Delivery of Care| Volume 213, P60-68, June 01, 2017

Variation in readmission expenditures after high-risk surgery

Published:February 23, 2017DOI:



      The Hospital Readmissions Reduction Program reduces payments to hospitals with excess readmissions for three common medical conditions and recently extended its readmission program to surgical patients. We sought to investigate readmission intensity as measured by readmission cost for high-risk surgeries and examine predictors of higher readmission costs.

      Materials and methods

      We used the Healthcare Cost and Utilization Project's State Inpatient Database to perform a retrospective cohort study of patients undergoing major chest (aortic valve replacement, coronary artery bypass grafting, lung resection) and major abdominal (abdominal aortic aneurysm repair [open approach], cystectomy, esophagectomy, pancreatectomy) surgery in 2009 and 2010. We fit a multivariable logistic regression model with generalized estimation equations to examine patient and index admission factors associated with readmission costs.


      The 30-d readmission rate was 16% for major chest and 22% for major abdominal surgery (P < 0.001). Discharge to a skilled nursing facility was associated with higher readmission costs for both chest (odds ratio [OR]: 1.99; 95% confidence interval [CI]: 1.60-2.48) and abdominal surgeries (OR: 1.86; 95% CI: 1.24-2.78). Comorbidities, length of stay, and receipt of blood or imaging was associated with higher readmission costs for chest surgery patients. Readmission >3 wk after discharge was associated with lower costs among abdominal surgery patients.


      Readmissions after high-risk surgery are common, affecting about one in six patients. Predictors of higher readmission costs differ among major chest and abdominal surgeries. Better identifying patients susceptible to higher readmission costs may inform future interventions to either reduce the intensity of these readmissions or eliminate them altogether.


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      1. Readmissions Reduction Program. Accessed June 5, 2014.

      2. Medicare Payment Advisory Commission. Report to Congress: promoting greater efficiency in Medicare. Accessed June 5, 2014.

        • Merkow R.P.
        • Ju M.H.
        • Chung J.W.
        • et al.
        Underlying reasons associated with hospital readmission following surgery in the United States.
        Jama. 2015; 313: 483-495
        • Gu Q.
        • Koenig L.
        • Faerberg J.
        • Steinberg C.R.
        • Vaz C.
        • Wheatley M.P.
        The medicare hospital readmissions reduction program: potential unintended consequences for hospitals serving vulnerable populations.
        Health Serv Res. 2014; 49: 818-837
        • Tsai T.C.
        • Joynt K.E.
        • Orav E.J.
        • Gawande A.A.
        • Jha A.K.
        Variation in surgical-readmission rates and quality of hospital care.
        N Engl J Med. 2013; 369: 1134-1142
        • Ghaferi A.A.
        • Birkmeyer J.D.
        • Dimick J.B.
        Variation in hospital mortality associated with inpatient surgery.
        N Engl J Med. 2009; 361: 1368-1375
        • Graham K.L.
        • Wilker E.H.
        • Howell M.D.
        • Davis R.B.
        • Marcantonio E.R.
        Differences between early and late readmissions among patients: a cohort study.
        Ann Intern Med. 2015; 162: 741-749
      3. Healthcare Cost and Utilization Project (HCUP). Overview of the State Inpatient Databases. Accessed October 16, 2014.

