Approximately one in 11 women who undergo hysterectomy for benign disease make potentially avoidable visits to the emergency department (ED) within 30 days of surgery for problems not requiring readmission, new data show. The study, published online July 11 in Obstetrics & Gynecology, found almost a third of ED visits were for such conditions as pain, constipation, nausea/vomiting, and vaginitis, many of which could have been managed in an ambulatory setting.
The findings highlight the need for expanded perioperative patient counseling and access to postoperative help lines, which may serve to reduce ED use and healthcare costs. “From a clinical perspective, a percentage of these visits could have been managed in an ambulatory setting or potentially avoided with improved perioperative management,” write Nichole Mahnert, MD, an obstetrician-gynecologist at Banner University Medical Center in Phoenix, Arizona, and colleagues. “Because pain and constipation were the most common avoidable diagnoses, enhanced perioperative education, stress reduction, and ambulatory support surrounding prevention and management of pain and constipation will be key to implement for all surgical patients.”
The team analyzed data from the statewide Michigan Surgical Quality Collaborative group of hospitals for patients who had undergone hysterectomies between January 1, 2013, and July 2, 2014, for benign, noncancer, and nonobstetric indications. Of a total of cohort of 10,274 hysterectomy patients, 932 (9.1%) presented to the ED within 30 days of hysterectomy without requiring readmission.
The mean age of women presenting to the ED was younger, at 44.5 ± 10.9 years vs 47.6 ± 10.8 years for the patients not visiting the ED, and about three quarters in both groups were white. The majority (88.1%) of the presenting group made only one ED visit. The most common ED diagnoses were abdominal or pelvic pain (16%), postoperative pain (7%), and constipation (5%).
Interestingly, compared with the referent group of privately insured patients, the study found a higher incidence of ED visits among those with Medicaid (19.5%; adjusted odds ratio [OR], 2.1) and uninsured/self-pay groups (13.3%; adjusted OR, 1.7).
Multivariable logistic regression identified several other demographic and clinical risk factors associated with an increased likelihood of presenting to the ED, including age 40 years or younger (OR, 2.4; 95% confidence interval [CI], 1.66 – 3.34) and parity of 3 or more (OR, 1.3; 95% CI, 1.07 – 1.51).
In terms of medical history, previous venous thromboembolism was associated with likelihood of ED presentation (OR, 2.1; 95% CI, 1.44 – 2.93), chronic obstructive pulmonary disease (OR, 1.7; 95% CI, 1.20 – 2.50), and a preoperative indication of chronic pelvic pain (OR, 1.2; 95% CI, 1.06 – 1.50).
Pain also emerged as a significant risk factor. Postoperative visual analog scale pain scores of 4 to 7 on postoperative day 1 were associated with a 30% greater likelihood of ED presentation compared with patients whose pain scores were 1 to 3 (OR, 1.3; 95% CI, 1.08 – 1.51). And those with pain scores of 8 to 10 had an 80% greater likelihood of ED presentation (OR, 1.8; 95% CI, 1.42 – 2.35).
“This suggests that women prone to difficult pain control are more likely to use the ED after surgery,” the authors write. “Counseling to review pain control expectations, collaboration with pain services, and relaxation programs will likely prove beneficial to women in this cohort and is an area that should be studied further.”
The authors noted that in previous research, patients with higher postoperative pain levels were similarly likely to be younger and report a history of preoperative pain, as well as to have coexistent anxiety and higher levels of pain catastrophizing.
Targeting patients with risk factors associated with unnecessary ED visits may result in reductions in healthcare costs, the authors conclude. “Indeed, both presurgical education and health optimization programs tailored to meet the needs of specific surgical populations and enhanced nursing support through telephone follow-up have demonstrated efficacy in improving outcomes and reducing costs in other surgical cohorts,” they write.
The Michigan Surgical Quality Collaborative database is funded by Blue Cross and Blue Shield of Michigan and Blue Care Network. One coauthor has served on research advisory boards for Daiichi Sankyo and AbbVie. The other authors have disclosed no relevant financial relationships.
Obstet Gynecol. Published online July 11, 2017. Abstract
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