A new US study finds that over 40% of complications after general surgery procedures arise after patients have been discharged, with three quarters occurring within the first two weeks of leaving hospital. At least one expert suggests the study highlights the importance of focusing on patient needs and calls for insurers to invest the proposed savings they would make into research for safer surgery.

Lead author Hadiza S. Kazaure, of Stanford University at Palo Alto in California, and colleagues, analyzed 2005 to 2012 data from the American College of Surgeons National Surgical Quality Improvement Program, and found, overall, 16.7% of general surgery patients experienced a postdischarge (PD) complication, and 41.5% of complications occurred postdischarge.

They write about their retrospective study online in the November issue of Archives of Surgery, a JAMA Network publication.

The period following discharge from hospital is a vulnerable time for surgery patients, and it can also be an expensive one for the healthcare system when patients have to go back into hospital because of a complication related to the procedure.

In their background information the researchers refer to the Patient Protection and Affordable Care Act, which says one of the targets to save costs is to reduce avoidable postdischarge hospitalization.

For their study, Kazaure and colleagues examined postdischarge (PD) complications that occurred within 30 days of leaving hospital in 21 groups of inpatient general hospital procedures. They were particularly interested in the types of procedure, the rates and the risk factors for PD complications.

The data they used covered 551,510 patients whose average age was nearly 55 years.

They found 75% of PD complications occurred within 14 days of leaving hospital.

They also note:

“We found that more than 40 percent of all post-operative complications occurred PD; approximately 1 in 14 general surgery patients who underwent an inpatient procedure experienced a PD complication.”

When they ranked PD complications by type of procedure, at the highest end they found 14.5% were for proctectomy (surgery involving the rectum), 12.6% were for enteric fistula repair (abnormal passageway repair) and 11.4% were for pancreatic procedures.

When they looked within each type of procedure, they found 78.7% of breast procedures had PD complications, followed by 69.4% of bariatric, and 62% of hernia repair procedures.

For all procedures, they found surgical site complications, infections and blood clots (thromboembolisms) were the most common complications, while a complication while still in hospital increased the chances of having one after discharge (12.5% compared with 6.2% without an inpatient complication).

The researchers also note that patients with a PD complication had higher rates of re-operation (17.9% compared with 4.6% without a PD complication).

Death was also more likely within 30 days after surgery in patients with a PD complication (6.9% versus 2% without a PD complication).

And the highest rates of re-operation and death were among patients whose PD complication was preceded by an inpatient complication.

The researchers conclude their study shows “PD complications account for a significant burden of postoperative complications and are an important avenue for quality improvement in inpatient general surgery”.

They call for more research to develop and explore the usefulness of a cost-effective and “fastidious” postdischarge follow-up system for surgical patients.

Desmond C. Winter of St. Vincent’s University Hospital, Dublin, Ireland, notes in an invited critique of the study published in the same issue of the journal, that every surgeon will read the paper from Kazaure and colleagues with interest, because “complications are the statistics that define us all”.

He says the need to reduce disease is what drives the scientific evolution of surgery.

“Patient needs, not financial penalties, should be everyone’s primary focus. Let us see further advancements in surgical care through research funded by the proposed insurer savings and together strive for safer surgery,” urges Winter.

Written by Catharine Paddock PhD