Just more than 121,300 patients were sent home after surgery but ended up visiting a hospital within a week, according to a report published Monday in the journal Surgery. Only about 4,219 (just over 1%) were immediately transferred to a hospital for immediate follow-up at the time of discharge.
“Most events for patients happen after they go home,” said study author Dr. Justin Fox, chief resident in general surgery at the Wright State University Boonshoft School of Medicine. The study evaluated whether hospital transfer rates at discharge are a good marker of quality. “From a quality measurement standpoint, we're missing a big chunk of the pie for adverse events for people.”
Using state-level administrative data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project, researchers looked at records of 3,821,670 patients who had surgery at one of 1,295 ambulatory surgery centers in California, Florida and Nebraska between July 1, 2008, and Sept. 30, 2009.
Overall, the most common procedures patients underwent were colonoscopy, upper gastrointestinal endoscopy, lens and cataract surgery, and pain management. Post-surgery hospital visits varied widely depending on the procedure.
For example, among patients who were sent home, only about 10 out of every 1,000 who had cataract procedures ended up at the hospital later, while as many as 81 out of every 1,000 who received a diagnostic cardiac catheterization did. Among patients hospitalized at discharge, those who had a breast biopsy were the less likely to be sent to the hospital (only about 0.1 out of every 1000) compared with patients undergoing diagnostic cardiac catheterization (about 19.1 out of every 1,000).
“Performing medical and operative procedures in ambulatory surgery centers has been beneficial for patients and the healthcare system, but these benefits could be negated if ambulatory surgery care leads to a heightened need for subsequent hospital-based, acute care after treatment,” according to the study.
The study included researchers from the Wright State University Boonshoft School of Medicine in Dayton, Ohio; the Yale School of Medicine and Yale Comprehensive Cancer Center; and the Department of Veterans Affairs VA Connecticut Healthcare System.
“We found the study interesting. It really speaks to the importance of quality reporting,” said William Prentice, CEO of the Ambulatory Surgery Center Association. “All outpatient centers can learn from it to make sure we're doing the best possible job in terms of patient care, whether it's to improve actual procedures or just improve post-care instruction.”
When an ambulatory surgery center is closed and a patient can't reach their surgeon, the patient is probably going to go to the emergency room, he said, but it could end up being for something minor.
Data on which procedures lead to higher subsequent hospital visits can help specialists in those areas determine where to focus attention, or determine if they need to be clearer about what a patient should expect when they are sent home.
“It's going to take some diving into data to look for answers,” Prentice said
In the meantime, there are some things that can be done at outpatient surgery centers now, which can help, Fox said. For example, talk to patients about post-operative care well before they have had the surgery instead of in the post-operative period when they are still recovering. Also recommended, clearer descriptions of the type of symptoms patients might experience post operatively. For hemorrhoid surgery, patients returned to the hospital for issues such as urinary retention and pain. Patients undergoing colonoscopy returned for abdominal pain, nausea and vomiting.
“Outpatient surgery is safe, but adverse events can happen,” Fox said. “It's important to keep track of patients and check in with them so that if adverse events or symptoms are occurring, they can get the care that they need without having to go to an emergency department or a hospital to get it.”
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