title: Is all-cause readmission an appropriate performance measure for pediatric surgeons? A case study in pyloromyotomy.
abstract: BACKGROUND
  All cause readmissions are used as a surrogate metric for quality of care for both hospitals and physicians, and are considered in pay for performance initiatives. However, the integrity of using all cause readmissions as a benchmark for surgical outcomes has received little attention. Pyloromyotomy for hypertrophic pyloric stenosis is considered a safe pediatric surgical procedure with few complications or readmissions. The incidence of in hospital complications has been reported, however the rate of readmissions and specifically the proportion of readmissions related to surgical complications have not been previously reported.
  
  
  METHODS
  Data were abstracted from the longitudinally linked Office of Statewide Health Planning and Development data from the State of California from 1995 to 2009, allowing patient tracking across all hospitals and years within California. Inclusion criteria were primary procedure code of pyloromyotomy, a diagnosis code of hypertrophic pyloric stenosis, and no prior record of any in-hospital admission.
  
  
  RESULTS
  A total of 1900 patients were identified: 16.8% girls, 31.7% whites, 5.1% blacks, and 58.2% Hispanics. The median length of stay was 2days (IQR 2-3days). The in-hospital complication rate was 5.16% and overall complication rate was 6.84%; there were no deaths. The rate of 30-day all-cause readmission was 4.01%, with a median of 0% across hospitals (IQR 0%-1.1%); and 13.2% of readmissions occurred at a different hospital. Surgically-related readmission rate was 2.16%. Surgically-related readmission comprised 36% readmissions at 30days, but only 13% readmissions overall. The top three primary diagnoses on readmission were respiratory infections (43%), nonrespiratory infections (14%) and other nonsurgical GI indications (14%). All-cause readmissions at 60days, 90days, 180days, and 1year were 5.8%, 7.3%, 10.4%, and 13.7%, respectively.
  
  
  CONCLUSIONS
  Thirty-day readmission for a surgical complication occurs in 1 of 50 patients undergoing a pyloromyotomy for hypertrophic pyloric stenosis but for all causes is twice as likely, 1 in 25 patients. All-cause readmission is an inadequate measure for the quality of surgical care and the performance of pediatric surgeons. This is a Prognostic Study with Level II Evidence.
authors.affiliation: Department of Surgery, Massachusetts General Hospital; Barts and the London School of Medicine and Dentistry, University of London.
authors.forename: Isobel H
authors.initials: IH
authors.lastname: Marks
authors.affiliation: Department of Surgery, Massachusetts General Hospital; Harvard Medical School.
authors.forename: David C
authors.initials: DC
authors.lastname: Chang
authors.affiliation: Harvard Medical School; Department of Pediatric Surgery, MassGeneral Hospital for Children.
authors.forename: Peter T
authors.initials: PT
authors.lastname: Masiakos
authors.affiliation: Harvard Medical School; Department of Pediatric Surgery, MassGeneral Hospital for Children. Electronic address: ckelleher3@partners.org.
authors.forename: Cassandra M
authors.initials: CM
authors.lastname: Kelleher
mesh_terms: D002140:California / Q000453:epidemiology; D002648:Child; D005260:Female; D006801:Humans; D008297:Male; D010359:Patient Readmission; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control*; D046248:Pyloric Stenosis, Hypertrophic / Q000601:surgery*; D000074882:Pyloromyotomy / Q000706:statistics & numerical data*; D012052:Reimbursement, Incentive; D012189:Retrospective Studies
keywords: Complications; Pyloric stenosis; Pyloromyotomy; Readmissions; Surgical outcomes