Impact of Post-Hospital Syndrome on Outcomes Following Elective, Ambulatory Surgery

Abstract

Objective: The aim of this study was to investigate whether post-hospital syndrome (PHS) places patients undergoing elective hernia repair at increased risk for adverse postoperative events.

Summary of background data: PHS is a transient period of health vulnerability following inpatient hospitalization for acute illness. PHS has been well studied in nonsurgical populations, but its effect on surgical outcomes is unclear.

Methods: State-specific datasets for California in 2011 available through the Healthcare Cost and Utilization Project (HCUP) were linked. Patients older than 18 years who underwent elective hernia repair were included. The primary exposure variable was PHS, defined as any inpatient admission within 90 days of an elective hernia repair performed in an ambulatory surgery center. The primary outcome was an adverse event, defined as any unplanned emergency department visit or inpatient admission within 30 days postoperatively. Mixed-effects logistic models were used for multivariable analyses.

Results: A total of 57,988 patients met inclusion criteria. The 30-day risk-adjusted adverse event rate was significantly higher for PHS patients versus non-PHS patients (11.8% vs 5.8%, P < 0.001). PHS patients were more likely than non-PHS patients to experience postoperative complications (odds ratio 2.2, 95% confidence interval 1.6-3.0). Adverse events attributable to PHS cost an additional $63,533.46 per 100 cases in California. The risk of adverse events due to PHS remained elevated throughout the 90-day window between hospitalization and surgery.

Conclusions: Patients hospitalized within 90 days of an elective surgery are at increased risk of adverse events postoperatively. The impact of PHS on outcomes is independent of baseline patient characteristics, medical comorbidities, quality of center performing the surgery, and reason for hospitalization before elective surgery. Adverse events owing to PHS are costly and represent a quality improvement target.

Figure 1

(A) Postoperative outcomes following elective hernia repair in exposed (PHS) and unexposed (no PHS) groups. (B) Kaplan-Maier failure curves for 30-day postoperative adverse events, by exposure. AE indicates adverse event; PHS, post-hospital syndrome.

Figure 2

Observed over expected adverse event rate, by ASC (ranked from lowest to highest) with 95% confidence intervals. ^†Predicted observed, with shrinkage adjustment. AE indicates Adverse event; ASC, ambulatory surgery center.

Figure 3

Costs associated with increased rate of postoperative adverse events for patients exposed to PHS. IQR indicates interquartile range; PHS, post-hospital syndrome. ¹Median cost of inpatient readmission in PHS group = $9545.53 (IQR: $6818.53–$15,819.27) vs median cost of inpatient readmission in non-PHS group = $10,698.92 (IQR: $5843.10–$19,642.17), P = 0.523. Median cost of inpatient readmission regardless of group = $10,588.91 (IQR: $5940.52–$19,378.55).

Figure 4

Adjusted odds and frequency of adverse events based on number of days between hospital discharge and elective hernia repair. AE indicates adverse event; CI, confidence interval; PHS, post-hospital syndrome.