Practice Economics

High-volume, low-mortality hospitals have lowest postsurgical readmissions

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Surgical readmission rates do measure quality

Readmissions have clearly become a tremendous focus for payers and oversight agencies. The Readmission Reduction Program put forth by the Centers for Medicare and Medicaid Services (CMS) will potentially penalize hospitals up to 3% for high readmission rates in fiscal year 2015. This penalty is higher than for any other CMS pay-for-performance programs. The main CMS measure compares hospitals on risk-adjusted all-cause hospital-wide readmissions.

The study by Tsai and his colleagues concluded that surgical readmission rates are a relevant and valid approach to measure surgical quality. However, this has been the topic of much debate in the surgical community, and admittedly, my thinking has evolved on this topic.

Readmissions have gained momentum because they are undoubtedly costly, but they also certainly adversely affect quality of life for the patient. Readmission quality metrics were initially pioneered for medical admissions. Medical readmissions were thought to be caused by issues with the transition from the inpatient team to the outpatient physicians; thus there was potentially a systems-based intervention that could be implemented. Hospitals were able to reduce readmission rates with early postdischarge follow-up visits to intervene (e.g., weigh patients, assess symptoms, and adjust diuretics for heart failure patients) and better coordination of care.

Surgeons have argued that readmissions after medical admissions differ considerably from readmissions after surgery. Surgical readmissions are almost entirely caused by postoperative complications, whereas readmissions after medical admissions are due to worsening of the clinical problem or issues with coordination of care. Thus, surgeons have suggested that surgical readmissions are not preventable with a change in postoperative follow-up visits or an improvement in coordination of care. Thus, some may argue that readmissions are unavoidable and simply an aggregate measure of postdischarge postoperative complications. Some also suggest that surgeons are penalized twice: once for the postoperative complication and again for the readmission that is likely related to the complication.

While this was my initial inclination, I do now believe there is value in readmission as a quality measure. There are likely many opportunities for hospitals to reduce readmissions and cost by dealing with more complications in the outpatient setting. For example, if a hospital has a high readmission rate and they find it is caused by surgical site infection (SSI), they could implement an outpatient system to deal with SSIs without needing to readmit patients. Hospitals have had success with this approach and have been able to insert PICC lines for antibiotics, open incisions, debride wounds, and place negative pressure wound therapy in the outpatient clinic.

In 2014, the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) will provide hospitals with risk-adjusted readmission rates. Since the CMS measure only provides an overall, hospital-wide rate, hospitals will need to examine their readmission performance for surgical patients overall and for individual surgeries to identify targeted opportunities for improvement. The ACS NSQIP will fill this need. Moreover, since the ACS NSQIP data abstractors record the reason for the readmission and other patient variables, ACS NSQIP hospitals will be able to better understand why the readmission happened and develop strategies to reduce readmissions. Hospitals will also be able to share experiences and best practices through the ACS NSQIP community to drive down readmission rates.

While readmission may not initially make intuitive sense as a surgical quality measure, it will likely prompt improvements in care for the patients and reduce costs for payers and hospitals, making it a worthwhile focus for quality improvement efforts.

Dr. Karl Bilimoria is an ACS Faculty Scholar and a surgical oncologist at Northwestern Memorial Hospital, Chicago, and an assistant professor of surgery at the Northwestern University Feinberg School of Medicine. He is also director of the Surgical Outcomes and Quality Improvement Center at Northwestern University.



Hospitals that conduct a high volume of surgical procedures and have a low 30-day mortality rate have lower readmission rates, according to a new study. Even so, about one in seven patients discharged after major surgery is readmitted in the first 30 days, the authors found.

The researchers also showed that strictly following surgical process measures – such as infection control techniques – was only weakly associated with reduced readmissions.

The results are not terribly surprising, according to the authors, Dr. Thomas C. Tsai and his colleagues from Harvard University, Brigham and Women’s Hospital, and the Veterans Affairs Boston Healthcare System. The researchers could not specifically determine why the higher-volume, lower-mortality hospitals had lower readmission rates, but they speculated that these facilities have systems in place to protect surgical patients from bad outcomes that might bring them back to the hospital. Their study was published Sept. 18 in the New England Journal of Medicine (2013;369:1134-42).

Dr. Thomas Tsai

The Medicare program now penalizes hospitals for excess readmissions after discharge for heart failure, heart attack, and pneumonia. For fiscal year 2013, which ends on Oct. 1, hospitals will be penalized 1% of their total Medicare billings if readmissions are too high. In fiscal 2014, chronic obstructive pulmonary disease and coronary artery bypass grafting will be added to the list of monitored conditions. The penalty rises to 2% in fiscal year 2014 and 3% in fiscal 2015. In coming years, the Centers for Medicare and Medicaid Services is expected to add more surgical procedures to the readmission penalty list.

The researchers analyzed national Medicare data, which comprised 479,471 discharges from 3,004 hospitals. These hospitals accounted for 90% of the discharges for the six major procedures studied: coronary artery bypass grafting, pulmonary lobectomy, endovascular repair of abdominal aortic aneurysm, open repair of AAA, colectomy, and hip replacement. The authors also analyzed Hospital Quality Alliance (HQA) surgical care scores. The HQA score is calculated based on how well hospitals perform on process measures established by the Surgical Care Improvement Project.

The three measures of surgical quality included the HQA score, procedure volume, and 30-day mortality. The primary outcome measure was a hospital-level composite of the six procedure-specific, risk-adjusted readmission rates at 30 days. The authors compared the characteristics of patients who were readmitted within 30 days with those who were not, and compared the characteristics of hospitals that had composite readmission rates above the median with those that had rates below the median.

The median composite risk-adjusted 30-day readmission rate was 13%. Patients who were readmitted tended to be older (78 years vs. 77 years) and had more comorbidities. The hospitals with readmission rates below the median were more likely to be nonprofit, nonteaching, and located in the West. They also had a higher number of full-time nurses per 1,000 patient-days and a lower proportion of Medicaid patients.

There was no significant difference between urban and rural hospitals.

The authors used multivariate models to gauge the impact of quality measures on readmission rates. After accounting for hospital characteristics, they found that hospitals with the highest volume of procedures had a readmission rate just under the median, compared with those with the lowest procedure volumes, which had a readmission rate of close to 17%.

Hospitals in the lowest quartile for mortality rates had a 13% readmission rate, compared with 14% for those in the highest mortality quartile.

Overall, there was no significant difference in readmissions between the hospitals that performed the best on the HQA score and those that were the poorest performers. That might be because there was only a very small variation in performance on the HQA score – with a median of 99% for high performers and 92% for low performers, said the authors.

Policymakers should be reassured by their consistent findings that readmissions are linked to certain quality measures – volume and mortality, the investigators said. But a direct link is still not definitive, said Dr. Tsai and his colleagues. Previous studies have indicated that volume did help reduce readmissions, while others have shown no relationship.

But those studies were conducted before the widespread use of minimally invasive procedures and process measures aimed at reducing postsurgical complications, the authors said.

The authors reported no relevant conflicts of interest.

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