Heidi Splete

CHICAGO – Complication rates for bariatric surgery patients on Medicare declined after Medicare began to cover the procedure in 2006, an analysis of state inpatient data from 12 states has found.

Data from previous studies suggest that bariatric surgery outcomes for Medicare patients improved after the implementation of Medicare’s National Coverage Determination in 2006, said Dr. Justin B. Dimick of the University of Michigan, Ann Arbor. But specific safety data on Medicare patients who have undergone bariatric surgery since the time of the decision are limited, Dr. Dimick said. The decision allowed for Medicare coverage of patients who sought care at facilities certified by the American College of Surgeons or the American Society for Metabolic and Bariatric Surgery.

To assess the impact of the National Coverage Determination on the safety of bariatric surgery, Dr. Dimick and his colleagues reviewed state inpatient data from 12 large, geographically dispersed states. Patients were identified on the basis of ICD-9 codes and diagnosis-related groups for weight loss surgery.

The outcomes were categorized according to any complication, a serious complication, or a reoperation.

The percentage of Medicare patients with any complications dropped from 12% before the determination to 8% afterward. Similarly, the percentage of non-Medicare patients with any complications dropped from 7% before to 5% after the determination.

In a multivariate analysis, the factors contributing to improved outcomes for bariatric surgery in Medicare patients were an increase in the use of laparoscopic gastric banding (lap band surgery), the transfer of patients to better hospitals, and quality improvement within individual hospitals, Dr. Dimick said.

Improvements in the safety of bariatric surgery did not, however, result from patients being redirected to safer hospitals, said Dr. Dimick. In fact, complication rates for procedures performed at Centers of Excellence versus non–Centers of Excellence were not significantly different (odds ratio for any complications, 0.97), he noted.

"CMS should consider dropping the COE [Centers of Excellence] aspect of the coverage decision [that] limits patient access without a beneficial improvement in outcomes," Dr. Dimick said. "Alternatively, CMS could revise the national coverage decision to further encourage participation in a quality improvement registry." Such a registry would need to include measures of long-term effectiveness to identify any unintended consequences of the increase in lap band surgery, he added.

Dr. Dimick is an equity owner and cofounder of ArborMetrix, a health care analytics and software firm.

CHICAGO – Complication rates for bariatric surgery patients on Medicare declined after Medicare began to cover the procedure in 2006, an analysis of state inpatient data from 12 states has found.

Data from previous studies suggest that bariatric surgery outcomes for Medicare patients improved after the implementation of Medicare’s National Coverage Determination in 2006, said Dr. Justin B. Dimick of the University of Michigan, Ann Arbor. But specific safety data on Medicare patients who have undergone bariatric surgery since the time of the decision are limited, Dr. Dimick said. The decision allowed for Medicare coverage of patients who sought care at facilities certified by the American College of Surgeons or the American Society for Metabolic and Bariatric Surgery.

To assess the impact of the National Coverage Determination on the safety of bariatric surgery, Dr. Dimick and his colleagues reviewed state inpatient data from 12 large, geographically dispersed states. Patients were identified on the basis of ICD-9 codes and diagnosis-related groups for weight loss surgery.

The outcomes were categorized according to any complication, a serious complication, or a reoperation.

The percentage of Medicare patients with any complications dropped from 12% before the determination to 8% afterward. Similarly, the percentage of non-Medicare patients with any complications dropped from 7% before to 5% after the determination.

In a multivariate analysis, the factors contributing to improved outcomes for bariatric surgery in Medicare patients were an increase in the use of laparoscopic gastric banding (lap band surgery), the transfer of patients to better hospitals, and quality improvement within individual hospitals, Dr. Dimick said.

Improvements in the safety of bariatric surgery did not, however, result from patients being redirected to safer hospitals, said Dr. Dimick. In fact, complication rates for procedures performed at Centers of Excellence versus non–Centers of Excellence were not significantly different (odds ratio for any complications, 0.97), he noted.

"CMS should consider dropping the COE [Centers of Excellence] aspect of the coverage decision [that] limits patient access without a beneficial improvement in outcomes," Dr. Dimick said. "Alternatively, CMS could revise the national coverage decision to further encourage participation in a quality improvement registry." Such a registry would need to include measures of long-term effectiveness to identify any unintended consequences of the increase in lap band surgery, he added.

Dr. Dimick is an equity owner and cofounder of ArborMetrix, a health care analytics and software firm.

CHICAGO – Complication rates for bariatric surgery patients on Medicare declined after Medicare began to cover the procedure in 2006, an analysis of state inpatient data from 12 states has found.

Data from previous studies suggest that bariatric surgery outcomes for Medicare patients improved after the implementation of Medicare’s National Coverage Determination in 2006, said Dr. Justin B. Dimick of the University of Michigan, Ann Arbor. But specific safety data on Medicare patients who have undergone bariatric surgery since the time of the decision are limited, Dr. Dimick said. The decision allowed for Medicare coverage of patients who sought care at facilities certified by the American College of Surgeons or the American Society for Metabolic and Bariatric Surgery.

To assess the impact of the National Coverage Determination on the safety of bariatric surgery, Dr. Dimick and his colleagues reviewed state inpatient data from 12 large, geographically dispersed states. Patients were identified on the basis of ICD-9 codes and diagnosis-related groups for weight loss surgery.

The outcomes were categorized according to any complication, a serious complication, or a reoperation.

The percentage of Medicare patients with any complications dropped from 12% before the determination to 8% afterward. Similarly, the percentage of non-Medicare patients with any complications dropped from 7% before to 5% after the determination.

In a multivariate analysis, the factors contributing to improved outcomes for bariatric surgery in Medicare patients were an increase in the use of laparoscopic gastric banding (lap band surgery), the transfer of patients to better hospitals, and quality improvement within individual hospitals, Dr. Dimick said.

Improvements in the safety of bariatric surgery did not, however, result from patients being redirected to safer hospitals, said Dr. Dimick. In fact, complication rates for procedures performed at Centers of Excellence versus non–Centers of Excellence were not significantly different (odds ratio for any complications, 0.97), he noted.

"CMS should consider dropping the COE [Centers of Excellence] aspect of the coverage decision [that] limits patient access without a beneficial improvement in outcomes," Dr. Dimick said. "Alternatively, CMS could revise the national coverage decision to further encourage participation in a quality improvement registry." Such a registry would need to include measures of long-term effectiveness to identify any unintended consequences of the increase in lap band surgery, he added.

Dr. Dimick is an equity owner and cofounder of ArborMetrix, a health care analytics and software firm.

CHICAGO – Breakdowns in the coordination of care, rather than communication, were the most common type of flow disruption at a level I trauma center, based on an analysis of data from 86 cases.

The finding contrasts with results from previous studies showing communication breakdowns as the top flow disruptions, and the study "is one of the first and largest to objectively document that flow disruptions in trauma care occur frequently," according to Dr. Daniel Shouhed of Cedars-Sinai Medical Center in Los Angeles.

"Defective systems allow human errors to cause harm to patients," Dr. Shouhed said at the annual clinical congress of the American College of Surgeons. "We believe systems can be better designed to prevent or detect errors before a patient is harmed."

As part of an effort to improve systems, Dr. Shouhed and his colleagues conducted a prospective observational study of flow disruptions over 2 months of 24-hour coverage in a level I trauma center.

Categories of flow disruptions included communication, coordination, environment, equipment, external interruptions, patient factors, technical skills, and training.

Communication breakdowns were defined as "disruptions that involve the verbal transition of information between at least two team members," while coordination breakdowns were defined as "disruptions that involve the interaction with some piece of equipment as well as at least one other team member," Dr. Shouhed said.

Flow disruptions were defined as low or high impact, based on whether they caused a pause in the progression of patient care or significant consequences to patient care. For example, a low-impact communication disruption might be "a scribe nurse unable to hear primary survey from resident," while a high-impact disruption might be "an ED attending did not hear request for STAT blood; order not placed."

Multiple physicians reviewed and scored each disruption. Each case could include three phases of care: trauma bay, imaging, and operating room (or interventional radiology).

The researchers observed 86 cases, 6 of which required immediate surgery. The average case duration was 102 minutes. On average, patients spent 25 minutes in the trauma bay, 30 minutes in the CT scanner, and 148 minutes in the operating room.

A total of 1,757 flow disruptions were observed. Of these, 46% occurred in the trauma bay, 33% in imaging, and 21% in the operating room. The researchers examined the effect of trauma level and trauma phase on the rate of flow disruptions, excluding the six OR cases because of the small sample size.

Flow disruption rates were divided into low-level (trauma 200) or high-level (trauma 100) activations, Dr. Shouhed said.

A comparison of the rate of flow disruptions between the trauma bay and imaging phases of care based on clinical impact scores showed a significantly higher rate of low-impact flow disruptions in the imaging phase, particularly among trauma 100 cases.

In examining the relationship between high clinical impact and low clinical impact flow disruptions, the researchers found a strong correlation between the rate of low-impact and high-impact flow disruptions among all phases of care.

"Most of the flow disruptions were low impact; however, we found that as the rate of low-impact flow disruptions increased, so did the rate of high-impact flow disruptions – thus attesting to the cascade of events that typically transpire when the progression of care is even slightly disrupted," said Dr. Shouhed.

Based on type of disruption and clinical impact, the highest rate of flow disruption involved breakdowns in coordination, which were associated with approximately three low clinical impact and one high clinical impact flow disruptions per hour.

"We believe that prospective observation allows individual hospitals to accurately identify systemic deficiencies and evaluate the impact interventions may have on improving patient safety and efficiency of care," he added.

The study was funded by a Military Operating Room of the Future grant from the Department of Defense.

CHICAGO – Breakdowns in the coordination of care, rather than communication, were the most common type of flow disruption at a level I trauma center, based on an analysis of data from 86 cases.

The finding contrasts with results from previous studies showing communication breakdowns as the top flow disruptions, and the study "is one of the first and largest to objectively document that flow disruptions in trauma care occur frequently," according to Dr. Daniel Shouhed of Cedars-Sinai Medical Center in Los Angeles.

"Defective systems allow human errors to cause harm to patients," Dr. Shouhed said at the annual clinical congress of the American College of Surgeons. "We believe systems can be better designed to prevent or detect errors before a patient is harmed."

As part of an effort to improve systems, Dr. Shouhed and his colleagues conducted a prospective observational study of flow disruptions over 2 months of 24-hour coverage in a level I trauma center.

