Neurosurgical readmissions as a key performance indicator: A Single-Center analysis of causes, patterns, and clinical relevance

Background: Thirty-day hospital readmission is widely promoted as a quality metric and key performance indicator (KPI). In neurosurgery, however, the relationship between readmission and quality of care is complex, as many readmissions are planned or reflect the natural progression of the disease rather than preventable adverse events. Objective: To describe the pattern, causes, and timelines of neurosurgical readmissions in a tertiary academic center and to critically appraise the suitability of 30-day readmission as a KPI for neurosurgical services. Methods: We performed a retrospective review of all admissions to the neurosurgery department at King Fahad Hospital of the University, Al-Khobar, Saudi Arabia, between October 2016 and September 2017. Demographic and clinical data were extracted from medical records, including diagnosis, procedures, in-hospital course, length of stay (LOS), discharge disposition, 30-day readmission, indication for readmission, and subspecialty category (tumor, hydrocephalus/ventriculoperitoneal shunt [HCP/VPS], vascular, spine, traumatic brain injury [TBI]). Readmissions were classified as: definitive treatment, infection, CSF-leak/VPS-related, palliative/terminal care, or diagnostic work-up. Descriptive statistics were used to summarize readmission rates and timelines. Results: Over the 12-month period, 314 neurosurgical admissions were recorded; 68 represented readmissions within 30 days, yielding a crude readmission rate of 22%. The most frequent indication for readmission was planned definitive treatment (42%), followed by CSF-leak/VPS-related problems (27%), infection (20%), palliative/terminal care (7%), and further diagnostic work-up (4%) (Fig. 1). When readmissions for scheduled definitive treatment were excluded, 48 “unplanned” readmissions remained (15% of all admissions). In this subset, CSF-related complications predominated (47%), followed by infection (34%), palliative care (13%) and additional work-up (6%) (Fig. 2). Neuro-oncology diagnoses accounted for the largest proportion of readmissions (34%), followed by HCP/VPS-related pathology (27%), vascular disease (20%), spine disorders (16%) and TBI (3%) (Fig. 4). Vascular patients had the longest primary LOS (mean 21 days, maximum 121 days) and the longest average interval to readmission (59 days, maximum 190 days). The longest readmission LOS was observed in HCP/VPS patients (mean 19 days), while the maximum readmission LOS reached 76 days in tumor patients (Table 1; Fig. 5–6). Among patients with more than one readmission, CSF-related problems and infections remained the dominant drivers, and a notable proportion exhibited multiple etiologies (“double” readmissions) (Fig. 3). Conclusions: In this single-center cohort, the crude 30-day readmission rate (22%) falls within the range reported for neurosurgical services. However, nearly half of readmissions were planned for definitive treatment and therefore do not reflect lapses in care. The remaining unplanned readmissions were largely driven by CSF-related problems and infection, conditions that are partly influenced by case mix and disease biology. These findings suggest that a simple 30-day readmission rate, when unadjusted for planned staging and case mix, may incompletely capture the multidimensional nature of neurosurgical quality. More nuanced indicators—distinguishing planned from unplanned readmissions, stratifying by subspecialty and reason, and incorporating LOS and complexity are needed to meaningfully inform quality improvement and resource allocation in neurosurgical practice.