Abstract
This study evaluates the prevalence of postprocedure emergency department visits and admissions and the association of these outcomes with relevant patient, procedure, and facility factors.
Outpatient surgical care and invasive medical procedures are increasing. Prior research from the Veterans Health Administration (VHA) found that wrong-side or wrong-site adverse events were more common in the outpatient setting than the inpatient setting when the procedure was performed outside the operating room.1 Both inpatient and outpatient operating room–based surgical procedures are evaluated by the National Surgical Quality Improvement Program2; however, non–operating room outpatient invasive procedures are not assessed. To address this gap and inform future research, we measured the prevalence of postprocedure emergency department (ED) visits and admissions and explored the association of these outcomes with relevant patient, procedure, and facility factors.3
Methods
The VHA Corporate Data Warehouse fiscal years 2012 to 2015 outpatient and procedure files were used to identify cases by Current Procedural Terminology code and outpatient setting for 5 high-volume subspecialties: urology, podiatry, cardiology (invasive and electrophysiologic procedures), interventional radiology, and gastroenterology. Only elective invasive procedures, defined as requiring general, monitored, or regional anesthesia, incision, device implantation, injection, or endoscopic entry of a sterile site, performed in facilities that treat more than 50 cases per year were retained.4 Patient demographics, including self-reported race/ethnicity and sex, comorbidities, 30-day prior visits and hospitalizations, number of procedures, procedural relative value unit, and facility’s geographic region, were extracted from the Corporate Data Warehouse. The surgical complexity rating of each facility was obtained from the VHA National Surgery Office.5 The Boston Veterans Affairs Healthcare System institutional review board approved the study and waived informed consent (data remained identifiable).
Outcomes included 0- to 14-day visits to a VHA ED and 1- to 14-day VHA admissions; we excluded observational stays and same-day admissions. The association between outcomes and patient, procedure, and facility characteristics for each specialty was assessed with logistic regression using SAS statistical software, version 9.2 (SAS Institute Inc). We controlled for temporal factors and facility-level fixed effects.
Results
There were 988 476 invasive outpatient procedures performed in 109 hospital outpatient departments, 23 ambulatory surgical centers, and 113 nonsurgical VHA facilities. Most cases were treated by specialists in gastroenterology (32%), urology (25%), and podiatry (25%). Incidence of 0- to 14-day postprocedure ED visits ranged from 1.3% (podiatry) to 3.4% (interventional radiology); 1- to 14-day postprocedure admissions ranged from 0.6% (podiatry) to 1.6% (interventional radiology) (Table 1). Higher rates of health care use in the 30 days before the procedure were associated with postprocedure use across all specialties (Table 2). Within each specialty, unmarried status, race, age, procedural relative value unit, and overall procedural complexity were significant indicators of postprocedural use outcomes.
Table 1. Patient Outcomes After Invasive Outpatient Procedures Across Veterans Health Administration Specialty Clinics.
| Specialty | No. (%) of Procedures | |||
|---|---|---|---|---|
| Total Procedures | 0- to 14-Day Stay | Any Postprocedure Care | ||
| ED Visit | Admission | |||
| Urologya | 252 068 (25.5) | 4667 (1.8) | 1587 (0.6) | 5986 (2.4) |
| Podiatry | 251 718 (25.5) | 3328 (1.3) | 1413 (0.6) | 4576 (1.8) |
| Cardiologya | 83 051 (8.4) | 2199 (2.6) | 1277 (1.5) | 3324 (4.0) |
| Interventional radiology | 82 855 (8.4) | 2794 (3.4) | 1323 (1.6) | 3912 (4.7) |
| Gastroenterology | 318 784 (32.2) | 6287 (2.0) | 1992 (0.6) | 7911 (2.5) |
| Total | 988 476 | 19 275 (2.0) | 7592 (0.8) | 25 709 (2.6) |
Abbreviation: ED, emergency department.
Cardiology includes the following Veterans Health Administration clinics: cardiac catheterization (333), electrophysiology laboratory (369), cardiology (303), pacemaker (311), and angiogram catheterization (152). Urology includes urology (411) and cystoscopy unit (413). Outpatient procedure data are from fiscal years 2012 to 2015.