Categories of flow disruptions included communication, coordination, environment, equipment, external interruptions, patient factors, technical skills, and training.

Communication breakdowns were defined as "disruptions that involve the verbal transition of information between at least two team members," while coordination breakdowns were defined as "disruptions that involve the interaction with some piece of equipment as well as at least one other team member," Dr. Shouhed said.

Flow disruptions were defined as low or high impact, based on whether they caused a pause in the progression of patient care or significant consequences to patient care. For example, a low-impact communication disruption might be "a scribe nurse unable to hear primary survey from resident," while a high-impact disruption might be "an ED attending did not hear request for STAT blood; order not placed."

Multiple physicians reviewed and scored each disruption. Each case could include three phases of care: trauma bay, imaging, and operating room (or interventional radiology).

The researchers observed 86 cases, 6 of which required immediate surgery. The average case duration was 102 minutes. On average, patients spent 25 minutes in the trauma bay, 30 minutes in the CT scanner, and 148 minutes in the operating room.

A total of 1,757 flow disruptions were observed. Of these, 46% occurred in the trauma bay, 33% in imaging, and 21% in the operating room. The researchers examined the effect of trauma level and trauma phase on the rate of flow disruptions, excluding the six OR cases because of the small sample size.

Flow disruption rates were divided into low-level (trauma 200) or high-level (trauma 100) activations, Dr. Shouhed said.

A comparison of the rate of flow disruptions between the trauma bay and imaging phases of care based on clinical impact scores showed a significantly higher rate of low-impact flow disruptions in the imaging phase, particularly among trauma 100 cases.

In examining the relationship between high clinical impact and low clinical impact flow disruptions, the researchers found a strong correlation between the rate of low-impact and high-impact flow disruptions among all phases of care.

"Most of the flow disruptions were low impact; however, we found that as the rate of low-impact flow disruptions increased, so did the rate of high-impact flow disruptions – thus attesting to the cascade of events that typically transpire when the progression of care is even slightly disrupted," said Dr. Shouhed.

Based on type of disruption and clinical impact, the highest rate of flow disruption involved breakdowns in coordination, which were associated with approximately three low clinical impact and one high clinical impact flow disruptions per hour.

"We believe that prospective observation allows individual hospitals to accurately identify systemic deficiencies and evaluate the impact interventions may have on improving patient safety and efficiency of care," he added.

The study was funded by a Military Operating Room of the Future grant from the Department of Defense.

CHICAGO – Breakdowns in the coordination of care, rather than communication, were the most common type of flow disruption at a level I trauma center, based on an analysis of data from 86 cases.

The finding contrasts with results from previous studies showing communication breakdowns as the top flow disruptions, and the study "is one of the first and largest to objectively document that flow disruptions in trauma care occur frequently," according to Dr. Daniel Shouhed of Cedars-Sinai Medical Center in Los Angeles.

"Defective systems allow human errors to cause harm to patients," Dr. Shouhed said at the annual clinical congress of the American College of Surgeons. "We believe systems can be better designed to prevent or detect errors before a patient is harmed."

As part of an effort to improve systems, Dr. Shouhed and his colleagues conducted a prospective observational study of flow disruptions over 2 months of 24-hour coverage in a level I trauma center.

Categories of flow disruptions included communication, coordination, environment, equipment, external interruptions, patient factors, technical skills, and training.

Communication breakdowns were defined as "disruptions that involve the verbal transition of information between at least two team members," while coordination breakdowns were defined as "disruptions that involve the interaction with some piece of equipment as well as at least one other team member," Dr. Shouhed said.

Flow disruptions were defined as low or high impact, based on whether they caused a pause in the progression of patient care or significant consequences to patient care. For example, a low-impact communication disruption might be "a scribe nurse unable to hear primary survey from resident," while a high-impact disruption might be "an ED attending did not hear request for STAT blood; order not placed."

Multiple physicians reviewed and scored each disruption. Each case could include three phases of care: trauma bay, imaging, and operating room (or interventional radiology).

The researchers observed 86 cases, 6 of which required immediate surgery. The average case duration was 102 minutes. On average, patients spent 25 minutes in the trauma bay, 30 minutes in the CT scanner, and 148 minutes in the operating room.

A total of 1,757 flow disruptions were observed. Of these, 46% occurred in the trauma bay, 33% in imaging, and 21% in the operating room. The researchers examined the effect of trauma level and trauma phase on the rate of flow disruptions, excluding the six OR cases because of the small sample size.

Flow disruption rates were divided into low-level (trauma 200) or high-level (trauma 100) activations, Dr. Shouhed said.

A comparison of the rate of flow disruptions between the trauma bay and imaging phases of care based on clinical impact scores showed a significantly higher rate of low-impact flow disruptions in the imaging phase, particularly among trauma 100 cases.

In examining the relationship between high clinical impact and low clinical impact flow disruptions, the researchers found a strong correlation between the rate of low-impact and high-impact flow disruptions among all phases of care.

"Most of the flow disruptions were low impact; however, we found that as the rate of low-impact flow disruptions increased, so did the rate of high-impact flow disruptions – thus attesting to the cascade of events that typically transpire when the progression of care is even slightly disrupted," said Dr. Shouhed.

Based on type of disruption and clinical impact, the highest rate of flow disruption involved breakdowns in coordination, which were associated with approximately three low clinical impact and one high clinical impact flow disruptions per hour.

"We believe that prospective observation allows individual hospitals to accurately identify systemic deficiencies and evaluate the impact interventions may have on improving patient safety and efficiency of care," he added.

The study was funded by a Military Operating Room of the Future grant from the Department of Defense.

Epilepsy increased the risk for sudden cardiac death threefold in a case-control study involving 1,019 cases of sudden cardiac death.

"A substantial portion of deaths in epilepsy happen suddenly," said Dr. Abdennasser Bardai of the University of Amsterdam and his colleagues. Both epilepsy and sudden cardiac arrest (SCA) are caused by pathological electrical activity, but the risk for SCA in epilepsy patients has not been well studied, they noted.

The researchers reviewed data from the Amsterdam Resuscitation Studies (ARREST) conducted between July 2005 and January 2010. They matched 1,019 cases of SCA with 2,834 controls. The average age of the patients was 64 years for cases and 58 years for controls, and the study population was about 70% male (PLoS ONE 7:e4274 [doi:10.1371/journal.pone.0042749]).

Overall, 12 SCA cases (1.4%) and 12 controls (0.4%) had an active epilepsy diagnosis. Individuals with epilepsy had nearly three times greater odds for having SCA than did controls (odds ratio, 2.9) after adjustment for cardiac ischemia, diabetes, and heart failure.

In a subanalysis, SCA risk was increased in individuals with epilepsy younger than 50 years, compared with those aged 50 years and older, and in women compared with men. Established risk factors for SCA, including hypertension, diabetes mellitus, heart failure, and hypercholesterolemia, also were risk factors in this study, the researchers noted.

Sudden unexpected death in epilepsy (SUDEP) "most frequently occurs in people with chronic epilepsy, poor seizure control, antiepileptic drug polytherapy, young age of onset, and a long history of epilepsy," the researchers wrote. "Our findings may suggest that the risk for SCA from cardiac causes extends to people with epilepsy beyond those with SUDEP," they added.

Although the findings suggest that SCA may contribute to SUDEP, other causes, such as respiratory depression, cannot be ruled out, the researchers said. In 11 of the 12 cases of SCA in epilepsy patients, no sign of seizure activity was noted before the SCA. The study was limited by the small number of individuals with active epilepsy who had SCA, and more research is needed to determine the causes of SCA risk in patients with epilepsy, the researchers added.

But the findings are "the first systematically collected evidence from a community-based study that epilepsy in the general population is associated with an increased risk for SCA," they wrote.

Dr. Bardai had no financial conflicts to disclose.

Epilepsy increased the risk for sudden cardiac death threefold in a case-control study involving 1,019 cases of sudden cardiac death.

"A substantial portion of deaths in epilepsy happen suddenly," said Dr. Abdennasser Bardai of the University of Amsterdam and his colleagues. Both epilepsy and sudden cardiac arrest (SCA) are caused by pathological electrical activity, but the risk for SCA in epilepsy patients has not been well studied, they noted.

The researchers reviewed data from the Amsterdam Resuscitation Studies (ARREST) conducted between July 2005 and January 2010. They matched 1,019 cases of SCA with 2,834 controls. The average age of the patients was 64 years for cases and 58 years for controls, and the study population was about 70% male (PLoS ONE 7:e4274 [doi:10.1371/journal.pone.0042749]).

Overall, 12 SCA cases (1.4%) and 12 controls (0.4%) had an active epilepsy diagnosis. Individuals with epilepsy had nearly three times greater odds for having SCA than did controls (odds ratio, 2.9) after adjustment for cardiac ischemia, diabetes, and heart failure.

In a subanalysis, SCA risk was increased in individuals with epilepsy younger than 50 years, compared with those aged 50 years and older, and in women compared with men. Established risk factors for SCA, including hypertension, diabetes mellitus, heart failure, and hypercholesterolemia, also were risk factors in this study, the researchers noted.

Sudden unexpected death in epilepsy (SUDEP) "most frequently occurs in people with chronic epilepsy, poor seizure control, antiepileptic drug polytherapy, young age of onset, and a long history of epilepsy," the researchers wrote. "Our findings may suggest that the risk for SCA from cardiac causes extends to people with epilepsy beyond those with SUDEP," they added.

Although the findings suggest that SCA may contribute to SUDEP, other causes, such as respiratory depression, cannot be ruled out, the researchers said. In 11 of the 12 cases of SCA in epilepsy patients, no sign of seizure activity was noted before the SCA. The study was limited by the small number of individuals with active epilepsy who had SCA, and more research is needed to determine the causes of SCA risk in patients with epilepsy, the researchers added.

But the findings are "the first systematically collected evidence from a community-based study that epilepsy in the general population is associated with an increased risk for SCA," they wrote.

Dr. Bardai had no financial conflicts to disclose.

Epilepsy increased the risk for sudden cardiac death threefold in a case-control study involving 1,019 cases of sudden cardiac death.

"A substantial portion of deaths in epilepsy happen suddenly," said Dr. Abdennasser Bardai of the University of Amsterdam and his colleagues. Both epilepsy and sudden cardiac arrest (SCA) are caused by pathological electrical activity, but the risk for SCA in epilepsy patients has not been well studied, they noted.

