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Is all-cause readmission an appropriate performance measure for pediatric surgeons? A case study in pyloromyotomy
Isobel H Marks1, David C Chang2, Peter T Masiakos3
1Department of Surgery, Massachusetts General Hospital; Barts and the London School of Medicine and Dentistry, University of London.
Insights
All-cause readmissions are twice as likely as surgical complication readmissions after pyloromyotomy for hypertrophic pyloric stenosis. This suggests all-cause readmissions are an inadequate metric for pediatric surgical quality.
Area of Science:
- Pediatric Surgery
- Health Services Research
- Quality Improvement
Background:
- All-cause readmissions are a key performance indicator for healthcare quality.
- Their utility as a benchmark for surgical outcomes, particularly in pediatric procedures like pyloromyotomy, is not well-established.
- Pyloromyotomy for hypertrophic pyloric stenosis is a common pediatric surgery with generally low complication rates.
Purpose of the Study:
- To investigate the rate and causes of all-cause readmissions following pyloromyotomy for hypertrophic pyloric stenosis.
- To compare all-cause readmissions with surgically-related readmissions.
- To evaluate the appropriateness of using all-cause readmissions as a quality metric for this procedure.
Main Methods:
- A retrospective analysis of 1900 patients undergoing pyloromyotomy for hypertrophic pyloric stenosis in California (1995-2009).
- Data were extracted from the Office of Statewide Health Planning and Development database.
- Inclusion criteria included a primary procedure code for pyloromyotomy, diagnosis of hypertrophic pyloric stenosis, and no prior hospital admissions.
Main Results:
- The 30-day all-cause readmission rate was 4.01%, while the surgically-related readmission rate was 2.16%.
- Surgically-related readmissions accounted for 36% of 30-day readmissions.
- The most common readmission diagnoses were respiratory infections (43%) and non-surgical gastrointestinal issues (14%).
Conclusions:
- All-cause readmissions are twice as common as surgically-related readmissions after pyloromyotomy.
- All-cause readmission is an insufficient metric for assessing the quality of pediatric surgical care for this procedure.
- The findings highlight the need for more specific quality indicators in pediatric surgery.
Introduction:
All cause readmissions are used as a surrogate metric for quality of care for both hospitals and physicians, and are considered in pay for performance initiatives. However, the integrity of using all cause readmissions as a benchmark for surgical outcomes has received little attention. Pyloromyotomy for hypertrophic pyloric stenosis is considered a safe pediatric surgical procedure with few complications or readmissions. The incidence of in hospital complications has been reported, however the rate of readmissions and specifically the proportion of readmissions related to surgical complications have not been previously reported.
Methods:
Data were abstracted from the longitudinally linked Office of Statewide Health Planning and Development data from the State of California from 1995 to 2009, allowing patient tracking across all hospitals and years within California. Inclusion criteria were primary procedure code of pyloromyotomy, a diagnosis code of hypertrophic pyloric stenosis, and no prior record of any in-hospital admission.
Results:
A total of 1900 patients were identified: 16.8% girls, 31.7% whites, 5.1% blacks, and 58.2% Hispanics. The median length of stay was 2days (IQR 2-3days). The in-hospital complication rate was 5.16% and overall complication rate was 6.84%; there were no deaths. The rate of 30-day all-cause readmission was 4.01%, with a median of 0% across hospitals (IQR 0%-1.1%); and 13.2% of readmissions occurred at a different hospital. Surgically-related readmission rate was 2.16%. Surgically-related readmission comprised 36% readmissions at 30days, but only 13% readmissions overall. The top three primary diagnoses on readmission were respiratory infections (43%), nonrespiratory infections (14%) and other nonsurgical GI indications (14%). All-cause readmissions at 60days, 90days, 180days, and 1year were 5.8%, 7.3%, 10.4%, and 13.7%, respectively.
Conclusion:
Thirty-day readmission for a surgical complication occurs in 1 of 50 patients undergoing a pyloromyotomy for hypertrophic pyloric stenosis but for all causes is twice as likely, 1 in 25 patients. All-cause readmission is an inadequate measure for the quality of surgical care and the performance of pediatric surgeons. This is a Prognostic Study with Level II Evidence.
