Abstract
Ambulatory surgery in geriatric populations is increasingly prevalent. Prior studies have demonstrated the association between frailty and readmissions in the inpatient setting. However, few data exist regarding the association between frailty and readmissions after outpatient procedures. To examine the association between frailty and 30-day unplanned readmissions after elective outpatient surgical procedures as well as the potential mediation of surgical complications. In this retrospective cohort study of elective outpatient procedures from 2012 and 2013 in the National Surgical Quality Improvement Program (NSQIP) database, 417 840 patients who underwent elective outpatient procedures were stratified into cohorts of individuals with a length of stay (LOS) of 0 days (LOS = 0) and those with a LOS of 1 or more days (LOS ≥ 1). Statistical analysis was performed from June 1, 2018, to March 31, 2019. Frailty, as measured by the Risk Analysis Index. The main outcome was 30-day unplanned readmission. Of the 417 840 patients in this study, 59.2% were women and unplanned readmission occurred in 2.3% of the cohort overall (LOS = 0, 2.0%; LOS ≥ 1, 3.4%). Frail patients (mean [SD] age, 64.9 [15.5] years) were more likely than nonfrail patients (mean [SD] age, 35.0 [15.8] years) to have an unplanned readmission in both LOS cohorts (LOS = 0, 8.3% vs 1.9%; LOS ≥ 1, 8.5% vs 3.2%; P < .001). Frail patients were also more likely than nonfrail patients to experience complications in both cohorts (LOS = 0, 6.9% vs 2.5%; LOS ≥ 1, 9.8% vs 4.6%; P < .001). In multivariate analysis, frailty doubled the risk of unplanned readmission (LOS = 0: adjusted relative risk [RR], 2.1; 95% CI, 2.0-2.3; LOS ≥ 1: adjusted RR, 1.8; 95% CI, 1.6-2.1). Complications occurred in 3.1% of the entire cohort, and frailty was associated with increased risk of complications (unadjusted RR, 2.6; 95% CI, 2.4-2.8). Mediation analysis confirmed that complications are a significant mediator in the association between frailty and readmissions; however, it also indicated that the association of frailty with readmission was only partially mediated by complications (LOS = 0, 22.8%; LOS ≥ 1, 29.3%). These findings suggest that frailty is a significant risk factor for unplanned readmission after elective outpatient surgery both independently and when partially mediated through increased complications. Screening for frailty might inform the development of interventions to decrease unplanned readmissions, including those for outpatient procedures.
Highlights
Unplanned hospital readmission represents a significant financial burden to the medical system and is closely tied to postoperative complications.[1,2,3] Most studies on readmission far have focused on inpatient surgical procedures.[4,5,6,7] Less is known about readmissions for outpatient procedures or those in the ambulatory setting despite an increased frequency of such procedures nationwide.[8]
Frailty doubled the risk of unplanned readmission (LOS = 0: adjusted relative risk [RR], 2.1; 95% CI, 2.0-2.3; length of stay (LOS) Ն 1: adjusted RR, 1.8; 95% CI, 1.6-2.1)
Complications occurred in 3.1% of the entire cohort, and frailty was associated with increased risk of complications
Summary
Unplanned hospital readmission represents a significant financial burden to the medical system and is closely tied to postoperative complications.[1,2,3] Most studies on readmission far have focused on inpatient surgical procedures.[4,5,6,7] Less is known about readmissions for outpatient procedures or those in the ambulatory setting despite an increased frequency of such procedures nationwide.[8] The cost savings associated with ambulatory surgery centers has led to increased use of ambulatory surgery by the elderly for common procedures.[9] Generally, outpatient surgery has been difficult to study because of its inconsistent definition in databases and the literature.[10,11,12] In addition, Medicare beneficiaries are increasingly being hospitalized under “observation” status despite staying in the hospital up to 3 days.[13] Of the few studies that have focused on readmissions in the outpatient surgery setting, readmissions have been linked to surgical complications, obesity, and increased patient age.[14,15]
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