The researchers reviewed data from the Amsterdam Resuscitation Studies (ARREST) conducted between July 2005 and January 2010. They matched 1,019 cases of SCA with 2,834 controls. The average age of the patients was 64 years for cases and 58 years for controls, and the study population was about 70% male (PLoS ONE 7:e4274 [doi:10.1371/journal.pone.0042749]).

Overall, 12 SCA cases (1.4%) and 12 controls (0.4%) had an active epilepsy diagnosis. Individuals with epilepsy had nearly three times greater odds for having SCA than did controls (odds ratio, 2.9) after adjustment for cardiac ischemia, diabetes, and heart failure.

In a subanalysis, SCA risk was increased in individuals with epilepsy younger than 50 years, compared with those aged 50 years and older, and in women compared with men. Established risk factors for SCA, including hypertension, diabetes mellitus, heart failure, and hypercholesterolemia, also were risk factors in this study, the researchers noted.

Sudden unexpected death in epilepsy (SUDEP) "most frequently occurs in people with chronic epilepsy, poor seizure control, antiepileptic drug polytherapy, young age of onset, and a long history of epilepsy," the researchers wrote. "Our findings may suggest that the risk for SCA from cardiac causes extends to people with epilepsy beyond those with SUDEP," they added.

Although the findings suggest that SCA may contribute to SUDEP, other causes, such as respiratory depression, cannot be ruled out, the researchers said. In 11 of the 12 cases of SCA in epilepsy patients, no sign of seizure activity was noted before the SCA. The study was limited by the small number of individuals with active epilepsy who had SCA, and more research is needed to determine the causes of SCA risk in patients with epilepsy, the researchers added.

But the findings are "the first systematically collected evidence from a community-based study that epilepsy in the general population is associated with an increased risk for SCA," they wrote.

Dr. Bardai had no financial conflicts to disclose.

CHICAGO – Approximately half of hospital readmissions are surgery related and one-third of these are due to infections, data from nearly 3,000 Medicare patients indicated.

Risk factors for readmission included male gender, higher ASA (American Society of Anesthesiologists) class, and longer hospital stay, Dr. Shanu N. Kothari said at the annual clinical congress of the American College of Surgeons.

Recent health care reform initiatives include a proposal to reduce reimbursement for certain 30-day hospital readmissions among Medicare patients, he noted.

Dr. Kothari of Gundersen Lutheran Health System in La Crosse, Wis., and his colleagues reviewed data from 2,865 Medicare patients who had surgery at their institution between Jan. 1, 2010, and May 16, 2011. A readmission was defined as any patient who was readmitted within 30 days of initial surgery. Patients with incomplete follow-up data and those who died within 30 days were excluded.

The overall 30-day readmission rate was 7%. Readmitted patients were significantly more likely to be male compared with nonreadmitted patients (54% vs. 44%) and significantly more likely to have an ASA class of 3 or greater (84% vs. 66%). There were no significant differences in age or body mass index between readmitted and nonreadmitted patients.

In addition, the average length of stay and operative times were significantly longer for readmitted patients vs. nonreadmitted patients (4.8 days vs. 2.8 days and 123 minutes vs. 98 minutes).

A majority of the procedures were general and orthopedic, and 77% were elective.

Of the readmitted patients, "84% had at least one chronic condition, and patients with cardiac disease, renal disease, and diabetes had higher readmission rates," Dr. Kothari said.

The reasons for readmission were divided into four categories: surgery related (53%), not related to the surgical procedure (35%), planned (7%), and patient related (5%).

The most common surgery-related reasons for readmission were infections (32%), medication side effects (12%), or pulmonary complications (9%), Dr. Kothari noted.

Most of the readmissions unrelated to the index surgical procedure were exacerbations of underlying conditions, such as renal failure or heart failure. Patient-related reasons for readmission included noncompliance with discharge instructions or medications, as well as psychological issues.

"Further study is needed to address reasons for readmission on a multicenter level," said Dr. Kothari. "Decreased reimbursement should be discouraged for readmissions directly related to patient noncompliance."

Dr. Kothari said he had no relevant financial disclosures.

CHICAGO – Approximately half of hospital readmissions are surgery related and one-third of these are due to infections, data from nearly 3,000 Medicare patients indicated.

Risk factors for readmission included male gender, higher ASA (American Society of Anesthesiologists) class, and longer hospital stay, Dr. Shanu N. Kothari said at the annual clinical congress of the American College of Surgeons.

Recent health care reform initiatives include a proposal to reduce reimbursement for certain 30-day hospital readmissions among Medicare patients, he noted.

Dr. Kothari of Gundersen Lutheran Health System in La Crosse, Wis., and his colleagues reviewed data from 2,865 Medicare patients who had surgery at their institution between Jan. 1, 2010, and May 16, 2011. A readmission was defined as any patient who was readmitted within 30 days of initial surgery. Patients with incomplete follow-up data and those who died within 30 days were excluded.

The overall 30-day readmission rate was 7%. Readmitted patients were significantly more likely to be male compared with nonreadmitted patients (54% vs. 44%) and significantly more likely to have an ASA class of 3 or greater (84% vs. 66%). There were no significant differences in age or body mass index between readmitted and nonreadmitted patients.

In addition, the average length of stay and operative times were significantly longer for readmitted patients vs. nonreadmitted patients (4.8 days vs. 2.8 days and 123 minutes vs. 98 minutes).

A majority of the procedures were general and orthopedic, and 77% were elective.

Of the readmitted patients, "84% had at least one chronic condition, and patients with cardiac disease, renal disease, and diabetes had higher readmission rates," Dr. Kothari said.

The reasons for readmission were divided into four categories: surgery related (53%), not related to the surgical procedure (35%), planned (7%), and patient related (5%).

The most common surgery-related reasons for readmission were infections (32%), medication side effects (12%), or pulmonary complications (9%), Dr. Kothari noted.

Most of the readmissions unrelated to the index surgical procedure were exacerbations of underlying conditions, such as renal failure or heart failure. Patient-related reasons for readmission included noncompliance with discharge instructions or medications, as well as psychological issues.

"Further study is needed to address reasons for readmission on a multicenter level," said Dr. Kothari. "Decreased reimbursement should be discouraged for readmissions directly related to patient noncompliance."

Dr. Kothari said he had no relevant financial disclosures.

CHICAGO – Approximately half of hospital readmissions are surgery related and one-third of these are due to infections, data from nearly 3,000 Medicare patients indicated.

Risk factors for readmission included male gender, higher ASA (American Society of Anesthesiologists) class, and longer hospital stay, Dr. Shanu N. Kothari said at the annual clinical congress of the American College of Surgeons.

Recent health care reform initiatives include a proposal to reduce reimbursement for certain 30-day hospital readmissions among Medicare patients, he noted.

Dr. Kothari of Gundersen Lutheran Health System in La Crosse, Wis., and his colleagues reviewed data from 2,865 Medicare patients who had surgery at their institution between Jan. 1, 2010, and May 16, 2011. A readmission was defined as any patient who was readmitted within 30 days of initial surgery. Patients with incomplete follow-up data and those who died within 30 days were excluded.

The overall 30-day readmission rate was 7%. Readmitted patients were significantly more likely to be male compared with nonreadmitted patients (54% vs. 44%) and significantly more likely to have an ASA class of 3 or greater (84% vs. 66%). There were no significant differences in age or body mass index between readmitted and nonreadmitted patients.

In addition, the average length of stay and operative times were significantly longer for readmitted patients vs. nonreadmitted patients (4.8 days vs. 2.8 days and 123 minutes vs. 98 minutes).

A majority of the procedures were general and orthopedic, and 77% were elective.

Of the readmitted patients, "84% had at least one chronic condition, and patients with cardiac disease, renal disease, and diabetes had higher readmission rates," Dr. Kothari said.

The reasons for readmission were divided into four categories: surgery related (53%), not related to the surgical procedure (35%), planned (7%), and patient related (5%).

The most common surgery-related reasons for readmission were infections (32%), medication side effects (12%), or pulmonary complications (9%), Dr. Kothari noted.

Most of the readmissions unrelated to the index surgical procedure were exacerbations of underlying conditions, such as renal failure or heart failure. Patient-related reasons for readmission included noncompliance with discharge instructions or medications, as well as psychological issues.

"Further study is needed to address reasons for readmission on a multicenter level," said Dr. Kothari. "Decreased reimbursement should be discouraged for readmissions directly related to patient noncompliance."

Dr. Kothari said he had no relevant financial disclosures.

Rheumatologic training provides a preparation for any physician who is interested in providing medical care in developing countries, according to Dr. Daniel Albert, who has been globetrotting on medical missions for decades, most recently in Borneo. "Rheumatologists have a broad training in internal medicine, and are great internists," Dr. Albert said. "Being a rheumatologist is very good background for the kind of work that I did [in Borneo], and a good background for clinic work in developing countries in general," he said.

Dr. Albert’s most recent adventure was a monthlong medical trip to Borneo in January 2012, via Health in Harmony, a nonprofit global health organization with an environmental slant. Health in Harmony is funded by individual donations and grants from a range of sources, including the Bill & Melinda Gates Foundation and the National Institutes of Health.

Courtesy Dr. Daniel Albert

Rheumatologists are well suited to clinic work in developing countries because they are trained to pursue patients’ problems in an analytic fashion that comes down to pattern recognition in a way. Rheumatologists deal with many abstract concepts, Dr. Albert noted. They are always forced to clarify: What are the objective features of the disease, and how do they relate to a possible diagnosis that you are considering?

"Working in a setting where medical resources are limited takes some flexibility in your approach to differential diagnosis, because you don’t have the facilities available that you do in developed countries. Serologic evaluation is nonexistent in most developing countries, so you are much more reliant on the physical exam and history skills," said Dr. Albert, who is a rheumatologist at the Audrey and Theodor Geisel School of Medicine at Dartmouth, Hanover, N.H.

No matter where rheumatologists practice, be it somewhere with high-tech equipment or in a rain forest, "we constantly have to sort through very vague complaints, and we have to do it by the use of our clinical skills," he said. "I think rheumatologists are in a particularly good analytic position to address many of the problems."

