The Laryngoscope
C 2014 The American Laryngological,
V
Rhinological and Otological Society, Inc.
Predictors of Readmission After Outpatient Otolaryngologic Surgery
Umang Jain, BA; Rakesh K. Chandra, MD; Stephanie S. Smith, MD; Matthew Pilecki, BA;
John Y. S. Kim, MD
Objectives/Hypothesis: Hospital readmissions increase costs to hospitals and patients. There is a paucity of data on
benchmark rates of readmission for otolaryngological surgery. Understanding the risk factors that increase readmission rates
may help enhance patient education and set system-wide expectations. We aimed to provide benchmark data on causes and
predictors of readmission following outpatient otolaryngological surgery.
Study Design: This study is a retrospective analysis of the 2011 National Surgical Quality Improvement Program
(NSQIP) dataset.
Methods: NSQIP was reviewed for outpatients with “Otolaryngology (ENT)” as their recorded surgical specialty. Readmission was tracked through the “Unplanned Readmission” variable. Patient characteristics and outcomes were compared
using chi-square analysis and student t tests for categorical and continuous variables, respectively. Multivariate regression
analysis investigated predictors of readmission.
Results: A total of 6,788 outpatient otolaryngological surgery patients were isolated. The unplanned readmission rate
was 2.01%. Multivariate regression analysis revealed superficial surgical site infection (odds ratio [OR] 2.672, confidence
interval [CI] 1.133-6.304, P 5.025) and work relative value units (RVU) (OR .972, CI .944–1, P 5.049) to be significant predictors of readmission.
Conclusion: Outpatient otolaryngological surgery has an associated 2.01% unplanned readmission rate. Superficial surgical site infection and work RVUs proved to be significant positive and negative risk factors, respectively, for readmission.
These findings will help to benchmark outpatient readmission rates and manage patient and hospital system expectations.
Key Words: unplanned readmissions, NSQIP.
Level of Evidence: 2c.
Laryngoscope, 124:1783–1788, 2014
INTRODUCTION
Unplanned hospital readmissions have become a
topic of particular interest in the United States due to
their proven contribution to high health care costs.1 A
recent MedPAC Medicare analysis revealed that readmissions make up 17.6% of Medicare costs—or $15 billion in expenditures annually—of which $12 billion are
potentially preventable.2 Increased costs due to preventable readmissions seem to expand beyond Medicare’s
coverage as well. As such, the healthcare system has
adopted readmissions as a quality measure, with
increased rates reflecting suboptimal healthcare, in
order to make a more efficient and cost-effective sys-
From the Division of Surgery, Northwestern University (U.J., M.P.,
Illinois; and the Department of Otolaryngology–Head & Neck
Surgery (R.K.C., S.S.S.), Feinberg School of Medicine, Chicago, Illinois.
Editor’s Note: This Manuscript was accepted for publication
November 19, 2013.
The American College of Surgeons National Surgical Quality
Improvement Program and the hospitals participating in the ACS
NSQIP are the source of the data used herein. They have not verified
and are not responsible for the statistical validity of the data analysis or
the conclusions derived by the authors.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to John Y.S. Kim, MD, Division of Surgery,
Northwestern University, Feinberg School of Medicine, 675 North St.
Clair Street, Galter Suite 19-250, Chicago, IL 60611.
E-mail: [email protected]
J.Y.S.K.),
DOI: 10.1002/lary.24533
Laryngoscope 124: August 2014
tem.3 The health and financial benefits of readmission
reduction have prompted payers and policymakers to
reform sectors of healthcare that are expensive and offer
opportunities for quality improvement.
The Obama Administration targeted these lowperforming sectors through the Affordable Care Act’s
Hospital Readmissions Reduction Program (HRRP).4
The HRRP targets hospital readmissions as a cost-andquality measure and enacts penalties for hospitals that
display above average hospital readmission rates.4
Although the HRRP currently only focuses on certain
medical conditions, its development should raise awareness regarding readmissions in surgical fields as well.
Seventy percent of surgical Medicare patients readmitted within 30 days were readmitted with a medical diagnosis—not a surgical one—of which 90% were
unplanned.5 Unplanned readmissions certainly factor
into higher medical bills. In order to prevent future
occurrences, the causes of these readmissions should be
explored. There is a paucity of data on hospital readmission rates following outpatient otolaryngological surgery;
therefore, we sought to provide benchmark rates and
outline significant causes for unplanned readmission following outpatient otolaryngological surgery.
