A study published in the March issue of the Journal of the American College of Surgeons (JACS) shows that data collected through the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) may be more useful than administrative records in accurately tracking and evaluating information on hospital readmissions. Accurate monitoring of the causes of readmissions is becoming increasingly relevant as The Centers for Medicare & Medicaid Services (CMS) seeks to publicly report on readmission rates and has even begun withholding payment for readmissions involving certain hospital-acquired complications.
"If we’re going to try to reduce readmissions and improve care for surgical patients, we have to know why they are being readmitted," said the study’s senior author, Karl Y. Bilimoria, MD, FACS, assistant professor of surgery and director of the surgical outcomes and quality improvement center at Northwestern University, Chicago, IL. "The CMS readmission data do not reliably offer that [information] to hospitals, and the more granular you can get with the information, the more actionable it will be locally for quality improvement and reduction of readmissions."
Currently, more than one in 10 surgical patients experiences complications requiring hospital readmission, according to a 2012 study also published in JACS.*
Comparisons of data
Most hospitals use their own clinical patient records and administrative data to determine how patients fare after a surgical procedure. However, this approach has its limitations. Clinical patient records are considered the gold standard of patient tracking because the treating physician or other health care professional records the information in real time. However, internal review of patient records does not allow hospitals to compare their results with those of other institutions.
Administrative data are provided for billing purposes only and usually by someone with no clinical training. Furthermore, administrative records do not provide reasons for readmissions or indicate whether a readmission was planned or unplanned.
Hospitals participating in ACS NSQIP may review clinical patient data and compare their outcomes with those at other hospitals in the database, and in January 2011, ACS NSQIP began collecting key data on the frequency and causes of readmissions.
In their study, Dr. Bilimoria and the Northwestern research team sought to determine whether the information in ACS NSQIP accurately reflected patient medical records and how the information compared with administrative data.
The surgeons examined data on 1,748 patients in Northwestern Memorial Hospital’s ACS NSQIP database. Nearly 70 percent of the patients had operations that required a hospital stay, and nearly all came to the hospital able to function independently. Approximately 7.5 percent were readmitted within 30 days of their operations.
The investigators then assessed the accuracy of the ACS NSQIP data by comparing it with the readmission data in the patients’ medical records—a comparison that yielded a rate of 99.8 percent agreement with the patients’ charts. Only two readmissions were not captured in the ACS NSQIP data.
Additionally, two readmissions were misclassified because the patients were readmitted through the emergency department (ED), and patients who come through the ED are not always recognized as a readmission. The difference highlights the need for comparing sources of information in order to improve the quality of surgical patient care and tracking. "Since seeing that inconsistency, we’ve been able to correct it," Dr. Bilimoria said.
ACS NSQIP also had a 95.7 percent agreement with the patient charts on tracking whether the readmission was planned or unplanned and nearly 80 percent agreement on the cause of the readmissions.
Whereas the study found 99.5 percent agreement between the administrative data and patient charts on recording readmissions, agreement was significantly lower on the reasons behind the readmission (55.1 percent).
"Historically, the most used source of readmission data has been administrative data," the authors wrote. However, Dr. Bilimoria said, "ACS NSQIP is as reliable as going through a chart. It’s certainly a better source than administrative data.
"It’s the type of data you can use to identify opportunities for improvement," Dr. Bilimoria added.
Data at work
Surgeons at Northwestern Memorial Hospital have used the data to improve their surgical site infection and urinary tract infection rates for surgical patients. "We keep an eye on all outcomes," Dr. Bilimoria said. "If we’re average on one quality of care standard, we can recognize it and work toward becoming excellent."
Other study participants are all affiliated with Northwestern Memorial Hospital and include Morgan M. Sellers; Ryan P. Merkow, MD; Amy Halverson, MD, FACS; Keiki Hinami, MD; Rachel R. Kelz, MD, MSCE, FACS; and David J. Bentrem, MD, FACS.
*Kassin, MT, Owen RM, Perez, SD. Risk factors for 30-day hospital readmission among general surgery patients. J Am Coll Surg. 2012;Sep:215(3):322-330.