Before he set out for Borneo, Dr. Albert said that he prepared in the same way any attending physician would in the United States. "Before going overseas, I think it is useful to do some background homework about diseases that might be more prevalent where you’re going than in America. For example, you certainly want to know about tuberculosis, because that is a worldwide problem that we don’t see much in the United States. In tropical areas, one must recognize malaria and also dengue fever," he said.

Once he was in Borneo, Dr. Albert said that he served as a resource of knowledge and expertise in a teaching mode for the Indonesian doctors, as well as for students and medical residents from the United States (Dartmouth, Yale, and Stanford universities) who were at the clinic. The Indonesian doctors often shared insights with the visiting physicians from their experiences, because they see a different spectrum of diseases than do U.S. physicians.

Among the clinic staff in both Borneo and other developing countries where Dr. Albert has served, he said he was impressed by the depth of knowledge about the common local diseases among the physician and nonphysician medical staff alike. Thanks to their expertise, "it is more important for you to share your expertise in your specialty than for you to be an expert on indigenous conditions," he said.

The people in Borneo actually are quite well nourished, and diseases of malnutrition are rare in Indonesia, according to Dr. Albert. The Health and Harmony program where he cared for patients is located in a fishing village, so the local residents have a good diet, consisting mainly of rice and fish, and fruit, which grows plentifully in everyone’s yard, he said.

"I think volunteering at a remote medical clinic is a far better way to get to know a country than traveling there as a tourist."

However, there are waterborne epidemics because of diseases due to poor water sanitation, but otherwise people have pretty good baseline health.

The Health and Harmony program consists of a walk-in clinic in the village called Sukadana and outreach clinics in remote areas. The Klinik ASRI would look familiar to most internists because it is similar to any other walk-in clinic, with three or four exam rooms and an urgent care facility, half a dozen nurses, and three or so general practice trainees. The job of supervising the clinic and its staff falls to the visiting physician from overseas.

Health in Harmony is a very well organized volunteer organization in a very pleasant part of Borneo, so it is considered a very desirable residency that attracts the top students. When Dr. Albert was there, he worked with three trainees. They were in their first year out of medical school, which is certified by the government as a residency.

Most of the time, the patient comes to the clinic alone or with one member of the family. But very sick patients may arrive with several relatives. And if they are very, very sick, they may come in with a substantial portion of their village. "It can be pretty interesting in clinic when you have large numbers of people accompanying a patient in a relatively small space," Dr. Albert said.

The journey to the outreach clinics is made via a van that carries a doctor, nurse, and driver to the remote location. This team usually stays in the home of a local chief there. Traditional healers are part of the culture in Borneo, and "the interface between traditional healers and Western doctors" occurred without tension or distrust, he said. "I hope to participate in the outreach clinics on a future trip, but did not do so on this visit. Traveling to the remote clinic, caring for patients, and returning takes 3 days, which was not possible for me on this trip," Dr. Albert said.

Clinic care runs smoothly. Staff collect demographic information from each patient at intake and enter it into donated Apple computers, along with short patient notes and the patient’s picture. Most of the medication at the clinic is donated, largely by the humanitarian association AmeriCares and volunteers who often bring medications with them to stock the pharmacy. The Indonesian government also provides some medicine.

Patients are charged on a sliding scale for the clinic visits and the medications. A unique element of the Health and Harmony program is the availability of barter options; patients can offer to work in place of payment, usually on the forest preserve or the organic farm, or they can pay in a variety of different crops.

As in America, a good 20% of people presenting to a clinic have musculoskeletal complaints. These are just the kinds of ailments that rheumatologists hope to diagnose and treat.

"It is more important for you to share your expertise in your specialty than for you to be an expert on indigenous conditions."

"I saw patients with rheumatoid arthritis whom we treated with methotrexate. We had a difficult time getting some lab tests, but not others. We were given a machine for blood counts, but we couldn’t do liver function tests. We were able to give patients folic acid supplements, and hydroxychloroquine was available. Of course, we didn’t have any biologics, but we had sulfasalazine," Dr. Albert said.

"We had some cases of septic arthritis. We had both intravenous and oral antibiotics to give them, so that wasn’t a problem," he said.

"Of course there were some patients that we weren’t able to help. We had people show up who were sick with a fatal disease like cancer, and we would have to say that we couldn’t do anything for them. We sent only a very few people elsewhere for treatment, largely because making such a trip with a very sick patient is such a difficult proposition. While I was there, the closest x-ray machine was about 2 hours away, and cost a lot of money, so we tried to work without much imaging. If we needed to send anyone for surgery, they had to go to a town that was 4 hours away by boat. Fortunately, there weren’t many surgical cases," he said.

Medical trips such as Dr. Albert’s to Borneo are for the adventurous. "We didn’t have running water, but we had water available in pots that felt great to pour over your head a few times a day, given the hot temperatures and high humidity. And it was perfectly fine. We also had bottled drinking water. I think volunteering at a remote medical clinic is a far better way to get to know a country than traveling there as a tourist. You come away with a deeper understanding of the culture and people, and I think you get a new perspective on happiness, seeing how people can be so happy with so little, compared to what we have in the United States."

"Not everyone can take a full month for this type of trip, but I have some flexibility in my work schedule that allows me to make up time before and after the trip. I advise anyone considering this type of trip to look for a well-run organization, such as Health in Harmony," Dr. Albert said.

Rheumatologic training provides a preparation for any physician who is interested in providing medical care in developing countries, according to Dr. Daniel Albert, who has been globetrotting on medical missions for decades, most recently in Borneo. "Rheumatologists have a broad training in internal medicine, and are great internists," Dr. Albert said. "Being a rheumatologist is very good background for the kind of work that I did [in Borneo], and a good background for clinic work in developing countries in general," he said.

Dr. Albert’s most recent adventure was a monthlong medical trip to Borneo in January 2012, via Health in Harmony, a nonprofit global health organization with an environmental slant. Health in Harmony is funded by individual donations and grants from a range of sources, including the Bill & Melinda Gates Foundation and the National Institutes of Health.

Courtesy Dr. Daniel Albert

Rheumatologists are well suited to clinic work in developing countries because they are trained to pursue patients’ problems in an analytic fashion that comes down to pattern recognition in a way. Rheumatologists deal with many abstract concepts, Dr. Albert noted. They are always forced to clarify: What are the objective features of the disease, and how do they relate to a possible diagnosis that you are considering?

"Working in a setting where medical resources are limited takes some flexibility in your approach to differential diagnosis, because you don’t have the facilities available that you do in developed countries. Serologic evaluation is nonexistent in most developing countries, so you are much more reliant on the physical exam and history skills," said Dr. Albert, who is a rheumatologist at the Audrey and Theodor Geisel School of Medicine at Dartmouth, Hanover, N.H.

No matter where rheumatologists practice, be it somewhere with high-tech equipment or in a rain forest, "we constantly have to sort through very vague complaints, and we have to do it by the use of our clinical skills," he said. "I think rheumatologists are in a particularly good analytic position to address many of the problems."

Before he set out for Borneo, Dr. Albert said that he prepared in the same way any attending physician would in the United States. "Before going overseas, I think it is useful to do some background homework about diseases that might be more prevalent where you’re going than in America. For example, you certainly want to know about tuberculosis, because that is a worldwide problem that we don’t see much in the United States. In tropical areas, one must recognize malaria and also dengue fever," he said.

Once he was in Borneo, Dr. Albert said that he served as a resource of knowledge and expertise in a teaching mode for the Indonesian doctors, as well as for students and medical residents from the United States (Dartmouth, Yale, and Stanford universities) who were at the clinic. The Indonesian doctors often shared insights with the visiting physicians from their experiences, because they see a different spectrum of diseases than do U.S. physicians.

Among the clinic staff in both Borneo and other developing countries where Dr. Albert has served, he said he was impressed by the depth of knowledge about the common local diseases among the physician and nonphysician medical staff alike. Thanks to their expertise, "it is more important for you to share your expertise in your specialty than for you to be an expert on indigenous conditions," he said.

The people in Borneo actually are quite well nourished, and diseases of malnutrition are rare in Indonesia, according to Dr. Albert. The Health and Harmony program where he cared for patients is located in a fishing village, so the local residents have a good diet, consisting mainly of rice and fish, and fruit, which grows plentifully in everyone’s yard, he said.

"I think volunteering at a remote medical clinic is a far better way to get to know a country than traveling there as a tourist."

However, there are waterborne epidemics because of diseases due to poor water sanitation, but otherwise people have pretty good baseline health.

The Health and Harmony program consists of a walk-in clinic in the village called Sukadana and outreach clinics in remote areas. The Klinik ASRI would look familiar to most internists because it is similar to any other walk-in clinic, with three or four exam rooms and an urgent care facility, half a dozen nurses, and three or so general practice trainees. The job of supervising the clinic and its staff falls to the visiting physician from overseas.

Health in Harmony is a very well organized volunteer organization in a very pleasant part of Borneo, so it is considered a very desirable residency that attracts the top students. When Dr. Albert was there, he worked with three trainees. They were in their first year out of medical school, which is certified by the government as a residency.

Most of the time, the patient comes to the clinic alone or with one member of the family. But very sick patients may arrive with several relatives. And if they are very, very sick, they may come in with a substantial portion of their village. "It can be pretty interesting in clinic when you have large numbers of people accompanying a patient in a relatively small space," Dr. Albert said.

The journey to the outreach clinics is made via a van that carries a doctor, nurse, and driver to the remote location. This team usually stays in the home of a local chief there. Traditional healers are part of the culture in Borneo, and "the interface between traditional healers and Western doctors" occurred without tension or distrust, he said. "I hope to participate in the outreach clinics on a future trip, but did not do so on this visit. Traveling to the remote clinic, caring for patients, and returning takes 3 days, which was not possible for me on this trip," Dr. Albert said.

Clinic care runs smoothly. Staff collect demographic information from each patient at intake and enter it into donated Apple computers, along with short patient notes and the patient’s picture. Most of the medication at the clinic is donated, largely by the humanitarian association AmeriCares and volunteers who often bring medications with them to stock the pharmacy. The Indonesian government also provides some medicine.

Patients are charged on a sliding scale for the clinic visits and the medications. A unique element of the Health and Harmony program is the availability of barter options; patients can offer to work in place of payment, usually on the forest preserve or the organic farm, or they can pay in a variety of different crops.

As in America, a good 20% of people presenting to a clinic have musculoskeletal complaints. These are just the kinds of ailments that rheumatologists hope to diagnose and treat.