        • Stitzenberg K.B.
        • Chang Y.
        • Smith A.B.
        • Nielsen M.E.
        Exploring the burden of inpatient readmissions after major cancer surgery.
        J Clin Oncol. 2015; 33: 455-464
        • Jacobs B.L.
        • Zhang Y.
        • Tan H.J.
        • Ye Z.
        • Skolarus T.A.
        • Hollenbeck B.K.
        Hospitalization trends after prostate and bladder surgery: implications of potential payment reforms.
        J Urol. 2013; 189: 59-65
        • Yu H.Y.
        • Hevelone N.D.
        • Lipsitz S.R.
        • Kowalczyk K.J.
        • Hu J.C.
        Use, costs and comparative effectiveness of robotic assisted, laparoscopic and open urological surgery.
        J Urol. 2012; 187: 1392-1399
        • Sachs T.
        • Pomposelli F.
        • Hamdan A.
        • Wyers M.
        • Schermerhorn M.
        Trends in the national outcomes and costs for claudication and limb threatening ischemia: angioplasty vs bypass graft.
        J Vasc Surg. 2011; 54: 1021-1031.e1021
        • Tsai T.C.
        • Orav E.J.
        • Joynt K.E.
        Disparities in surgical 30-day readmission rates for Medicare beneficiaries by race and site of care.
        Ann Surg. 2014; 259: 1086-1090
        • Shih T.
        • Ryan A.M.
        • Gonzalez A.A.
        • Dimick J.B.
        Medicare's hospital readmission reduction program in surgery may disproportionately affect minority-serving hospitals.
        Ann Surg. 2015; 261: 1027-1031
        • Deyo R.A.
        • Cherkin D.C.
        • Ciol M.A.
        Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.
        J Clin Epidemiol. 1992; 45: 613-619
        • Gonzalez A.A.
        • Abdelsattar Z.M.
        • Dimick J.B.
        • Dev S.
        • Birkmeyer J.D.
        • Ghaferi A.A.
        Time-to-readmission and mortality after high-risk surgery.
        Ann Surg. 2015; 262: 53-59
        • Hu M.
        • Jacobs B.L.
        • Montgomery J.S.
        • et al.
        Sharpening the focus on causes and timing of readmission after radical cystectomy for bladder cancer.
        Cancer. 2014; 120: 1409-1416
        • Walters D.M.
        • Nagji A.S.
        • Stukenborg G.J.
        • et al.
        Predictors of hospital discharge to an extended care facility after major general thoracic surgery.
        Am surgeon. 2014; 80: 284-289
        • Tan H.J.
        • Wolf Jr., J.S.
        • Ye Z.
        • Wei J.T.
        • Miller D.C.
        Complications and failure to rescue after laparoscopic versus open radical nephrectomy.
        J Urol. 2011; 186: 1254-1260
        • Ghaferi A.A.
        • Osborne N.H.
        • Birkmeyer J.D.
        • Dimick J.B.
        Hospital characteristics associated with failure to rescue from complications after pancreatectomy.
        J Am Coll Surg. 2010; 211: 325-330
        • Ghaferi A.A.
        • Birkmeyer J.D.
        • Dimick J.B.
        Hospital volume and failure to rescue with high-risk surgery.
        Med Care. 2011; 49: 1076-1081
        • Ghaferi A.A.
        • Birkmeyer J.D.
        • Dimick J.B.
        Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients.
        Ann Surg. 2009; 250: 1029-1034
        • Ghaferi A.A.
        • Dimick J.B.
        Understanding failure to rescue and improving safety culture.
        Ann Surg. 2015; 261: 839-840
        • Johnston M.
        • Arora S.
        • Anderson O.
        • King D.
        • Behar N.
        • Darzi A.
        Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients.
        Ann Surg. 2015; 261: 831-838
        • Sheetz K.H.
        • Dimick J.B.
        • Ghaferi A.A.
        The association between hospital care intensity and surgical outcomes in medicare patients.
        JAMA Surg. 2014; 149: 1254-1259
        • Brooke B.S.
        • Stone D.H.
        • Cronenwett J.L.
        • et al.
        Early primary care provider follow-up and readmission after high-risk surgery.
        JAMA Surg. 2014; 149: 821-828
        • Girotti M.E.
        • Shih T.
        • Dimick J.B.
        Health policy update: rethinking hospital readmission as a surgical quality measure.
        JAMA Surg. 2014; 149: 757-758
        • Stimson C.J.
        • Chang S.S.
        • Barocas D.A.
        • et al.
        Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series.
        J Urol. 2010; 184: 1296-1300