Table 2. Logistic Regression Results Predicting 0- to 14-Day ED Visits or 1- to 14-Day Hospital Admissions After Invasive Outpatient Procedures by Veterans Health Administration Specialty Clinica.
| Factors Associated With Postprocedure Care | OR (95% CI) | ||||
|---|---|---|---|---|---|
| Urology | Podiatry | Cardiology | Interventional Radiology | Gastroenterology | |
| No. of facilities | 175 | 237 | 112 | 85 | 145 |
| No. of operations (No. of events) | 252 068 (5986) | 251 718 (4576) | 83 051 (3324) | 82 855 (3912) | 318 784 (7911) |
| Patient Demographics | |||||
| Female | 0.93 (0.78-1.10) | 1.07 (0.94-1.22) | 0.86 (0.69-1.09) | 0.93 (0.78-1.09) | 1.06 (0.97-1.15) |
| Married | 0.93 (0.88-0.98)b | 0.97 (0.91-1.03) | 0.98 (0.91-1.05) | 0.98 (0.92-1.05) | 0.94 (0.89-0.98)b |
| Race/ethnicity | |||||
| White | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| African American | 1.12 (1.04-1.20)b | 1.01 (0.93-1.10) | 0.99 (0.89-1.10) | 0.92 (0.84-1.00)b | 1.16 (1.09-1.23)b |
| Native American | 1.12 (0.81-1.57) | 1.1 (0.83-1.44) | 1.14 (0.74-1.76) | 1.03 (0.69-1.55) | 0.87 (0.65-1.16) |
| Asian Pacific Islander | 1.09 (0.81-1.46) | 1.08 (0.78-1.48) | 0.87 (0.57-1.32) | 1.01 (0.73-1.39) | 0.79 (0.6-1.04) |
| Missing | 1.02 (0.89-1.16) | 0.88 (0.74-1.04) | 0.93 (0.77-1.13) | 0.84 (0.69-1.01) | 0.98 (0.87-1.11) |
| Unknown or not reported | 1.01 (0.8-1.27) | 0.94 (0.72-1.21) | 1.12 (0.85-1.50) | 1.02 (0.79-1.32) | 0.95 (0.77-1.18) |
| Age group, y | |||||
| 18-57 | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| 58-63 | 0.91 (0.82-1.01) | 0.81 (0.74-0.89)b | 0.93 (0.83-1.05) | 0.95 (0.86-1.06) | 0.84 (0.79-0.90)b |
| 64-67 | 0.94 (0.85-1.03) | 0.87 (0.79-0.95)b | 0.87 (0.77-0.97)b | 0.94 (0.85-1.04) | 0.78 (0.73-0.84)b |
| 68-73 | 0.86 (0.78-0.95)b | 0.95 (0.86-1.05) | 0.92 (0.81-1.04) | 0.99 (0.88-1.10) | 0.76 (0.71-0.82)b |
| 74-100 | 1.05 (0.95-1.15) | 0.96 (0.87-1.06) | 0.93 (0.82-1.05) | 1.04 (0.93-1.16) | 0.98 (0.91-1.06) |
| Comorbidity | |||||
| Coagulopathy | 1.36 (1.04-1.77)b | 1.03 (0.72-1.46) | 0.85 (0.55-1.30) | 1.36 (0.97-1.09) | 1.11 (0.87-1.42) |
| Patient Prior Health Care Use | |||||
| ED visits 30 d earlier | |||||
| 0-11 | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| 12-15 | 1.2 (1.10-1.30)b | 1.07 (0.96-1.20) | 0.87 (0.77-0.99)b | 1.2 (1.06-1.36)b | 1.21 (1.13-1.31)b |
| 16-21 | 1.28 (1.17-1.39)b | 1.2 (1.08-1.34)b | 0.96 (0.85-1.09) | 1.3 (1.15-1.48)b | 1.45 (1.35-1.57)b |
| 22-32 | 1.47 (1.36-1.59)b | 1.22 (1.11-1.34)b | 1.01 (0.9-1.13) | 1.49 (1.33-1.66)b | 1.69 (1.58-1.81)b |
| 33-60 | 1.88 (1.73-2.04)b | 1.66 (1.52-1.82)b | 1.15 (1.03-1.29)b | 1.68 (1.51-1.86)b | 2.12 (1.98-2.27)b |
| Hospitalization 30 d prior | 1.81 (1.65-1.98)b | 1.72 (1.56-1.89)b | 1.4 (1.26-1.56)b | 1.27 (1.16-1.38)b | 1.75 (1.6-1.90)b |
| Procedure Characteristics | |||||
| ≥1 Procedure on visit day | 1 (0.94-1.07) | 0.95 (0.86-1.04) | 1.08 (1-1.18) | 1.06 (0.96-1.16) | 1.08 (1.03-1.14)b |
| Procedure RVUs | |||||
| 0.04-1.01 | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| 1.02-1.53 | 0.96 (0.89-1.03) | 1.18 (1.05-1.33)b | 1.03 (0.82-1.29) | 0.93 (0.83-1.06) | 1.2 (0.98-1.47) |
| 1.55-2.39 | 1.23 (1.08-1.41)b | 1 (0.92-1.1) | 1.11 (0.93-1.33) | 1.12 (1.01-1.23)b | 1.2 (1.02-1.41)b |
| 2.4-3.56 | 1.36 (1.26-1.47)b | 1.48 (1.26-1.74)b | 0.78 (0.64-0.95)b | 1.06 (0.93-1.20) | 1.08 (0.92-1.27) |
| 3.57-23.5 | 1.69 (1.47-1.95)b | 1.76 (1.52-2.05)b | 0.82 (0.7-0.96)b | 1.34 (1.21-1.47)b | 1.21 (1.02-1.43)b |
| Facility Characteristics | |||||
| Nonsurgical facility | |||||
| ASC | 1.04 (0.76-1.43) | 1.15 (0.89-1.47) | 1 [Reference]c | 1 [Reference]c | 1.62 (1.23-2.13)b |
| Standard hospital | 1.4 (0.99-1.97) | 1.68 (1.25-2.24)b | 2.56 (1.87-3.50)b | ||
| Intermediate hospital | 1.61 (1.21-2.16)b | 1.54 (1.24-1.93)b | 2.32 (1.8-2.98)b | ||
| Complex hospital | 1.44 (1.09-1.89)b | 1.61 (1.32-1.97)b | 1.06 (0.87-1.3) | 1.15 (0.92-1.43) | 2.35 (1.85-2.99)b |
| Pacific region | |||||