"It is more important for you to share your expertise in your specialty than for you to be an expert on indigenous conditions."

"I saw patients with rheumatoid arthritis whom we treated with methotrexate. We had a difficult time getting some lab tests, but not others. We were given a machine for blood counts, but we couldn’t do liver function tests. We were able to give patients folic acid supplements, and hydroxychloroquine was available. Of course, we didn’t have any biologics, but we had sulfasalazine," Dr. Albert said.

"We had some cases of septic arthritis. We had both intravenous and oral antibiotics to give them, so that wasn’t a problem," he said.

"Of course there were some patients that we weren’t able to help. We had people show up who were sick with a fatal disease like cancer, and we would have to say that we couldn’t do anything for them. We sent only a very few people elsewhere for treatment, largely because making such a trip with a very sick patient is such a difficult proposition. While I was there, the closest x-ray machine was about 2 hours away, and cost a lot of money, so we tried to work without much imaging. If we needed to send anyone for surgery, they had to go to a town that was 4 hours away by boat. Fortunately, there weren’t many surgical cases," he said.

Medical trips such as Dr. Albert’s to Borneo are for the adventurous. "We didn’t have running water, but we had water available in pots that felt great to pour over your head a few times a day, given the hot temperatures and high humidity. And it was perfectly fine. We also had bottled drinking water. I think volunteering at a remote medical clinic is a far better way to get to know a country than traveling there as a tourist. You come away with a deeper understanding of the culture and people, and I think you get a new perspective on happiness, seeing how people can be so happy with so little, compared to what we have in the United States."

"Not everyone can take a full month for this type of trip, but I have some flexibility in my work schedule that allows me to make up time before and after the trip. I advise anyone considering this type of trip to look for a well-run organization, such as Health in Harmony," Dr. Albert said.

Rheumatologic training provides a preparation for any physician who is interested in providing medical care in developing countries, according to Dr. Daniel Albert, who has been globetrotting on medical missions for decades, most recently in Borneo. "Rheumatologists have a broad training in internal medicine, and are great internists," Dr. Albert said. "Being a rheumatologist is very good background for the kind of work that I did [in Borneo], and a good background for clinic work in developing countries in general," he said.

Dr. Albert’s most recent adventure was a monthlong medical trip to Borneo in January 2012, via Health in Harmony, a nonprofit global health organization with an environmental slant. Health in Harmony is funded by individual donations and grants from a range of sources, including the Bill & Melinda Gates Foundation and the National Institutes of Health.

Courtesy Dr. Daniel Albert

Rheumatologists are well suited to clinic work in developing countries because they are trained to pursue patients’ problems in an analytic fashion that comes down to pattern recognition in a way. Rheumatologists deal with many abstract concepts, Dr. Albert noted. They are always forced to clarify: What are the objective features of the disease, and how do they relate to a possible diagnosis that you are considering?

"Working in a setting where medical resources are limited takes some flexibility in your approach to differential diagnosis, because you don’t have the facilities available that you do in developed countries. Serologic evaluation is nonexistent in most developing countries, so you are much more reliant on the physical exam and history skills," said Dr. Albert, who is a rheumatologist at the Audrey and Theodor Geisel School of Medicine at Dartmouth, Hanover, N.H.

No matter where rheumatologists practice, be it somewhere with high-tech equipment or in a rain forest, "we constantly have to sort through very vague complaints, and we have to do it by the use of our clinical skills," he said. "I think rheumatologists are in a particularly good analytic position to address many of the problems."

Before he set out for Borneo, Dr. Albert said that he prepared in the same way any attending physician would in the United States. "Before going overseas, I think it is useful to do some background homework about diseases that might be more prevalent where you’re going than in America. For example, you certainly want to know about tuberculosis, because that is a worldwide problem that we don’t see much in the United States. In tropical areas, one must recognize malaria and also dengue fever," he said.

Once he was in Borneo, Dr. Albert said that he served as a resource of knowledge and expertise in a teaching mode for the Indonesian doctors, as well as for students and medical residents from the United States (Dartmouth, Yale, and Stanford universities) who were at the clinic. The Indonesian doctors often shared insights with the visiting physicians from their experiences, because they see a different spectrum of diseases than do U.S. physicians.

Among the clinic staff in both Borneo and other developing countries where Dr. Albert has served, he said he was impressed by the depth of knowledge about the common local diseases among the physician and nonphysician medical staff alike. Thanks to their expertise, "it is more important for you to share your expertise in your specialty than for you to be an expert on indigenous conditions," he said.

The people in Borneo actually are quite well nourished, and diseases of malnutrition are rare in Indonesia, according to Dr. Albert. The Health and Harmony program where he cared for patients is located in a fishing village, so the local residents have a good diet, consisting mainly of rice and fish, and fruit, which grows plentifully in everyone’s yard, he said.

"I think volunteering at a remote medical clinic is a far better way to get to know a country than traveling there as a tourist."

However, there are waterborne epidemics because of diseases due to poor water sanitation, but otherwise people have pretty good baseline health.

The Health and Harmony program consists of a walk-in clinic in the village called Sukadana and outreach clinics in remote areas. The Klinik ASRI would look familiar to most internists because it is similar to any other walk-in clinic, with three or four exam rooms and an urgent care facility, half a dozen nurses, and three or so general practice trainees. The job of supervising the clinic and its staff falls to the visiting physician from overseas.

Health in Harmony is a very well organized volunteer organization in a very pleasant part of Borneo, so it is considered a very desirable residency that attracts the top students. When Dr. Albert was there, he worked with three trainees. They were in their first year out of medical school, which is certified by the government as a residency.

Most of the time, the patient comes to the clinic alone or with one member of the family. But very sick patients may arrive with several relatives. And if they are very, very sick, they may come in with a substantial portion of their village. "It can be pretty interesting in clinic when you have large numbers of people accompanying a patient in a relatively small space," Dr. Albert said.

The journey to the outreach clinics is made via a van that carries a doctor, nurse, and driver to the remote location. This team usually stays in the home of a local chief there. Traditional healers are part of the culture in Borneo, and "the interface between traditional healers and Western doctors" occurred without tension or distrust, he said. "I hope to participate in the outreach clinics on a future trip, but did not do so on this visit. Traveling to the remote clinic, caring for patients, and returning takes 3 days, which was not possible for me on this trip," Dr. Albert said.

Clinic care runs smoothly. Staff collect demographic information from each patient at intake and enter it into donated Apple computers, along with short patient notes and the patient’s picture. Most of the medication at the clinic is donated, largely by the humanitarian association AmeriCares and volunteers who often bring medications with them to stock the pharmacy. The Indonesian government also provides some medicine.

Patients are charged on a sliding scale for the clinic visits and the medications. A unique element of the Health and Harmony program is the availability of barter options; patients can offer to work in place of payment, usually on the forest preserve or the organic farm, or they can pay in a variety of different crops.

As in America, a good 20% of people presenting to a clinic have musculoskeletal complaints. These are just the kinds of ailments that rheumatologists hope to diagnose and treat.

"It is more important for you to share your expertise in your specialty than for you to be an expert on indigenous conditions."

"I saw patients with rheumatoid arthritis whom we treated with methotrexate. We had a difficult time getting some lab tests, but not others. We were given a machine for blood counts, but we couldn’t do liver function tests. We were able to give patients folic acid supplements, and hydroxychloroquine was available. Of course, we didn’t have any biologics, but we had sulfasalazine," Dr. Albert said.

"We had some cases of septic arthritis. We had both intravenous and oral antibiotics to give them, so that wasn’t a problem," he said.

"Of course there were some patients that we weren’t able to help. We had people show up who were sick with a fatal disease like cancer, and we would have to say that we couldn’t do anything for them. We sent only a very few people elsewhere for treatment, largely because making such a trip with a very sick patient is such a difficult proposition. While I was there, the closest x-ray machine was about 2 hours away, and cost a lot of money, so we tried to work without much imaging. If we needed to send anyone for surgery, they had to go to a town that was 4 hours away by boat. Fortunately, there weren’t many surgical cases," he said.

Medical trips such as Dr. Albert’s to Borneo are for the adventurous. "We didn’t have running water, but we had water available in pots that felt great to pour over your head a few times a day, given the hot temperatures and high humidity. And it was perfectly fine. We also had bottled drinking water. I think volunteering at a remote medical clinic is a far better way to get to know a country than traveling there as a tourist. You come away with a deeper understanding of the culture and people, and I think you get a new perspective on happiness, seeing how people can be so happy with so little, compared to what we have in the United States."

"Not everyone can take a full month for this type of trip, but I have some flexibility in my work schedule that allows me to make up time before and after the trip. I advise anyone considering this type of trip to look for a well-run organization, such as Health in Harmony," Dr. Albert said.

A novel coronavirus has been identified in a 60-year-old man with acute pneumonia who died of progressive respiratory and renal failure 11 days after hospital admission, according to a report in the New England Journal of Medicine that was published online on Oct. 17.

The virus, known as HCoV-EMC, is a previously unknown betacoronavirus species. The closest known relatives are two bat coronaviruses: HKU4 and HKU5.

"The clinical picture was remarkably similar to that of the severe acute respiratory distress syndrome [(SARS)] outbreak in 2003 and reminds us that animal coronaviruses can cause severe disease in humans," said lead author Dr. Ali Moh Zaki of the Dr. Soliman Fakeeh Hospital in Jeddah, Saudi Arabia, and his colleagues.

The patient was a 60-year-old Saudi man who first presented with a 7-day history of fever, cough, expectoration, and shortness of breath, the researchers said (N. Engl. J. Med. 2012 [doi:10.1056/NEJMoa211721]). He had no history of heart or kidney disease, did not smoke, and took no medications chronically.

The researchers tested a sputum sample when the patient was admitted to the hospital, and the results suggested that the virus was replicating. Tests of infected cell cultures with indirect immunofluorescence assays were negative for likely viruses including influenza A and B, respiratory syncytial virus, adenovirus, and parainfluenza viruses types 1 to 3. But serum samples collected at 10 and 11 days after the patient was hospitalized "reacted strongly when dilutions of 1:20 were tested on immunofluorescence assay specific for IgG antibodies," the researchers noted. By contrast, 2,400 control samples from other patients at the same hospital between 2010 and 2012 were negative, suggesting that the patient had developed antibodies to a previously unknown virus.