Although large outcomes databases have traditionally provided detailed and generalizable surgical data,
readmissions data has only recently been tracked. Thus,
using the National Surgical Quality Improvement Program (NSQIP) database, which represents over 400
Jain et al.: Readmission After Outpatient Otolaryngologic Surgery
1783
TABLE I.
Readmission Rates Categorized by CPT Code and Ranked by
Number of Readmission Occurrences (Procedures with n > 50).
Procedure
CPT
n
Readmission Rate
Thyroidectomy, total or
subtotal for malignancy;
with limited neck
dissection
60252
54
7.41%
Cervical lymphadenectomy
(modified radical neck
dissection)
38724
89
5.62%
Uvulopalatopharyngoplasty
42145
293
3.41%
Tonsillectomy and
adenoidectomy; age 12
years or older
42821
422
3.08%
Glossectomy; less than
one-half tongue
41120
66
(COPD), bleeding disorder, hypertension requiring medication,
and work relative value units (RVU). Medical complications
documented by NSQIP include deep vein thrombosis (DVT),
pulmonary embolism, unplanned reintubation, ventilator
dependence (> 48 hours), renal insufficiency, acute renal failure, coma, stroke, cardiac arrest, myocardial infarction, peripheral nerve injury, pneumonia, urinary tract infection, bleeding
requiring transfusion, sepsis, and septic shock. Additionally,
surgical complications recorded by NSQIP include superficial,
deep, and organ/space surgical site infection (SSI), as well as
prosthesis failure.
Statistical Analysis
3.03%
CPT 5current procedural terminology.
hospitals across the United States, we sought to investigate
readmissions after outpatient otolaryngological surgery.
MATERIALS AND METHODS
A retrospective analysis was performed on data collected
from the 2011 NSQIP participant use files. The data collection
methods for NSQIP have been previously described in detail.6–8
Briefly, 240 variables, including patient demographics, comorbidities, preoperative laboratory values, perioperative details,
and 30-day risk-adjusted postoperative outcomes were prospectively collected for each patient. To ensure accuracy, certified
nurse reviewers are rigorously trained to collect patient information according to standardized definitions and the data is
regularly audited. Deidentified patient information is freely
available to all institutional members who comply with the
ACS-NSQIP Data Use Agreement. The Data Use Agreement
implements the protections afforded by the Health Insurance
Portability and Accountability Act of 1996 and the ACS-NSQIP
Hospital Participation Agreement.
Patients undergoing outpatient otolaryngological surgery
were identified using the “Surgical Specialty” and “Inpatient/
Outpatient” variables. Patients with no gender information
were excluded. A total of 6,788 outpatient otolaryngological surgery patients were identified.
The five procedures (categorized by current procedural terminology [CPT] code and only considering those with n > 50)
with the highest readmissions rates were found: 1) thyroidectomy, total or subtotal for malignancy, with limited neck dissection; 2) cervical lymphadenectomy (modified radical neck
dissection); 3) uvulopalatopharyngoplasty; 4) tonsillectomy and
adenoidectomy; and 5) glossectomy, less than one-half tongue.
(Table I) Closed procedures (n 5 2,127) included all tonsillectomy, adenoidectomy, laryngoscopy, and nasal sinus endoscopy
CPT codes. Open procedures (n 5 2151) included all thyroidectomy, neck dissection, lymph node dissection, and salivary gland
excision CPT codes. Open/contaminated procedures (n 5 18)
included all CPT codes for laryngectomy, mandibulectomy, composite resection, and craniofacial resection. Readmission rates
for outpatient cardiac, general, gynecological, neurological,
orthopedic, plastic, thoracic, urologic, and vascular surgical procedures were also found from the NSQIP database. (Fig. 1).
Patient demographics and risk factors (Table II), as well
as postoperative outcomes (Table III), were calculated through
frequency analysis. History of COPD, superficial surgical site
infection, work RVUs, American Society of Anesthesiology
(ASA) Class 3-5, obesity, and gender were found to be significant in bivariate screen analysis (n 10, P <.2) and were
included in the final multivariate logistic regression to determine independent predictors of unplanned readmission in all
procedures (Table IV). A separate regression considered all procedures except tonsillectomies and included age, obesity, RVUs,
and operative time as variables (Table V). Hosmer-Lemeshow
(HL) tests for calibration were computed to assess the goodnessof-fit model.
