More than 40% of postoperative complications occurred after discharge and were more commonly associated with certain procedures – along with a significantly increased risk of reoperations and death – in a large retrospective study of adults who had undergone general surgery as inpatients.
The results indicate that postdischarge (PD) complications "account for a significant burden of postoperative complications and are an important avenue for quality improvement in inpatient general surgery," concluded Dr. Hadiza S. Kazaure of the department of general surgery, Stanford (Calif.) University, and her coauthors. "More research is needed to develop and explore the utility of a cost-effective and fastidious PD follow-up system for surgical patients," they added, noting that their findings "underscore the need for systematic collection of PD adverse event data to improve postoperative surgical care in the United States" (Arch. Surg. 2012;147:1000-07). The study was based on data from the American College of Surgeons National Surgical Quality Improvement Program (2005-2010) on 551,510 adult patients (mean age, 55 years) who had undergone inpatient surgery that fell into one of 21 types of general surgery procedure categories at U.S. hospitals. The authors analyzed the rates and types of PD complications, as well as associations between the types of surgical procedures, reoperations, and mortality, within 30 days of surgery.
Within 30 days of surgery, nearly 17% of these patients had a complication. Nearly 7% of those complications occurred after discharge, accounting for almost 42% of postoperative complications. Most – 75% – of the PD complications occurred within the first 14 days of discharge, indicating that this period is "a particularly vulnerable time" for patients undergoing general surgery, the authors said.
The highest rates of PD complications were among the patients who underwent a proctectomy (a 14.5% complication rate), followed by those who had an enteric fistula repair (13%) and a pancreatic procedure (11%). Complication rates after discharge were lowest among those undergoing fundoplasty (3%) or an endocrine procedure, which included thyroid, parathyroid, and adrenal procedures (1.5%).
Breast surgery patients accounted for the highest proportion of complications occurring during the PD period. Almost 80% of complications after breast surgery occurred after discharge, compared with 70% after bariatric procedures and 62% after ventral hernia repair. And almost 83% of the PD complications that occurred in surgical patients fell into one of the following 10 categories: colectomy, small bowel procedures, bariatric procedures, ventral hernia repair, appendectomy, cholecystectomy, pancreatic procedures, exploratory laparotomy, breast procedures, and gastrectomy.
Surgical site complications, infections, and thromboembolic events accounted for almost 91% of PD complications after discharge. Patients who had a PD complication were more likely to be older and male, and were more likely to have diabetes, to use steroids, and to have had a complication while in the hospital. Other factors associated with PD complications were an American Society of Anesthesiologist class higher than 3, a mean 35-minute longer operation time, and a mean 3-day longer hospital stay.
Reoperation rates and mortality rates were 18% and 7%, respectively, among those with a PD complication vs. 5% and 2% among those who did not have a complication after discharge – a significant difference.
Since the risk of postdischarge complications was associated with "baseline complexity of illness and potentially modifiable factors such as diabetes, obesity, and use of steroids, our findings could facilitate identification of patients at increased risk and allow for targeted preventive interventions," the authors said.
While they believe this is the largest study of complications occurring after discharge in general surgery patients in the United States, the authors noted some limitations, including possible coding errors and no markers of illness severity.
No conflict of interest disclosures were reported.