Genetic sequencing of the new virus linked it to a Betacoronavirus genus and set it apart from known human coronaviruses, which belong to the Alphacoronavirus genus, the researchers explained.

At the time of hospital admission, the patient’s body mass index was 35 kg/m², his blood pressure was 140/80 mm Hg, his pulse was 117 beats per minute, and his temperature was 38.3  C. The patient was initially treated with oseltamivir, levofloxacin, piperacillin-tazobactam, and micafungin; meropenem was started on day 4.

"No symptoms were observed in the hospital among doctors and nurses caring for the patient, which suggests that the disease did not spread readily," the researchers said. However, the more thorough epidemiologic investigations can be conducted with the completion of the genomic sequencing of HCoV-EMC and the development of virus-specific rapid diagnostic tests, they added.

The Center for Infectious Disease Research and Policy at the University of Minnesota (CIDRAP) reported on the gene sequencing and testing methods used to identify the virus, and on the status of a second infected patient – a 49-year-old man from Qatar – who presented with similar symptoms and was last reported to be in stable condition.

"Although HCoV-EMC does not have many of the worrisome characteristics of SARS-CoV, we should take notice of the valuable lessons learned during the 2003 SARS outbreak with respect to outbreak investigations and management," the researchers said.

The study was supported in part by the European Commission Seventh Framework Program for Research and Technology Development Project EMPERIE.

Lead author Dr. Zaki had no financial conflicts to disclose. Several of the study coauthors have financial interest in Viroclinics Biosciences B.V. through a holding company administered by Erasmus Medical Center in Rotterdam, the Netherlands. Viroclinics and Erasmus Medical Center have jointly filed a patent on the new virus genome.

A novel coronavirus has been identified in a 60-year-old man with acute pneumonia who died of progressive respiratory and renal failure 11 days after hospital admission, according to a report in the New England Journal of Medicine that was published online on Oct. 17.

The virus, known as HCoV-EMC, is a previously unknown betacoronavirus species. The closest known relatives are two bat coronaviruses: HKU4 and HKU5.

"The clinical picture was remarkably similar to that of the severe acute respiratory distress syndrome [(SARS)] outbreak in 2003 and reminds us that animal coronaviruses can cause severe disease in humans," said lead author Dr. Ali Moh Zaki of the Dr. Soliman Fakeeh Hospital in Jeddah, Saudi Arabia, and his colleagues.

The patient was a 60-year-old Saudi man who first presented with a 7-day history of fever, cough, expectoration, and shortness of breath, the researchers said (N. Engl. J. Med. 2012 [doi:10.1056/NEJMoa211721]). He had no history of heart or kidney disease, did not smoke, and took no medications chronically.

The researchers tested a sputum sample when the patient was admitted to the hospital, and the results suggested that the virus was replicating. Tests of infected cell cultures with indirect immunofluorescence assays were negative for likely viruses including influenza A and B, respiratory syncytial virus, adenovirus, and parainfluenza viruses types 1 to 3. But serum samples collected at 10 and 11 days after the patient was hospitalized "reacted strongly when dilutions of 1:20 were tested on immunofluorescence assay specific for IgG antibodies," the researchers noted. By contrast, 2,400 control samples from other patients at the same hospital between 2010 and 2012 were negative, suggesting that the patient had developed antibodies to a previously unknown virus.

Genetic sequencing of the new virus linked it to a Betacoronavirus genus and set it apart from known human coronaviruses, which belong to the Alphacoronavirus genus, the researchers explained.

At the time of hospital admission, the patient’s body mass index was 35 kg/m², his blood pressure was 140/80 mm Hg, his pulse was 117 beats per minute, and his temperature was 38.3  C. The patient was initially treated with oseltamivir, levofloxacin, piperacillin-tazobactam, and micafungin; meropenem was started on day 4.

"No symptoms were observed in the hospital among doctors and nurses caring for the patient, which suggests that the disease did not spread readily," the researchers said. However, the more thorough epidemiologic investigations can be conducted with the completion of the genomic sequencing of HCoV-EMC and the development of virus-specific rapid diagnostic tests, they added.

The Center for Infectious Disease Research and Policy at the University of Minnesota (CIDRAP) reported on the gene sequencing and testing methods used to identify the virus, and on the status of a second infected patient – a 49-year-old man from Qatar – who presented with similar symptoms and was last reported to be in stable condition.

"Although HCoV-EMC does not have many of the worrisome characteristics of SARS-CoV, we should take notice of the valuable lessons learned during the 2003 SARS outbreak with respect to outbreak investigations and management," the researchers said.

The study was supported in part by the European Commission Seventh Framework Program for Research and Technology Development Project EMPERIE.

Lead author Dr. Zaki had no financial conflicts to disclose. Several of the study coauthors have financial interest in Viroclinics Biosciences B.V. through a holding company administered by Erasmus Medical Center in Rotterdam, the Netherlands. Viroclinics and Erasmus Medical Center have jointly filed a patent on the new virus genome.

A novel coronavirus has been identified in a 60-year-old man with acute pneumonia who died of progressive respiratory and renal failure 11 days after hospital admission, according to a report in the New England Journal of Medicine that was published online on Oct. 17.

The virus, known as HCoV-EMC, is a previously unknown betacoronavirus species. The closest known relatives are two bat coronaviruses: HKU4 and HKU5.

"The clinical picture was remarkably similar to that of the severe acute respiratory distress syndrome [(SARS)] outbreak in 2003 and reminds us that animal coronaviruses can cause severe disease in humans," said lead author Dr. Ali Moh Zaki of the Dr. Soliman Fakeeh Hospital in Jeddah, Saudi Arabia, and his colleagues.

The patient was a 60-year-old Saudi man who first presented with a 7-day history of fever, cough, expectoration, and shortness of breath, the researchers said (N. Engl. J. Med. 2012 [doi:10.1056/NEJMoa211721]). He had no history of heart or kidney disease, did not smoke, and took no medications chronically.

The researchers tested a sputum sample when the patient was admitted to the hospital, and the results suggested that the virus was replicating. Tests of infected cell cultures with indirect immunofluorescence assays were negative for likely viruses including influenza A and B, respiratory syncytial virus, adenovirus, and parainfluenza viruses types 1 to 3. But serum samples collected at 10 and 11 days after the patient was hospitalized "reacted strongly when dilutions of 1:20 were tested on immunofluorescence assay specific for IgG antibodies," the researchers noted. By contrast, 2,400 control samples from other patients at the same hospital between 2010 and 2012 were negative, suggesting that the patient had developed antibodies to a previously unknown virus.

Genetic sequencing of the new virus linked it to a Betacoronavirus genus and set it apart from known human coronaviruses, which belong to the Alphacoronavirus genus, the researchers explained.

At the time of hospital admission, the patient’s body mass index was 35 kg/m², his blood pressure was 140/80 mm Hg, his pulse was 117 beats per minute, and his temperature was 38.3  C. The patient was initially treated with oseltamivir, levofloxacin, piperacillin-tazobactam, and micafungin; meropenem was started on day 4.

"No symptoms were observed in the hospital among doctors and nurses caring for the patient, which suggests that the disease did not spread readily," the researchers said. However, the more thorough epidemiologic investigations can be conducted with the completion of the genomic sequencing of HCoV-EMC and the development of virus-specific rapid diagnostic tests, they added.

The Center for Infectious Disease Research and Policy at the University of Minnesota (CIDRAP) reported on the gene sequencing and testing methods used to identify the virus, and on the status of a second infected patient – a 49-year-old man from Qatar – who presented with similar symptoms and was last reported to be in stable condition.

"Although HCoV-EMC does not have many of the worrisome characteristics of SARS-CoV, we should take notice of the valuable lessons learned during the 2003 SARS outbreak with respect to outbreak investigations and management," the researchers said.

The study was supported in part by the European Commission Seventh Framework Program for Research and Technology Development Project EMPERIE.

Lead author Dr. Zaki had no financial conflicts to disclose. Several of the study coauthors have financial interest in Viroclinics Biosciences B.V. through a holding company administered by Erasmus Medical Center in Rotterdam, the Netherlands. Viroclinics and Erasmus Medical Center have jointly filed a patent on the new virus genome.

CHICAGO – High-volume intra-abdominal irrigation significantly increased the risk of postoperative abscess in a study of 327 appendectomy patients and led investigators to conclude that use of irrigation should be limited in these patients.

The classical thinking that irrigation during appendectomies washes away bacteria is changing, as additional data suggest that irrigation might create pockets of fluid that can lead to the formation of abscesses, Dr. Esteban Gnass said at the annual clinical congress of the American College of Surgeons.

Previous studies have shown that postoperative abscess (POA) formation significantly increases the length of a patient’s hospital stay and hospital costs, said Dr. Gnass of Riverside County Regional Medical Center in Moreno Valley, Calif.

To determine the association between irrigation during surgery and POA formation, he and his colleagues reviewed data from 265 laparoscopic and 62 open procedures conducted between January 2009 and June 2011. There were no significant demographic differences between patients in the two procedure groups. Patients also were subdivided according to perforated vs. nonperforated and irrigated vs. nonirrigated.

A total of 17 postoperative abscesses were observed, all of which occurred in irrigated patients. In addition, 88% of the postoperative abscess cases involved at least 500 mL of irrigation. "Large irrigation volumes carried a higher risk of POA," Dr. Gnass said.

After controlling for multiple variables, the investigators found that both irrigation volume and perforation were significantly associated with abscess formation.

In both the laparoscopic and open groups, 100% of perforated patients received at least 500 mL of irrigation, compared with 75% of the nonperforated patients in the laparoscopy group and 0% of nonperforated patients in the open group.

POA rates and perforation rates were not significantly different between laparoscopic and open groups (5% vs. 4%, and 25% vs. 37%, respectively).

On further analysis of the POA cases only, perforation rates were not significantly different between laparoscopic and open groups (72% vs. 67%).

"Surgical technique was not associated with abscess formation," Dr. Gnass noted.

Among the perforated cases only, postoperative abscesses developed in 18% of those who received at least 500 mL of irrigation and in none of those who received less than 500 mL of irrigation.

More research in the form of a prospective, randomized trial is needed to confirm the results, but based on the current findings, "we can suggest limiting the use of irrigation to 500 cc or less" in appendectomy procedures, Dr. Gnass said.

He reported having no relevant financial disclosures.

