Incidence and Risk Factors for Hospital Readmission or Unexpected Visits in Women Undergoing Unscheduled Cesarean Delivery

Abstract

Objective Hospital readmissions are increasingly tracked and assessed for value-based compensation. Our objective was to determine the incidence and risk factors associated with post-cesarean delivery (CD) readmissions or unexpected visits, defined as unexpected office or emergency room visits.

Study Design This is a secondary analysis of a multicenter randomized controlled trial of adjunctive azithromycin prophylaxis for CD performed in laboring patients with viable pregnancies. Patients were followed up to 6 weeks postpartum. Our primary outcome was a composite of hospital readmission or unexpected visit, defined as unscheduled clinic or emergency department visits. Data of hospital readmissions, unexpected visits, and their reasons were collected. Demographics, antepartum, intrapartum, and postpartum risk factors were evaluated in bivariate analyses and multivariable logistic regression modeling.

Results A total of 1,019 women were randomized to azithromycin and 994 to placebo. The prevalence of readmission or unexpected visit was 10.2% (95% confidence interval [CI]: 8.9–11.6), with rates of 3.8% (95% CI: 3.0–4.7%) hospital readmissions, 6.9% (95% CI: 5.8–8.0%) emergency room visits, and 4.2% (95% CI: 3.4–5.2%) unexpected clinic visits. The most common causes were infectious disease and hypertensive disorder. Women with readmissions or unexpected visits were more likely to be obese and diabetic, as well as experience longer length of ruptured membranes, intrauterine pressure catheter placement, and postpartum fevers. On multivariable analysis, diabetes (adjusted odds ratio [aOR]: 1.6, 95% CI: 1.1–2.4), prolonged ruptured membranes (aOR: 1.9, 95% CI: 1.3–2.8), and postpartum fevers (aOR: 4.6, 95% CI: 3.0–7.0) were significantly positively associated with readmission or unscheduled visit, while azithromycin was a protective (aOR: 0.6, 95% CI: 0.5–0.9).

Conclusion Women who had postpartum fever were at especially high risk for readmission or unexpected visits. Diabetes, prolonged ruptured membranes, and postpartum fevers were significantly associated with the adverse outcome, and azithromycin was associated with lower rates of readmission and unexpected visits.

Keywords

cesarean - readmission - pregnancy

• References

• 1 Management OoBa. New Study on Hospital Readmissions. 2009
• 2 Clapp MA, Little SE, Zheng J, Robinson JN. A multi-state analysis of postpartum readmissions in the United States. Am J Obstet Gynecol 2016; 215 (01) 113.e1-113.e10
• 3 Batra P, Fridman M, Leng M, Gregory KD. Emergency department care in the postpartum period: California births, 2009-2011. Obstet Gynecol 2017; 130 (05) 1073-1081
• 4 Betrán AP, Ye J, Moller A-B, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014. PLoS One 2016; 11 (02) e0148343
• 5 Gibbs RS. Clinical risk factors for puerperal infection. Obstet Gynecol 1980; 55 (5, Suppl): 178S-184S
• 6 Tita AT, Szychowski JM, Boggess K. , et al; C/SOAP Trial Consortium. Adjunctive azithromycin prophylaxis for cesarean delivery. N Engl J Med 2016; 375 (13) 1231-1241
• 7 Thigpen BD, Hood WA, Chauhan S. , et al. Timing of prophylactic antibiotic administration in the uninfected laboring gravida: a randomized clinical trial. Am J Obstet Gynecol 2005; 192 (06) 1864-1868
• 8 Smaill FM, Grivell RM. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database Syst Rev 2014; (10) CD007482
• 9 Liu S, Heaman M, Joseph KS. , et al; Maternal Health Study Group of the Canadian Perinatal Surveillance System. Risk of maternal postpartum readmission associated with mode of delivery. Obstet Gynecol 2005; 105 (04) 836-842
• 10 Clapp MA, Robinson JN, Little SE. The relationship between the rising cesarean delivery and postpartum readmission rates. J Perinatol 2017; 37 (04) 355-359
• 11 Liu S, Heaman M, Kramer MS, Demissie K, Wen SW, Marcoux S. ; Maternal Health Study Group of the Canadian Perinatal Surveillance System. Length of hospital stay, obstetric conditions at childbirth, and maternal readmission: a population-based cohort study. Am J Obstet Gynecol 2002; 187 (03) 681-687
• 12 Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 1999; 20 (11) 725-730
• 13 Belfort MA, Clark SL, Saade GR. , et al. Hospital readmission after delivery: evidence for an increased incidence of nonurogenital infection in the immediate postpartum period. Am J Obstet Gynecol 2010; 202 (01) 35.e1-35.e7
• 14 Brousseau EC, Danilack V, Cai F, Matteson KA. Emergency department visits for postpartum complications. J Womens Health (Larchmt) 2018; 27 (03) 253-257
• 15 Clark SL, Belfort MA, Dildy GA. , et al. Emergency department use during the postpartum period: implications for current management of the puerperium. Am J Obstet Gynecol 2010; 203 (01) 38.e1-38.e6
• 16 Harper LM, Kilgore M, Szychowski JM, Andrews WW, Tita ATN. Economic evaluation of adjunctive azithromycin prophylaxis for cesarean delivery. Obstet Gynecol 2017; 130 (02) 328-334
• 17 Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin no. 199: use of prophylactic antibiotics in labor and delivery. Obstet Gynecol 2018; 132 (03) e103-e119