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Seniors at High Risk for Readmission after Ambulatory Surgery

Medication errors and confusion about post-surgical care lead to costly readmission

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August 10, 2015 | by Marla Paul
CHICAGO --- Patients 65 and older who have ambulatory surgery are much more likely to be readmitted to the hospital within 30 days than younger patients, regardless of their health before surgery, reports a new, large national Northwestern Medicine study. The likely cause, based on previous research, is difficulty understanding medication dosing and discharge instructions, as well as cognitive impairment among older patients. 

The study found age is an independent risk factor for ambulatory surgical complications, which was not previously known. 

Over a 30-day period, seniors were 54 percent more likely to be readmitted to the hospital compared to patients younger than 65 years, the study reports, after accounting for differences in other medical problems. The problem is likely to worsen as economic pressures to reduce health care costs lead to even more complex surgeries in an ambulatory setting, the authors said.

“These seniors were supposed to stay out of the hospital since the procedures were performed in the ambulatory setting, but they were admitted to the hospital within 30 days,” said corresponding study author Dr. Gildasio De Oliveira Jr. “Age was the biggest factor associated with readmission and complications. It’s not because they are sicker, it’s because they are older and have trouble understanding their discharge instructions and medication dosing, which often are not clearly explained.”

De Oliveira is an assistant professor at the Center for Healthcare Studies at Northwestern University Feinberg School of Medicine and a physician at Northwestern Memorial Hospital.

To prevent costly readmissions, seniors need clearer, more understandable discharge instructions and to be evaluated for their ability to care for themselves after surgery, said De Oliveira, who also is an assistant professor in anesthesiology at Feinberg.

The study on senior hospital readmissions, which was published in the August issue of the Journal of the American Geriatrics Society, examined data from 53,667 patients who underwent ambulatory surgery in academic medical centers. The authors used the 2012 National Surgical Quality Improvement Program data set. 

Economic pressures to reduce health care costs have resulted in a 300 percent increase in ambulatory surgeries over the past decade. Now more than 70 percent of surgical procedures are performed in an outpatient setting, including more complex surgeries, such as hysterectomy, spine surgery and thyroid surgery. About 9 million ambulatory surgeries annually are performed on patients 65 and older.

“When patients are sent home on the same day, a lot is required of them to take care of themselves, and it’s beyond the capability of a lot of older individuals,” De Oliveira said. “They have to administer opioids and monitor themselves for emergency problems such as bleeding or infection.”

Seniors, of whom 44 percent have low health literacy, may have difficulty understanding how medicine is prescribed and take too much or too little. Undertaking pain medication can lead to cardiovascular problems and poor healing of the wound, in addition to increased pain, De Oliveira said. Seniors’ low health literacy is not necessarily related to education level or socio-economic status, he noted.

In a subsequent study underway at Northwestern, the investigators noticed that a patient, who had had a lumpectomy, removed her sterile strips holding the wound together instead of just changing the gauze. She had to return to the surgeon. Another patient took four opioid pills an hour instead of four a day and ended up in the emergency room. 

The solution is to design clearer discharge instructions tailored to seniors, De Oliveira said.

“Before allowing patients to get ambulatory surgery, surgeons also should verify if patients are able to take care of themselves at home, and if they have support,” De Oliveira said. “If not, patients should be admitted to the hospital after surgery or have some type of formal support by a nurse to help them at home.”

Other Northwestern authors include Dr. Jane Holl, Dr. Lee Ann Lindquist, Nicholas J. Hackett, Dr. John Y. S. Kim and Robert J. McCarthy.

Topics: Research, Health