RESULTS
Outcome
The primary outcome of this study was 30-day unplanned
readmission. NSQIP incorporated a new variable entitled
“Unplanned Readmission” into its 2011 dataset, which is
defined as “readmission (to the same or another hospital) for a
postoperative occurrence likely related to the principal surgical
procedure” within 30 days of the procedure.6 We utilized the
“Unplanned Readmission” variable to calculate readmission
rates and to provide a more focused investigation into predictors of readmission.
A total of 6,788 otolaryngological surgery cases
were extracted from the 2011 NSQIP database. One
hundred thirty-six patients were readmitted within 30
Risk-Adjustment Factors
Patient demographics and medical comorbidities were
tracked as potential cofounders. Patient demographics collected
included sex, race, and age, as well as various clinical characteristics such as smoking, alcohol use, chemotherapy/radiotherapy in last 30 days, previous operation in last 30 days, obesity,
diabetes, dyspnea, chronic obstructive pulmonary disease
Laryngoscope 124: August 2014
1784
Fig. 1. Readmission
specialties.
rates
for
various
outpatient
surgical
Jain et al.: Readmission After Outpatient Otolaryngologic Surgery
TABLE II.
Demographics.
Non-readmitted
%
Readmitted
%
P
2654
3988
40.0%
60.0%
66
70
48.53%
51.47%
0.044
White
Black
4840
425
72.9%
6.4%
105
11
77.21%
8.09%
Asian
246
3.7%
2
1.47%
Other
Age
99
45.27 618.057
1.5%
1
41.38 6 18.470
0.74%
1279
104
19.3%
1.6%
28
0
20.59%
0.00%
Chemotherapy < 30 days
21
0.3%
3
2.21%
0.012
Radiotherapy < 90 days
Previous operation < 30 days
15
63
0.2%
0.9%
4
3
2.94%
2.21%
<.0001
0.146
Obesity
2240
33.7%
53
38.97%
0.201
Diabetes
Dyspnea
508
309
7.6%
4.7%
9
8
6.62%
5.88%
0.404
0.304
COPD
135
2.0%
5
3.68%
0.15
Bleeding disorder
Hypertension (req. med)
70
1784
1.1%
26.9%
2
35
1.47%
25.74%
0.426
0.428
Sex
Male
Female
Race
0.522
0.356
Clinical Characteristics
Smoke
Alcohol
Work RVU
9.53 66.349
8.78 66.532
Total n
6,642
0.697
0.12
0.424
136
COPD 5 chronic obstructive pulmonary disease; RVU 5 relative value units.
days following the primary surgical procedure for an
overall cohort rate of 2.01%. Table I shows that thyroidectomy (total or subtotal for malignancy; with limited
neck dissection) was the single procedure in the database (of those with more than 50 occurrences), with the
highest readmission rate of 7.41%. Closed, open, and
open/contaminated procedures had readmission rates of
2.63%, 2.09%, and 0%, respectively.
Male sex, alcohol use, chemotherapy within 30
days, radiotherapy within 30 days, previous operation
within 30 days, and history of COPD were found to be
significantly increased in the readmitted versus the nonreadmitted cohort (Table II). There were seven surgical
complications and 23 medical complications in the
patients who were readmitted. The most common surgical complication was superficial wound infection; and
the most common medical complication was pneumonia,
followed by ventilator dependence for greater than 48
hours, DVT, and unplanned reintubation (Table III).
After bivariate screen analysis of 44 unique variables found in the NSQIP database, six variables were
ultimately included in the risk-adjusted multivariate
logistic regression following all outpatient ENT surgery.
The regression identified two significant predictors for
readmission following all outpatient ENT surgery:
superficial surgical site infection (OR 3.597, CI 1.09411.83, P 5.035) and work RVUs (OR .972, CI .944-1,
P 5.049) (Table IV). The regression considering all ENT
Laryngoscope 124: August 2014
procedures except tonsillectomies included four variables after bivariate screen analysis and found two significant predictors: obesity (OR 1.507, CI 1.028-2.21,
P 5.036) and operative time (OR 1.003, CI 1-1.005,
P 5.023) (Table V).
DISCUSSION
Surgical outcomes studies pinpoint specific patient
characteristics and complications most associated with
readmissions. This data is vital to a healthcare system
focused on reducing costs and adverse patient outcomes.
Government, insurance companies, and hospitals can
utilize this information to effectively target cost-saving
interventions for the patient groups most vulnerable to
readmission.