| Atlantic | 1.09 (0.92-1.3) | 0.9 (0.74-1.09) | 0.74 (0.6-0.92)b | 0.9 (0.7-1.14) | 0.92 (0.8-1.06) |
| Continental | 1.03 (0.86-1.23) | 0.79 (0.64-0.96)b | 0.9 (0.72-1.12) | 0.87 (0.66-1.13) | 0.95 (0.81-1.10) |
| Southeast | 0.91 (0.76-1.09) | 0.88 (0.72-1.07) | 0.81 (0.66-1.01) | 0.85 (0.66-1.09) | 0.9 (0.78-1.05) |
| Midwest | 1 (0.84-1.20) | 0.89 (0.73-1.07) | 0.81 (0.65-1.00)b | 0.9 (0.71-1.15) | 0.96 (0.83-1.10) |
Abbreviations: ASC, ambulatory surgery center; ED, emergency department; OR, odds ratio, RVU, relative value unit.
Outpatient procedure data are from fiscal years 2012-2015. Comorbidities defined using Elixhauser methods based on International Classification of Diseases, Ninth Revision, coded diagnoses from visits and admissions 1 year before procedure. Table excludes nonsignificant variables in the model and temporal effects. Model C statistics range from 0.6 (cardiology) to 0.63 (urology).
Significance at P < .05.
ASC or low-complexity hospital (procedures were entirely performed in surgical facilities and rarely in ASCs or standard hospitals).
Discussion
Improving patient outcomes after outpatient procedures is important to health care practitioners and policy makers.6 Although procedures that do not require an inpatient or operating room stay are assumed to present fewer risks, these results demonstrate that postprocedure ED visits and admissions are not rare. Underlying disease severity may contribute to increases in postprocedure use; higher rates of visits and admissions in the prior month were significant indicators. Of importance, when preprocedural use was accounted for, racial/ethnic and age disparities were observed. We did not assess whether 1- to 14-day admissions were planned or preventable, which may explain the higher admission rates for certain specialties (eg, interventional radiology and cancer treatments). However, because ED visits and admissions that occurred outside the VHA were not captured in this data set, these findings are likely to be an underestimate of the true rate of postprocedure outcomes. More work is needed to confirm these results in a nonveteran sample; however, our findings have significant population health relevance because the VHA is the largest US health care system.
These findings suggest that although invasive outpatient procedures are not routinely included in patient safety or quality measurement, they account for a significant burden of postprocedure care. Improving surveillance of invasive procedures may lead to quality improvement initiatives that can benefit patients while potentially reducing ED visits and admissions.
References
- 1.Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-1034. [DOI] [PubMed] [Google Scholar]
- 2.Khuri SF, Daley J, Henderson W, et al. ; National VA Surgical Quality Improvement Program . The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. Ann Surg. 1998;228(4):491-507. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Mull HJ, Rosen AK, Charns MP, Itani KMF, Rivard PE. Identifying risks and opportunities in outpatient surgical patient safety: a qualitative analysis of Veterans Health Administration staff perceptions [published online November 4, 2017]. J Patient Saf. 2017. doi: 10.1097/PTS.0000000000000311 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Mull HJ, Rosen AK, Rivard PE, Itani KMF. Defining outpatient surgery: perspectives of surgical staff in the Veterans Health Administration. Am Surg. 2016;82(11):1142-1145. [PMC free article] [PubMed] [Google Scholar]
- 5.VA National Surgery Office (NSO) Surgical Services Homepage. 2015. https://www.va.gov/health/surgery/. Accessed March 19, 2018.
- 6.Centers for Medicare & Medicaid Services 2016 Measure Updates and Specifications Report: Hospital Visits After Hospital Outpatient Surgery Measure (Risk-Standardized Hospital Visits Within 7 Days After Hospital Outpatient Surgery Measure), Version 1.1. Washington, DC: Centers for Medicare & Medicaid Services; 2016. [Google Scholar]