Primary Care Follow-Up After Emergency Surgery Tied to Fewer Readmissions

Among patients hospitalized for an emergency general surgery (EGS) condition, primary care follow-up within 30 days of discharge was associated with a significant reduction in readmission rates, according to a retrospective cohort study of Medicare beneficiaries.

Adjusted odds of a 30-day readmission were 67% lower for patients who had a primary care follow-up within 30 days of discharge compared with those who did not (adjusted OR 0.33, 95% CI 0.31-0.36), reported Rachel Kelz, MD, of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, and colleagues.

“This finding highlights the potential role of PCP [primary care physician] follow-up in the early identification and management of complications and the prevention of progression of disease to a level of severity requiring readmission,” Kelz and colleagues wrote in JAMA Surgery.

Patients who were treated operatively during their initial EGS visit had 79% reduced odds of readmission with a follow-up visit (adjusted OR 0.21, 95% CI 0.18-0.25), and those treated nonoperatively had 64% reduced odds (adjusted OR 0.36, 95% CI 0.34-0.39), compared with patients without a follow-up.

Postoperative care used to mean longer stays in the hospital, Kelz told MedPage Today. “And now we’re really down to days — if days — that people stay in the hospital. So that post-discharge care space really deserves a lot of attention, and our primary care colleagues are really, quite frankly, the champions of a lot of care delivered in that domain.”

Among patients undergoing EGS, 8.1% have an unplanned readmission — and older adults experience the highest rates of readmission. Though primary care follow-up has been linked to lower readmission rates after hospitalization for other medical conditions and high-risk surgery, the implications with EGS conditions have remained unclear.

Primary care providers can help flag and treat postoperative complications like infection before they progress, or help patients make adjustments to medications, Kelz explained, preventing what could otherwise become an emergency.

She said the findings further highlight the importance of coordination of care in preventing hospital readmissions, and the role advanced practice practitioners could play in delivering care to communities where access is scarce.

“We now have incredibly well-trained allied health providers, so nurse practitioners and physician associates, and in many cases experienced nurses, who can provide a lot of primary care, and we’re not encouraging their opportunity to practice across the full scope of their training,” Kelz noted.

She also underscored the potential for remote care and telehealth to boost access to primary care for older adults, as did Yuman Fong, MD, of the City of Hope Medical Center in Duarte, California, in an invited commentary.

“Already, sensors are being tested and used in many health plans to take care of patients with heart failure and pulmonary failure at home to prevent hospital admissions,” Fong wrote, adding that it’s likely that perioperative primary care specialists will “evolve to become our partnered remote medicine colleagues to deliver superb care for surgical patients in the 21st century.”

For this study, Kelz and colleagues used data from the CMS Master Beneficiary Summary File, Inpatient, Carrier (Part B), and Durable Medical Equipment files between September 2016 and November 2018.

They included 345,360 Medicare fee-for-service beneficiaries ages 66 and older admitted through the emergency department with a primary diagnosis of a general abdominal, colorectal, hepatopancreatobiliary, intestinal obstruction, hernia, and upper gastrointestinal EGS condition, who received a general surgery consultation during the admission.

Patients without continuous Medicare Part A and Part B coverage, those enrolled in a health maintenance organization during the year before and the 30 days after the EGS admission, and patients who died in-hospital during admission were excluded.

Of the included patients, mean age was 74.4, 54.4% was women, and 83.9% were white; 45.4% had a primary care follow-up within 30 days after discharge. Black patients, patients with dual Medicare-Medicaid eligibility, and patients with three or more comorbidities were less likely to have a follow-up.

Overall, 17.5% of Medicare beneficiaries hospitalized for an EGS condition were readmitted within 30 days after discharge. The most common readmission diagnosis for the operative group was infection after a procedure, and sepsis for the nonoperative group.

Study limitations included the inability to identify severity and management of comorbidities, a lack of detailed clinical data not fully capturing the relationship between surgical complications and 30-day readmissions, and unmeasured confounders, including the possibility that healthier patients may be more likely to seek a primary care follow-up earlier, which Kelz and team tried to take into consideration.

The study also had a short time frame that may not have captured other visits that mitigated readmission, and did not look at the potential implications of telehealth appointments.

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