Our study found that 2.01% of patients undergoing
outpatient otolaryngological surgery were readmitted
within 30 days after their initial procedure for a nonplanned event. This rate was lower than those of outpatient general, cardiac, neurological, thoracic, urologic,
and vascular surgeries, but higher than gynecological,
orthopedics, and plastic procedures (Fig. 1). The differences in unplanned readmissions rates between these
specialties may partly be due to differing anatomic locations and various degrees of surgical invasiveness associated with different specialties. While otolaryngologic
procedures center on the face and neck, general surgery
Jain et al.: Readmission After Outpatient Otolaryngologic Surgery
1785
TABLE III.
Outcomes.
Non-readmitted
%
Readmission
%
P
Surgical Complications
53
Superficial wound infection
Deep wound infection
44
6
32.35%
4.41%
4
3
7
0.06%
0.04%
0.015
0.001
Organ space infection
2
1.47%
0
0.00%
0.96
Prosthesis failure
Medical Complications
1
32
0.74%
0
23
0.00%
0.98
DVT
0
0.00%
3
0.04%
< .0001
Pulmonary embolism
Unplanned reintubation
2
1
1.47%
0.74%
2
3
0.03%
0.04%
0.002
< .0001
Ventilator > 48 hrs
1
0.74%
4
0.06%
< .0001
Renal insufficiency
Acute renal failure
0
0
0.00%
0.00%
1
0
0.01%
0.00%
0.02
Coma
0
0.00%
1
0.01%
0.02
Stroke
Cardiac arrest
0
2
0.00%
1.47%
0
0
0.00%
0.00%
0.96
Myocardial infarction
0
0.00%
0
0.00%
Peripheral nerve injury
Pneumonia
3
5
2.21%
3.68%
0
6
0.00%
0.09%
0.941
< .0001
UTI
11
8.09%
1
0.01%
0.216
Transfusion
Sepsis
7
0
5.15%
0.00%
0
2
0.00%
0.03%
0.868
<.0001
Septic shock
0
0.00%
0
0.00%
DVT 5 deep vein thrombosis; UTI 5 urinary tract infection.
and cardiac procedures focus on deeper regions of the
body that are at a higher risk for bacterial contamination and infection. On the other hand, plastics procedures largely focus on soft tissues and rarely enter the
abdominal cavity. Gynecological surgeries largely utilize
laparoscopic techniques that are less invasive and timeconsuming—causing fewer complications as well.
The unplanned readmission rate of 2.01% associated
with outpatient otolaryngological surgery was lower than
the 4.8% rate seen in inpatient otolaryngological procedures from the same dataset. Outpatient surgical candi-
TABLE IV.
Multivariate Regression, All Procedures.
dates are often healthier and have a lower risk for
postoperative complications than their inpatient counterparts. Additionally, outpatient procedures are often
shorter and less complicated than inpatient procedures—
both are known to factor into complication rates.9–12
The most common surgical infection in our cohort
was superficial surgical site infection (SSSI), which was
expected given the anatomic region and depth addressed
by otolaryngological procedures. In fact, SSIs are quite
common among all surgical procedures. Nearly half a million SSIs occur in the United States every year and cost
the healthcare system more than $10 billion. Previous
studies have shown that risk factors such as obesity and
intraoperative transfusions—which our patient population also presents with—largely contribute to SSIs.13,14
95% CI
Odds Ratio
Lower
Upper
P
History of COPD
1.333
0.476
3.73
0.584
*SSSI
3.597
1.094
11.831
0.035
*Work RVU
ASA Class 3–5
0.972
1.46
0.944
0.984
1
2.166
0.049
0.06
Obesity
1.192
0.833
1.706
0.337
Male gender
1.349
0.955
1.906
0.09
HL 5 .606.
*denotes statistical significance, P <.05
ASA 5 American Society of Anesthesiology; CI 5 confidence interval;
COPD 5 chronic obstructive pulmonary disease; RVU 5 relative value units;
SSSI 5 superficial surgical site infection.
Laryngoscope 124: August 2014
1786
TABLE V.
Multivariate Regression (tonsillectomy procedures excluded).
95% CI
Odds Ratio
Age
Lower
Upper
P
1
0.988
1.012
0.985
*Obesity
Work RVU
1.507
0.984
1.028
0.949
2.21
1.021
0.036
0.394
*Operative Time
1.003
1
1.005
0.023
HL 5 .844.
*Statistical significance, P <.05.
CI 5 confidence interval ; HL 5 Hosmer-Lemeshow.