CHICAGO – High-volume intra-abdominal irrigation significantly increased the risk of postoperative abscess in a study of 327 appendectomy patients and led investigators to conclude that use of irrigation should be limited in these patients.

The classical thinking that irrigation during appendectomies washes away bacteria is changing, as additional data suggest that irrigation might create pockets of fluid that can lead to the formation of abscesses, Dr. Esteban Gnass said at the annual clinical congress of the American College of Surgeons.

Previous studies have shown that postoperative abscess (POA) formation significantly increases the length of a patient’s hospital stay and hospital costs, said Dr. Gnass of Riverside County Regional Medical Center in Moreno Valley, Calif.

To determine the association between irrigation during surgery and POA formation, he and his colleagues reviewed data from 265 laparoscopic and 62 open procedures conducted between January 2009 and June 2011. There were no significant demographic differences between patients in the two procedure groups. Patients also were subdivided according to perforated vs. nonperforated and irrigated vs. nonirrigated.

A total of 17 postoperative abscesses were observed, all of which occurred in irrigated patients. In addition, 88% of the postoperative abscess cases involved at least 500 mL of irrigation. "Large irrigation volumes carried a higher risk of POA," Dr. Gnass said.

After controlling for multiple variables, the investigators found that both irrigation volume and perforation were significantly associated with abscess formation.

In both the laparoscopic and open groups, 100% of perforated patients received at least 500 mL of irrigation, compared with 75% of the nonperforated patients in the laparoscopy group and 0% of nonperforated patients in the open group.

POA rates and perforation rates were not significantly different between laparoscopic and open groups (5% vs. 4%, and 25% vs. 37%, respectively).

On further analysis of the POA cases only, perforation rates were not significantly different between laparoscopic and open groups (72% vs. 67%).

"Surgical technique was not associated with abscess formation," Dr. Gnass noted.

Among the perforated cases only, postoperative abscesses developed in 18% of those who received at least 500 mL of irrigation and in none of those who received less than 500 mL of irrigation.

More research in the form of a prospective, randomized trial is needed to confirm the results, but based on the current findings, "we can suggest limiting the use of irrigation to 500 cc or less" in appendectomy procedures, Dr. Gnass said.

He reported having no relevant financial disclosures.

CHICAGO – High-volume intra-abdominal irrigation significantly increased the risk of postoperative abscess in a study of 327 appendectomy patients and led investigators to conclude that use of irrigation should be limited in these patients.

The classical thinking that irrigation during appendectomies washes away bacteria is changing, as additional data suggest that irrigation might create pockets of fluid that can lead to the formation of abscesses, Dr. Esteban Gnass said at the annual clinical congress of the American College of Surgeons.

Previous studies have shown that postoperative abscess (POA) formation significantly increases the length of a patient’s hospital stay and hospital costs, said Dr. Gnass of Riverside County Regional Medical Center in Moreno Valley, Calif.

To determine the association between irrigation during surgery and POA formation, he and his colleagues reviewed data from 265 laparoscopic and 62 open procedures conducted between January 2009 and June 2011. There were no significant demographic differences between patients in the two procedure groups. Patients also were subdivided according to perforated vs. nonperforated and irrigated vs. nonirrigated.

A total of 17 postoperative abscesses were observed, all of which occurred in irrigated patients. In addition, 88% of the postoperative abscess cases involved at least 500 mL of irrigation. "Large irrigation volumes carried a higher risk of POA," Dr. Gnass said.

After controlling for multiple variables, the investigators found that both irrigation volume and perforation were significantly associated with abscess formation.

In both the laparoscopic and open groups, 100% of perforated patients received at least 500 mL of irrigation, compared with 75% of the nonperforated patients in the laparoscopy group and 0% of nonperforated patients in the open group.

POA rates and perforation rates were not significantly different between laparoscopic and open groups (5% vs. 4%, and 25% vs. 37%, respectively).

On further analysis of the POA cases only, perforation rates were not significantly different between laparoscopic and open groups (72% vs. 67%).

"Surgical technique was not associated with abscess formation," Dr. Gnass noted.

Among the perforated cases only, postoperative abscesses developed in 18% of those who received at least 500 mL of irrigation and in none of those who received less than 500 mL of irrigation.

More research in the form of a prospective, randomized trial is needed to confirm the results, but based on the current findings, "we can suggest limiting the use of irrigation to 500 cc or less" in appendectomy procedures, Dr. Gnass said.

He reported having no relevant financial disclosures.

CHICAGO – Approximately half of hospital readmissions are surgery related and one-third of these are due to infections, data from nearly 3,000 Medicare patients indicated.

Risk factors for readmission included male gender, higher ASA (American Society of Anesthesiologists) class, and longer hospital stay, Dr. Shanu N. Kothari said at the annual clinical congress of the American College of Surgeons.

Recent health care reform initiatives include a proposal to reduce reimbursement for certain 30-day hospital readmissions among Medicare patients, he noted.

Dr. Kothari of Gundersen Lutheran Health System in La Crosse, Wis., and his colleagues reviewed data from 2,865 Medicare patients who had surgery at their institution between Jan. 1, 2010, and May 16, 2011. A readmission was defined as any patient who was readmitted within 30 days of initial surgery. Patients with incomplete follow-up data and those who died within 30 days were excluded.

The overall 30-day readmission rate was 7%. Readmitted patients were significantly more likely to be male compared with nonreadmitted patients (54% vs. 44%) and significantly more likely to have an ASA class of 3 or greater (84% vs. 66%). There were no significant differences in age or body mass index between readmitted and nonreadmitted patients.

In addition, the average length of stay and operative times were significantly longer for readmitted patients vs. nonreadmitted patients (4.8 days vs. 2.8 days and 123 minutes vs. 98 minutes).

A majority of the procedures were general and orthopedic, and 77% were elective.

Of the readmitted patients, "84% had at least one chronic condition, and patients with cardiac disease, renal disease, and diabetes had higher readmission rates," Dr. Kothari said.

The reasons for readmission were divided into four categories: surgery related (53%), not related to the surgical procedure (35%), planned (7%), and patient related (5%).

The most common surgery-related reasons for readmission were infections (32%), medication side effects (12%), or pulmonary complications (9%), Dr. Kothari noted.

Most of the readmissions unrelated to the index surgical procedure were exacerbations of underlying conditions, such as renal failure or heart failure. Patient-related reasons for readmission included noncompliance with discharge instructions or medications, as well as psychological issues.

"Further study is needed to address reasons for readmission on a multicenter level," said Dr. Kothari. "Decreased reimbursement should be discouraged for readmissions directly related to patient noncompliance."

Dr. Kothari said he had no relevant financial disclosures.

CHICAGO – Approximately half of hospital readmissions are surgery related and one-third of these are due to infections, data from nearly 3,000 Medicare patients indicated.

Risk factors for readmission included male gender, higher ASA (American Society of Anesthesiologists) class, and longer hospital stay, Dr. Shanu N. Kothari said at the annual clinical congress of the American College of Surgeons.

Recent health care reform initiatives include a proposal to reduce reimbursement for certain 30-day hospital readmissions among Medicare patients, he noted.

Dr. Kothari of Gundersen Lutheran Health System in La Crosse, Wis., and his colleagues reviewed data from 2,865 Medicare patients who had surgery at their institution between Jan. 1, 2010, and May 16, 2011. A readmission was defined as any patient who was readmitted within 30 days of initial surgery. Patients with incomplete follow-up data and those who died within 30 days were excluded.

The overall 30-day readmission rate was 7%. Readmitted patients were significantly more likely to be male compared with nonreadmitted patients (54% vs. 44%) and significantly more likely to have an ASA class of 3 or greater (84% vs. 66%). There were no significant differences in age or body mass index between readmitted and nonreadmitted patients.

In addition, the average length of stay and operative times were significantly longer for readmitted patients vs. nonreadmitted patients (4.8 days vs. 2.8 days and 123 minutes vs. 98 minutes).

A majority of the procedures were general and orthopedic, and 77% were elective.

Of the readmitted patients, "84% had at least one chronic condition, and patients with cardiac disease, renal disease, and diabetes had higher readmission rates," Dr. Kothari said.

The reasons for readmission were divided into four categories: surgery related (53%), not related to the surgical procedure (35%), planned (7%), and patient related (5%).

The most common surgery-related reasons for readmission were infections (32%), medication side effects (12%), or pulmonary complications (9%), Dr. Kothari noted.

Most of the readmissions unrelated to the index surgical procedure were exacerbations of underlying conditions, such as renal failure or heart failure. Patient-related reasons for readmission included noncompliance with discharge instructions or medications, as well as psychological issues.

"Further study is needed to address reasons for readmission on a multicenter level," said Dr. Kothari. "Decreased reimbursement should be discouraged for readmissions directly related to patient noncompliance."

Dr. Kothari said he had no relevant financial disclosures.

CHICAGO – Approximately half of hospital readmissions are surgery related and one-third of these are due to infections, data from nearly 3,000 Medicare patients indicated.

Risk factors for readmission included male gender, higher ASA (American Society of Anesthesiologists) class, and longer hospital stay, Dr. Shanu N. Kothari said at the annual clinical congress of the American College of Surgeons.

Recent health care reform initiatives include a proposal to reduce reimbursement for certain 30-day hospital readmissions among Medicare patients, he noted.

Dr. Kothari of Gundersen Lutheran Health System in La Crosse, Wis., and his colleagues reviewed data from 2,865 Medicare patients who had surgery at their institution between Jan. 1, 2010, and May 16, 2011. A readmission was defined as any patient who was readmitted within 30 days of initial surgery. Patients with incomplete follow-up data and those who died within 30 days were excluded.

The overall 30-day readmission rate was 7%. Readmitted patients were significantly more likely to be male compared with nonreadmitted patients (54% vs. 44%) and significantly more likely to have an ASA class of 3 or greater (84% vs. 66%). There were no significant differences in age or body mass index between readmitted and nonreadmitted patients.

In addition, the average length of stay and operative times were significantly longer for readmitted patients vs. nonreadmitted patients (4.8 days vs. 2.8 days and 123 minutes vs. 98 minutes).

A majority of the procedures were general and orthopedic, and 77% were elective.

Of the readmitted patients, "84% had at least one chronic condition, and patients with cardiac disease, renal disease, and diabetes had higher readmission rates," Dr. Kothari said.

