Jain et al. [1] have offered a fascinating insight into rates of readmission after inpatient plastic surgery and predictors of such readmissions. The facts as they present them are inarguable, and clearly present opportunities for both clinical quality improvement and cost savings. However the story that they tell might not be the whole story-from a quality improvement perspective or a cost one.

Firstly the paper looks at readmission rates-but not all complications will result in a readmission. These complications that do not result in readmission will still by definition cause morbidity and are likely to be associated with some costs. Some of these complications might be as serious as those that result in readmission-not least because it is not always the seriousness of the illness itself that precipitates admission. In an elderly and vulnerable patient who lives alone, a minor complication might result in a readmission-however the opposite might be the case in a younger and more robust patient. The complications that result in readmission are quite simply not all the complications or even necessarily the most serious complications.

Secondly even though the analysis clearly demonstrates the factors that predict readmission that does not mean that anything can be done about these factors. Some of them (such as having a history of chronic obstructive pulmonary disease) certainly are not modifiable factors. For all the factors, there is undoubtedly a prima facie case to be made that targeted interventions to prevent complications might prevent readmissions. However this prim facie case is far from strong evidence that these targeted interventions will prevent complications and readmissions. In any case targeted interventions are likely to be associated with at least some costs and the costs might actually outweigh the costs of readmissions.

Even though Jain et al. have come up with some interesting findings we should be cautious before reading too much into them or radically changing current practice in light of them.

Yours Sincerely,

Dr Kieran Walsh