Objective
The purpose of this study was to analyze reasons for postpartum readmission.
Study Design
We conducted a database analysis of readmissions within 6 weeks after delivery during 2007, with extended (180 day) analysis for pneumonia, appendicitis, and cholecystitis. Linear regression analysis, survival curve fitting, and Gehan-Breslow statistic with Holm-Sidak all-pairwise analysis for multiple comparisons were used. Probability values of < .05 were considered significant.
Results
Of 222,751 women delivered, 2655 women (1.2%) were readmitted within 6 weeks (0.83% vaginal delivery and 1.8% cesarean section delivery; P < .001). A high percentage of these readmittances occurred within the first 6 weeks: pneumonia (84%), appendicitis (43%), or cholecystitis (46%). Cumulative readmission rates were higher in the first 6 weeks after delivery than in the next 20 weeks (pneumonia curve gradient, 3.7 vs 0.11; appendicitis curve gradient, 1.1 vs 0.36; cholecystitis curve gradient, 6.6 vs 1.7).
Conclusion
The cause of postpartum readmission is primarily infectious in origin. A recent pregnancy appears to increase the risk of pneumonia, appendicitis, and cholecystitis.
The postpartum period is associated with significant physiologic changes that include major alterations in the immune system. Despite the recognized importance of the puerperium period in obstetric care, few data exist that describe puerperal morbidity beyond the period of the initial hospitalization for delivery. The few articles that have addressed postpartum readmission have focused primarily on the relationship between the route of delivery and the need for subsequent readmission rather than a comprehensive analysis of the conditions that necessitate readmission. This limited focus has prevented the acquisition of data that could facilitate the development of programs to prevent readmission. Such data may also allow a critical examination of the contribution of infectious or inflammatory processes that are not commonly associated with pregnancy to the overall readmission rate.
For Editors’ Commentary, see Table of Contents
See related editorial, page 1
The prevention of morbidity is the primary goal of any such evaluation. However, hospital readmissions have critical economic implications, particularly in an era of health care reform, and may account for up to 20% of all health care costs. Indeed, the White House Office of Management and Budget has proposed a series of incentives and penalties to reduce readmission costs that include bundling of payments for hospitalization to include postacute care costs that are incurred within 30 days of discharge.
It was against this background that we sought to examine the indications for readmission after delivery. We hypothesized that both conditions, which are related directly to pregnancy and morbidity that traditionally have been believed to be unrelated to pregnancy, would contribute to readmission rates. Secondarily, we examined the incidence of readmission on the basis of delivery method.
Materials and Methods
We initially performed an internal quality-driven audit of ICD-9 discharge diagnosis codes for all women who delivered during 2007 who were readmitted within 6 weeks of the original delivery discharge date. This analysis involved 114 Hospital Corporation of America (HCA) hospitals in 21 states across the United States. In terms of delivery volume, these facilities ranged from <1000/year to >10,000/year (1 hospital). This population has been shown in previous publications to be representative of the US population as a whole. Because some women who delivered late in 2007 were not admitted until the first few weeks of 2008, readmission analysis for such women included some 2008 data. Readmissions were stratified according to readmission diagnosis and mode of delivery ( Tables 1 and 2 ).
Type of delivery | Number readmission, n | Number births, n | Readmission rate, % | Odds ratio (95% CI) |
---|---|---|---|---|
Vaginal | 1168 | 140,746 | 0.83 | — |
Primary cesarean | 986 | 46,639 | 2.1 a | 2.58 (2.37–2.81) a |
Repeat cesarean | 482 | 35,366 | 1.4 a , b | 1.65 (1.48–1.84) a |
0.64 (0.57–0.71) b | ||||
Total cesarean | 1468 | 82,005 | 1.8 a , b | 2.18 (2.02–2.35) a |
1.18 (1.09–1.29) b | ||||
Total readmissions | 2636 | 222,751 | 1.2 | — |
a P < .001, indicates a significant difference when compared with vaginal delivery;
b P < .001, indicates a significant difference when compared with primary cesarean section delivery.
Indication for readmission | Vaginal delivery, n | Rate per 10,000 deliveries | Cesarean delivery, n | Rate per 10,000 deliveries | Odds ratio (95% CI) |
---|---|---|---|---|---|
Gallbladder disease | 152 | 10.8 | 124 | 15.1 a | 1.40 (1.10–1.78) |
Pneumonia | 25 | 1.8 | 36 | 4.4 b | 2.47 (1.48–4.12) |
Appendicitis | 25 | 1.8 | 18 | 2.2 | 1.24 (0.67–2.27) |
Hypertension | 231 | 16.4 | 196 | 23.9 b | 1.46 (1.20–1.76) |
Uterine infection | 130 | 9.2 | 197 | 24.0 b | 2.60 (2.09–3.25) |
Urinary tract infection | 115 | 8.2 | 72 | 8.8 | 1.07 (0.80–1.44) |
Specific medical/surgical condition | 85 | 6 | 102 | 12.4 b | 2.06 (1.55–2.75) |
Wound infection without disruption | 0 | 0 | 172 | 21.0 b | NA |
Hemorrhage | 101 | 7.2 | 60 | 7.3 | 1.02 (0.74–1.40) |
Symptoms without diagnosis/miscellaneous | 47 | 3.3 | 93 | 11.3 b | 3.40 (2.39–4.83) |
Mastitis | 81 | 5.8 | 41 | 5 | 0.87 (0.60–1.26) |
Cardiomyopathy | 37 | 2.6 | 49 | 6.0 b | 2.27 (1.48–3.48) |
Deep venous thrombosis | 21 | 1.5 | 58 | 7.1 b | 4.74 (2.88–7.81) |
Wound disruption | 0 | 0 | 79 | 9.6 b | NA |
Other nonsurgical complications | 0 | 0 | 45 | 5.5 b | NA |
Psychiatric/drug abuse | 24 | 1.7 | 18 | 2.2 | 1.29 (0.70–2.37) |
Infection: nongenitourinary | 17 | 1.2 | 17 | 2.1 | 1.72 (0.88–3.36) |
Sepsis/bacteremia | 13 | 0.9 | 19 | 2.3 a | 2.51 (1.24–5.08) |
Spinal headache | 18 | 1.3 | 12 | 1.5 | 1.14 (0.55–2.38) |
Pulmonary edema: nonspecific | 3 | 0.2 | 24 | 2.9 b | 13.73 (4.14–45.61) |
Cellulitis | 19 | 1.3 | 2 | 0.2 a | 0.18 (0.042–0.78) |
Intestinal obstruction/ileus/fistula | 0 | 0 | 19 | 2.8 b | NA |
Neoplasm | 11 | 0.8 | 6 | 0.7 | 0.94 (0.35–2.53) |
Episiotomy breakdown/fistula | 5 | 0.4 | 0 | 0 | NA |
Sterilization | 3 | 0.2 | 2 | 0.2 | 1.14 (0.19–6.85) |
Vaginal/vulvar infection | 3 | 0.2 | 1 | 0.1 | 0.57 (0.060–5.50) |
Necrotizing fasciitis | 0 | 0 | 4 | 0.5 a | NA |
Foreign body | 2 | 0.1 | 0 | 0 | NA |
Injury to pelvic organ | 0 | 0 | 2 | 0.2 | NA |
T otals | 140,746 | 82,005 |