative readmissions are preventable suggests that they are linked to the quality of care during the index hospitalization. The aim of this study is to understand the relative contributions of patient factors, operative characteristics and post-operative hospital course on readmissions.
Methods:
VA NSQIP data on a cohort of inpatient general, vascular and orthopedic surgeries performed between 2008-14 were merged with clinical data including laboratory, vitals, prior healthcare utilization and post-operative complications. Variables were categorized into the following groups: (1) Preoperative, (2) Operative, (3) Postoperative/Pre-discharge, and (4) Post-discharge. Logistic models predicting 30-day readmission were constructed by sequentially adding groups into the model. We compared models using adjusted R2 and C-statistics.
Results:
Our sample included 243,956 patients in 121 VA hospitals. Overall readmission rate was 12.4% (general:13.9%, vascular:17.9%, orthopedic:8.4%). Figure 1 demonstrates the incremental contribution to the readmission model assessed by cumulative R2 and C-statistic of each timepoint. Overall, 7.7% of readmission occurrence was explained by preoperative and planned operative information (C-statistic=0.68). This increased to 10.1% (C-statistic=0.70) when index hospital intra-operative and post-operative data were added. Post-discharge complications markedly improved model R2 to 26.5% (C-statistic=0.76)
Conclusion:
Information known prior to surgical admission is an important predictor of postoperative readmission, however, the hospital course had little incremental impact on explaining either post-discharge complications or readmission. Efforts should focus on enhanced post-discharge surveillance and early intervention.


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