Jain et al.: Readmission After Outpatient Otolaryngologic Surgery
This information is essential for physicians and hospitals
to know in order to preemptively educate and monitor
patients at risk for postoperative complications.
SSSI was also found to be a significant contributor
to unplanned readmission by multivariate regression
analysis. Patients with a SSSI were 3.59 times more
likely to be readmitted to the hospital within 30 days of
the initial otolaryngologic procedure than those patients
who did not suffer from a SSSI (CI 1.094-11.83,
P 5.035). Work RVUs were also found to be significant
predictors of readmission; however, an odds ratio of .972
suggests that as procedures became more complex and
work RVU increased, the rate of unplanned readmission
actually decreased (CI .944-1, P 5.049). This seemingly
contradictory finding requires further study, possibly
with a larger patient cohort.
A separate multivariable regression excluding tonsillectomies was completed because of the disproportionally high number of tonsillectomy-related cases
(n 5 2,049) in the study (Table V). Longer operative
times (OR 1.003, CI 1-1.005, P 5.023) and obesity
(OR1.507, CI 1.028-2.21, P 5.036) were found to be significant factors for readmission in this reduced cohort.
Obese patients often have wound healing complications,
and obesity has been found to be a significant predictor
of readmissions in other surgical specialties.15–17 Of
interest, obesity was not found to be a statistically significant factor for readmission in the full cohort of
patients. However, this should not discount the clinical
significance of obesity and associated risks that it carries
for patients during surgery.
Other potential predictors of readmission, such as
ASA class ratings, show nonstatistically significant
increases in unplanned readmission but must be discussed for their clinical significance. Patients with a high
ASA class rating (3, 4, or 5; patient with severe systemic
disease, patient with severe systemic disease that is a
constant threat to life, or moribund patient not expected
to survive the operation, respectively) were 1.46 times
more likely to be readmitted to the hospital than patients
with a low rating (1 or 2; normal healthy patient and
patient with mild systemic disease, respectively) in the
full cohort (CI .984-2.166, P 5.06). A higher sample size
may help us pair the clinical significance of ASA class
and obesity, among other factors, with statistical significance and help us understand all the predictors of readmissions in outpatient otolaryngologic procedures.
In that regard, while the NSQIP database features
a large, geographically diverse patient population and
tracks numerous demographic variables and postoperative outcomes, the database is still limited. Since outcomes are only reported for 30 days after surgery, there
may be an underreporting of complications. The welldocumented high risk for bleeding after tonsillectomy
procedures may also not be completely captured by this
short window. Previous studies have suggested that
monitoring patients for a minimum of 90 days to 1 year
would capture more surgical outcomes data.18,19 NSQIP
also just began tracking readmissions data in 2011—better conclusions about unplanned readmissions can be
reached as more data is collected and analyzed in the
Laryngoscope 124: August 2014
coming years. Last, NSQIP may be limited in the variables it captures that are associated with hospital readmission. However, this robust database ultimately
provides a valid measure of the outcomes associated
with outpatient otolaryngological surgery, as well as the
preoperative comorbidities these patients have that predispose them to return to the hospital within 30 days
after their surgery.
By isolating patient characteristics and outcomes
that relate closely to unplanned readmission after outpatient otolaryngologic surgery, we can help improve
patient education and better guide patient expectations.
Physicians can identify and warn patients who are more
likely to incur a readmission of their increased risks,
while the healthcare system and insurance companies
can better target their resources toward at-risk patients
in order to reduce costs and operate more efficiently.20,21
CONCLUSION
Unplanned readmission after outpatient otolaryngological surgery has a rate of 2.01%. Superficial surgical
site infection and work RVUs are independent predictors
of readmission. Benchmarking readmission rates and
causes of readmission after outpatient otolaryngological
surgery may provide a platform for further risk reduction efforts and set system-wide expectations.
ACKNOWLEDGMENT
Author contributions: All of the following contributed significantly to the development of this article through data
analysis, manuscript preparation, or analysis and editing
of final manuscript. 1) Umang Jain, BA: data analysis,
manuscript preparation, literature review. 2) Rakesh K.
Chandra, MD: manuscript preparation. 3) Stephanie S.
Smith, MD: manuscript preparation, data analysis. 4)
Matthew Pilecki, BA : data Analysis. 5) John Y.S. Kim,
MD: data analysis, manuscript preparation, literature
review.
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Jain et al.: Readmission After Outpatient Otolaryngologic Surgery