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Emergency Room Visits and Readmissions after Pediatric Urologic Surgery
Angela M. Arlen, MD, Laura S. Merriman, MD, Edwin A. Smith, MD, FAAP, FACS, Bruce H. Broecker, MD, FAAP, FACS, Hal C. Scherz, MD, FAAP, FACS, Andrew J. Kirsch, MD, FAAP, FACS.
Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA.

BACKGROUND:
Reducing hospital readmissions and postoperative emergency room visits have become a major focus of efforts to increase quality of medical care while simultaneously reducing costs. In 2012, the Centers for Medicare & Medicaid Services began penalizing hospitals for high readmission rates as part of the Patient Protection and Affordable Care Act's Hospital Readmission Reduction Program (HRRP). While lack of socioeconomic resources and access to primary care can lead to readmissions, the discharging hospital is currently held most responsible for preventing readmissions. Given the paucity of available data regarding readmissions after pediatric urologic surgery, we report on the all-cause unplanned return to system visits within 30 days following urologic surgeries performed in a pediatric population.
METHODS:
Between January 1, 2012 and December 31, 2012, over 4000 surgeries were performed by pediatric urologists at our institution. Ninety-nine children had 106 unplanned returns to the healthcare system within 30 days of their orginial surgery. Patient demographics, insurance status, type of surgery and reason for return were assessed.
RESULTS:
Four thousand and ninety-seven pediatric urology surgeries were performed at our institution during the 2012 calendar year, with 106 documented unplanned returns to system (2.59%), including emergency department and urgent care visits. Ninety-three patients had a single return visit, 5 had 2 visits, and a single child had 3. Mean time from surgical discharge to return visit was 142.1 hours (range 8 to 571 hours). Returns were classified by chief complaint including pain (32), infection (30), volume status (14), bleeding (11), catheter concern (8) and other (11). The majority of children (76.4%) with an unplanned return to the system underwent a same day surgical procedure. Circumcision, hypospadias repair and inguinal/scrotal procedures led to the majority of return visits, accounting for 21.7%, 20.7% and 18.9% of returns respectively. Of the 106 return to system visits, 22 (20.75%) resulted in hospital readmission, and 5 (4.72%) required an unplanned secondary procedure. The overall readmission rate for all surgeries was 0.54% with a reoperation rate of 0.12%. The majority of children (65.7%) with unplanned healthcare visits following surgery had government funded insurance.
CONCLUSIONS:
The overall rate of unplanned return to system visits in the pediatric population undergoing urologic surgery is quite low, with the most commonly performed procedures generating the majority of returns. Preventable returns and readmissions are being targeted as potential cost reduction and quality control measures. In order to establish a standard of care and further understand potential opportunities to improve practice and reduce preventable readmissions, return to system rates across pediatric hospitals need to be analyzed.


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