The reasons for readmission were divided into four categories: surgery related (53%), not related to the surgical procedure (35%), planned (7%), and patient related (5%).

The most common surgery-related reasons for readmission were infections (32%), medication side effects (12%), or pulmonary complications (9%), Dr. Kothari noted.

Most of the readmissions unrelated to the index surgical procedure were exacerbations of underlying conditions, such as renal failure or heart failure. Patient-related reasons for readmission included noncompliance with discharge instructions or medications, as well as psychological issues.

"Further study is needed to address reasons for readmission on a multicenter level," said Dr. Kothari. "Decreased reimbursement should be discouraged for readmissions directly related to patient noncompliance."

Dr. Kothari said he had no relevant financial disclosures.

CHICAGO – Approximately one-third of surgical complications were diagnosed after patients left the hospital, based on data from nearly 60,000 procedures performed at 112 hospitals.

Reporting postoperative complications, including surgical site infections, has become a mandatory quality reporting initiative for hospitals, and the Affordable Care Act requires reporting of readmissions, said Dr. Melanie Morris of the University of Alabama at Birmingham.

"Some postoperative complications may lead to readmissions, but this may not tell the whole story," she noted at the annual clinical congress of the American College of Surgeons.

To determine the timing of postoperative complications and the nature of readmissions, Dr. Morris and her colleagues reviewed Veterans Affairs data from the noncardiac Surgical Care Improvement Project (SCIP) cohort from 2005 to 2009 for 59,464 surgical procedures in which there was at least one complication.

"It’s very important that patients are accurately educated on the signs and symptoms of complications so they know to seek timely care after discharge."

Surgical cases were classified by specialty into gastrointestinal, gynecologic, orthopedic, and vascular. Complications were grouped into organ-based systems. For example, urinary complications included renal failure, renal insufficiency, and urinary tract infections; respiratory complications included failure to wean, pneumonia, and reintubation; and surgical site infections (SSIs) included both deep and superficial wounds.

The overall complication rate was approximately 15%, and 32% of complications were diagnosed after hospital discharge, Dr. Morris said. More than half (56%) of all SSIs were diagnosed after discharge, she added.

A statistically significant difference appeared in postdischarge complications by surgical specialty. The SSI rate was 5.4%, followed by respiratory complications (5.0%), urinary tract infection (4.9%), cardiac complications (3.2%), and venous thromboembolism (1.2%).

"Our GI surgical patients had the highest overall complication rate," Dr. Morris noted. Among GI patients, colectomy patients had the highest SSI rate (11%), and 23% of the GI complications were diagnosed after hospital discharge.

In addition, 78% of SSIs in orthopedic patients were diagnosed after discharge, as were 39% of SSIs in GI patients, 77% of SSIs in vascular surgery patients, and 95% of SSIs in gynecologic patients, said Dr. Morris.

There were no significant differences in length of hospital stay based on complications, Dr. Morris said.

The overall readmission rate was 11.9%, and 70% of these patients had no identifiable postoperative complication. Of those who did have an identifiable postop complication, 72% were diagnosed before discharge from the hospital.

The probability of being readmitted to the hospital over time was highest in patients with a postdischarge diagnosis of a complication. The overall length of stay was 5 days, and the average length of stay for patients with any complication was 9 days.

Patient-specific factors associated with an increased risk of readmission included a history of heart failure, renal failure, diabetes, weight loss, and smoking. Procedure-specific factors associated with an increased risk of readmission included a longer operating time, a more contaminated wound, and a higher ASA (American Society of Anesthesiologists) class.

Length of stay was slightly protective for readmission, and the presence of any complication was associated with a high risk of readmission.

"It’s very important that patients are accurately educated on the signs and symptoms of complications so they know to seek timely care after discharge," said Dr. Morris. "Postoperative complications must be measured beyond hospital discharge to capture the whole story.

"Systematic collection of postoperative complications must include postdischarge data as well as readmissions to accurately measure quality," she said.

Dr. Morris said she had no relevant financial disclosures.

CHICAGO – Approximately one-third of surgical complications were diagnosed after patients left the hospital, based on data from nearly 60,000 procedures performed at 112 hospitals.

Reporting postoperative complications, including surgical site infections, has become a mandatory quality reporting initiative for hospitals, and the Affordable Care Act requires reporting of readmissions, said Dr. Melanie Morris of the University of Alabama at Birmingham.

"Some postoperative complications may lead to readmissions, but this may not tell the whole story," she noted at the annual clinical congress of the American College of Surgeons.

To determine the timing of postoperative complications and the nature of readmissions, Dr. Morris and her colleagues reviewed Veterans Affairs data from the noncardiac Surgical Care Improvement Project (SCIP) cohort from 2005 to 2009 for 59,464 surgical procedures in which there was at least one complication.

"It’s very important that patients are accurately educated on the signs and symptoms of complications so they know to seek timely care after discharge."

Surgical cases were classified by specialty into gastrointestinal, gynecologic, orthopedic, and vascular. Complications were grouped into organ-based systems. For example, urinary complications included renal failure, renal insufficiency, and urinary tract infections; respiratory complications included failure to wean, pneumonia, and reintubation; and surgical site infections (SSIs) included both deep and superficial wounds.

The overall complication rate was approximately 15%, and 32% of complications were diagnosed after hospital discharge, Dr. Morris said. More than half (56%) of all SSIs were diagnosed after discharge, she added.

A statistically significant difference appeared in postdischarge complications by surgical specialty. The SSI rate was 5.4%, followed by respiratory complications (5.0%), urinary tract infection (4.9%), cardiac complications (3.2%), and venous thromboembolism (1.2%).

"Our GI surgical patients had the highest overall complication rate," Dr. Morris noted. Among GI patients, colectomy patients had the highest SSI rate (11%), and 23% of the GI complications were diagnosed after hospital discharge.

In addition, 78% of SSIs in orthopedic patients were diagnosed after discharge, as were 39% of SSIs in GI patients, 77% of SSIs in vascular surgery patients, and 95% of SSIs in gynecologic patients, said Dr. Morris.

There were no significant differences in length of hospital stay based on complications, Dr. Morris said.

The overall readmission rate was 11.9%, and 70% of these patients had no identifiable postoperative complication. Of those who did have an identifiable postop complication, 72% were diagnosed before discharge from the hospital.

The probability of being readmitted to the hospital over time was highest in patients with a postdischarge diagnosis of a complication. The overall length of stay was 5 days, and the average length of stay for patients with any complication was 9 days.

Patient-specific factors associated with an increased risk of readmission included a history of heart failure, renal failure, diabetes, weight loss, and smoking. Procedure-specific factors associated with an increased risk of readmission included a longer operating time, a more contaminated wound, and a higher ASA (American Society of Anesthesiologists) class.

Length of stay was slightly protective for readmission, and the presence of any complication was associated with a high risk of readmission.

"It’s very important that patients are accurately educated on the signs and symptoms of complications so they know to seek timely care after discharge," said Dr. Morris. "Postoperative complications must be measured beyond hospital discharge to capture the whole story.

"Systematic collection of postoperative complications must include postdischarge data as well as readmissions to accurately measure quality," she said.

Dr. Morris said she had no relevant financial disclosures.

CHICAGO – Approximately one-third of surgical complications were diagnosed after patients left the hospital, based on data from nearly 60,000 procedures performed at 112 hospitals.

Reporting postoperative complications, including surgical site infections, has become a mandatory quality reporting initiative for hospitals, and the Affordable Care Act requires reporting of readmissions, said Dr. Melanie Morris of the University of Alabama at Birmingham.

"Some postoperative complications may lead to readmissions, but this may not tell the whole story," she noted at the annual clinical congress of the American College of Surgeons.

To determine the timing of postoperative complications and the nature of readmissions, Dr. Morris and her colleagues reviewed Veterans Affairs data from the noncardiac Surgical Care Improvement Project (SCIP) cohort from 2005 to 2009 for 59,464 surgical procedures in which there was at least one complication.

"It’s very important that patients are accurately educated on the signs and symptoms of complications so they know to seek timely care after discharge."

Surgical cases were classified by specialty into gastrointestinal, gynecologic, orthopedic, and vascular. Complications were grouped into organ-based systems. For example, urinary complications included renal failure, renal insufficiency, and urinary tract infections; respiratory complications included failure to wean, pneumonia, and reintubation; and surgical site infections (SSIs) included both deep and superficial wounds.

The overall complication rate was approximately 15%, and 32% of complications were diagnosed after hospital discharge, Dr. Morris said. More than half (56%) of all SSIs were diagnosed after discharge, she added.

A statistically significant difference appeared in postdischarge complications by surgical specialty. The SSI rate was 5.4%, followed by respiratory complications (5.0%), urinary tract infection (4.9%), cardiac complications (3.2%), and venous thromboembolism (1.2%).

"Our GI surgical patients had the highest overall complication rate," Dr. Morris noted. Among GI patients, colectomy patients had the highest SSI rate (11%), and 23% of the GI complications were diagnosed after hospital discharge.

In addition, 78% of SSIs in orthopedic patients were diagnosed after discharge, as were 39% of SSIs in GI patients, 77% of SSIs in vascular surgery patients, and 95% of SSIs in gynecologic patients, said Dr. Morris.

There were no significant differences in length of hospital stay based on complications, Dr. Morris said.

The overall readmission rate was 11.9%, and 70% of these patients had no identifiable postoperative complication. Of those who did have an identifiable postop complication, 72% were diagnosed before discharge from the hospital.

The probability of being readmitted to the hospital over time was highest in patients with a postdischarge diagnosis of a complication. The overall length of stay was 5 days, and the average length of stay for patients with any complication was 9 days.

Patient-specific factors associated with an increased risk of readmission included a history of heart failure, renal failure, diabetes, weight loss, and smoking. Procedure-specific factors associated with an increased risk of readmission included a longer operating time, a more contaminated wound, and a higher ASA (American Society of Anesthesiologists) class.

Length of stay was slightly protective for readmission, and the presence of any complication was associated with a high risk of readmission.

"It’s very important that patients are accurately educated on the signs and symptoms of complications so they know to seek timely care after discharge," said Dr. Morris. "Postoperative complications must be measured beyond hospital discharge to capture the whole story.

"Systematic collection of postoperative complications must include postdischarge data as well as readmissions to accurately measure quality," she said.

Dr. Morris said she had no relevant financial disclosures.