Importance

Single-site studies have described an association between use of selective serotonin reuptake inhibitors (SSRIs) and adverse outcomes of surgery. Multicenter studies including a broad range of surgical procedures that explore rare outcomes, such as bleeding and mortality, and that account for indications for administration of SSRIs are needed.

Objective

To determine whether perioperative use of SSRIs is associated with adverse outcomes of surgery in a national sample of patients.

Design

Retrospective study of patients 18 years or older who underwent major surgery from January 1, 2006, through December 31, 2008, at 375 US hospitals. We used multivariable hierarchical models to estimate associations between SSRI use and our outcomes. Pharmacy data were used to determine whether a patient received an SSRI in the perioperative period.

Setting

Three hundred seventy-five US hospitals.

Participants

Five hundred thirty thousand four hundred sixteen patients 18 years or older.

Exposure

Perioperative use of SSRIs.

Main outcomes and measures

In-hospital mortality, length of stay, readmission at 30 days, bleeding events, transfusions, and incidence of ventricular arrhythmias.

Results

Patients receiving SSRIs were more likely to have obesity, chronic pulmonary disease, or hypothyroidism (P < .001 for each) and more likely to have depression (41.0% vs 6.2%, P < .001). After adjustment, patients receiving SSRIs had higher odds of in-hospital mortality (adjusted odds ratio, 1.20 [95% CI, 1.07-1.36]), bleeding (1.09 [1.04-1.15]), and readmission at 30 days (1.22 [1.18-1.26]). Similar results were observed in propensity-matched analyses, although the risk of inpatient mortality was attenuated among patients with depression. Sensitivity analyses suggest that, to invalidate our results, an unmeasured covariate would have to have higher prevalence and be more strongly associated with mortality than any covariate included in our models.

Conclusions and relevance

Receiving SSRIs in the perioperative period is associated with a higher risk for adverse events. Determining whether patient factors or SSRIs themselves are responsible for elevated risks requires prospective study.

Converting the health care delivery system into a learning organization is a key strategy for improving health outcomes. Although the collaborative learning organization approach has been successful in neonatal intensive care units and disease-specific collaboratives, there are few examples in general medicine and none in adult medicine that have leveraged the role of hospitalists nationally across multiple institutions to implement improvements. The authors describe the rationale for and early work of the Hospital Medicine Reengineering Network (HOMERuN), a collaborative of hospitals, hospitalists, and multidisciplinary care teams founded in 2011 that seeks to measure, benchmark, and improve the efficiency, quality, and outcomes of care in the hospital and afterwards. Robust and timely evaluation, with learning and refinement of approaches across institutions, should accelerate improvement efforts. The authors review HOMERuN's collaborative model, which focuses on a community-based participatory approach modified to include hospital-based staff as well as the larger community. HOMERuN's initial project is described, focusing on care transition measurement using perspectives from the patient, caregiver, and providers. Next steps and sustainability of the organization are discussed, including benchmarking, collaboration, and effective dissemination of best practices to stakeholders.

Background:Many experts believe that hospitals with more frequent readmissions provide lower-quality care, but little is known about how the preventability of readmissions might change over the postdischarge time frame. Objective:To determine whether readmissions within 7 days of discharge differ from those between 8 and 30 days after discharge with respect to preventability. Design:Prospective cohort study. Setting:10 academic medical centers in the United States. Patients:822 adults readmitted to a general medicine service. Measurements:For each readmission, 2 site-specific physician adjudicators used a structured survey instrument to determine whether it was preventable and measured other characteristics. Results:Overall, 36.2% of early readmissions versus 23.0% of late readmissions were preventable (median risk difference, 13.0 percentage points [interquartile range, 5.5 to 26.4 percentage points]). Hospitals were identified as better locations for preventing early readmissions (47.2% vs. 25.5%; median risk difference, 22.8 percentage points [interquartile range, 17.9 to 31.8 percentage points]), whereas outpatient clinics (15.2% vs. 6.6%; median risk difference, 10.0 percentage points [interquartile range, 4.6 to 12.2 percentage points]) and home (19.4% vs. 14.0%; median risk difference, 5.6 percentage points [interquartile range, -6.1 to 17.1 percentage points]) were better for preventing late readmissions. Limitation:Physician adjudicators were not blinded to readmission timing, community hospitals were not included in the study, and readmissions to nonstudy hospitals were not included in the results. Conclusion:Early readmissions were more likely to be preventable and amenable to hospital-based interventions. Late readmissions were less likely to be preventable and were more amenable to ambulatory and home-based interventions. Primary Funding Source:Association of American Medical Colleges.