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The 5th Vital Sign: Postoperative Pain Predicts 30-day Readmission and Emergency Department Visits
Mary T Hawn1, Laura Graham2, Tyler Wahl2, Elise Aucoin2, Karishma Desai1, Melanie Morris2, Kamal Itani3, Gordon Telford4, Joshua Richman5, Tina Hernandez-Boussard1
1Stanford University, Stanford, CA;2University of Alabama at Birmingham, Birmingham, AL;3Boston VAMC, Boston, MA;4Medical College of Wisconsin, Milwaukee, WI;5University of Alabama at Birmingham, Birminham, AL

Objectives: Surgical readmissions have few known modifiable predictors. We hypothesized that inpatient postoperative pain trajectories are associated with 30-day inpatient readmission and emergency department (ED) visits.
Methods: National VASQIP data on inpatient general, vascular, and orthopedic surgery from 2008-2014 were merged with laboratory, vital sign, healthcare utilization, and postoperative complications data. Six distinct postoperative inpatient pain trajectories were identified: (1) persistently low, (2) mild to low, (3) persistently mild (4) moderate to low, (5) persistently moderate or (6) persistently high based on postoperative pain scores. Regression models estimated the association between pain trajectories and post-discharge utilization while controlling for important patient and clinical variables.
Results: Our sample included 211,213 surgeries: 45% orthopedics, 37% general, and 18% vascular. Overall, the 30-day unplanned readmission rate was 10.8% and 30-day ED utilization rate was 14.2%. Patients in the high pain trajectories had the highest rates of post-discharge readmissions and ED visits (14.4% and 16.3%, respectively, p<0.001). In multivariable models, compared to the persistently low pain trajectory, there was a dose dependent increase in post-discharge ED visits and readmission for pain-related diagnoses (X2 trend p<0.001) (FIGURE).
Conclusions: Postoperative pain trajectories identify populations at risk for 30-day readmissions and ED visits and does not appear to be mediated by post-discharge complications. Addressing pain control expectations prior to discharge may help reduce surgical readmissions in high pain categories.

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