title: Causes of 30-day readmission after aneurysmal subarachnoid hemorrhage.
abstract: OBJECTIVE
  Hospital readmission is a common but controversial quality measure increasingly used to influence hospital compensation in the US. The objective of this study was to evaluate the causes for 30-day hospital readmission following aneurysmal subarachnoid hemorrhage (SAH) to determine the appropriateness of this performance metric and to identify potential avenues for improved patient care.
  
  
  METHODS
  The authors retrospectively reviewed the medical records of all patients who received surgical or endovascular treatment for aneurysmal SAH at Barnes-Jewish Hospital between 2003 and 2013. Two senior faculty identified by consensus the primary medical/surgical diagnosis associated with readmission as well as the underlying causes of rehospitalization.
  
  
  RESULTS
  Among 778 patients treated for aneurysmal SAH, 89 experienced a total of 97 readmission events, yielding a readmission rate of 11.4%. The median time from discharge to readmission was 9 days (interquartile range 3-17.5 days). Actual hydrocephalus or potential concern for hydrocephalus (e.g., headache) was the most frequent diagnosis (26/97, 26.8%), followed by infections (e.g., wound infection [5/97, 5.2%], urinary tract infection [3/97, 3.1%], and pneumonia [3/97, 3.1%]) and thromboembolic events (8/97, 8.2%). In most cases (75/97, 77.3%), we did not identify any treatment lapses contributing to readmission. The most common underlying causes for readmission were unavoidable development of SAH-related pathology (e.g., hydrocephalus; 36/97, 37.1%) and complications related to neurological impairment and immobility (e.g., thromboembolic event despite high-dose chemoprophylaxis; 21/97, 21.6%). The authors determined that 22/97 (22.7%) of the readmissions were likely preventable with alternative management. In these cases, insufficient outpatient medical care (for example, for hyponatremia; 16/97, 16.5%) was the most common shortcoming.
  
  
  CONCLUSIONS
  Most readmissions after aneurysmal SAH relate to late consequences of hemorrhage, such as hydrocephalus, or medical complications secondary to severe neurological injury. Although a minority of readmissions may potentially be avoided with closer medical follow-up in the transitional care environment, readmission after SAH is an insensitive and likely inappropriate hospital performance metric.
authors.affiliation: Departments of 1 Neurological Surgery and.
authors.forename: Jacob K
authors.initials: JK
authors.lastname: Greenberg
authors.affiliation: Departments of 1 Neurological Surgery and.
authors.forename: Chad W
authors.initials: CW
authors.lastname: Washington
authors.affiliation: Departments of 1 Neurological Surgery and.
authors.forename: Ridhima
authors.initials: R
authors.lastname: Guniganti
authors.affiliation: Departments of 1 Neurological Surgery and.
authors.forename: Ralph G
authors.initials: RG
authors.lastname: Dacey
authors.affiliation: Departments of 1 Neurological Surgery and.|Neurology, and.|Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri.
authors.forename: Colin P
authors.initials: CP
authors.lastname: Derdeyn
authors.affiliation: Departments of 1 Neurological Surgery and.|Neurology, and.
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Zipfel
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D012307:Risk Factors; D013345:Subarachnoid Hemorrhage / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D013997:Time Factors
keywords: BJH = Barnes-Jewish Hospital; CMS = Centers for Medicare and Medicaid Services; COPD = chronic obstructive pulmonary disease; DVT = deep vein thrombosis; IQR = interquartile range; SAH = subarachnoid hemorrhage; UTI = urinary tract infection; health care; hospital readmission; patient readmission; qualitative research; quality indicators; subarachnoid hemorrhage; vascular disorders