CHICAGO - A study from Northwestern Medicine® and the American College of Surgeons published today in JAMA suggests that penalizing hospitals for patient readmissions following surgery may be ineffective, and even counterproductive, for improving the quality of hospital care in America. The authors of the study, titled "Underlying Reasons Associated with Hospital Readmission Following Surgery in the United States," found that most surgical readmissions are not due to poor care coordination or mismanagement of known issues. Instead, readmissions were due to expected surgical complications, such as wound infections, that occurred after discharge and were not present during a patient's hospital stay more than 97 percent of the time.
"There has been a growing focus on reducing hospital readmissions from policymakers in recent years, including readmissions after surgery," said lead author Karl Y. Bilimoria, MD, MS, a surgical oncologist and vice chair for quality at Northwestern Memorial Hospital, and director of the Surgical Outcomes and Quality Improvement Center at Northwestern University Feinberg School of Medicine. "But before this study, we didn't really understand the underlying reasons why patients were being readmitted to hospitals following surgery."
Currently, a hospital's rate of all its unplanned patient readmissions, which includes surgical patients, is publicly reported by the Centers for Medicare & Medicaid Services (CMS). In addition, a hospital's reimbursement from CMS gets reduced if CMS determines that a hospital has too many readmissions within a period of 30 days following a patient's discharge for certain care, including total hip and knee replacement surgery. This policy, known as the Readmissions Reduction Program, became effective on October 1, 2012 as part of the Affordable Care Act (ACA), but it initially only focused on readmissions for heart attack, heart failure and pneumonia. The study authors note other surgery types will be incorporated into CMS' Readmissions Reduction Program in the near future.
To better understand the reasons behind postoperative readmissions, researchers collected data from the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) from 346 U.S. hospitals for the full year of 2012. These data specifically included the underlying reason for why the readmission occurred based on the medical record, discussions with treating doctors, and the patients themselves - data that are not available elsewhere. Six different surgical procedure types were reviewed based on their clinical and CMS policy relevancy, resulting in a total of 498,875 separate patient cases being analyzed for the study. The six procedures reviewed were:
- Bariatric surgery,
- Colectomy or proctectomy,
- Hysterectomy,
- Total hip or knee replacement,
- Ventral hernia repair, and
- Lower extremity vascular bypass.
Researchers found that 5.7 percent of the patient cases had unplanned readmissions. Of those unplanned readmissions, only 2.3 percent of patients were readmitted due to a complication that occurred during their initial stay in the hospital.
"These results clearly demonstrates that the vast majority of complications that cause readmissions are not due to a lack of coordination or complications that occurred during the initial hospitalizations," said Bilimoria. "These complications were new and occurred after the patients were discharged and were recovering at home."
The study also found that the most common cause for unplanned readmissions was surgical-site infections at 19.5 percent, followed by delayed return of bowel function with an overall rate of 10.3 percent. The study's authors go on to point out that while these two postsurgical complications are the top two causes for readmissions, compliance with available quality measures to reduce these complications is often already high among hospitals in America and implementing, "policies requiring reductions in readmissions without understanding how to impact improvement could be counterproductive."
"Many of the issues that were identified can help hospitals better focus their efforts to continue to reduce potential readmissions. Our results also highlighted that many of the complications involved in readmissions, such as surgical-site infections, are already well-know and part of other CMS pay-for-performance programs, which means hospitals are effectively being penalized twice for the same complications," added Bilimoria.
Additional complications resulting in readmissions that were identified during the analysis included dehydration or nutritional deficiency, bleeding, an intravenous blood clot and prosthesis or graft issues, but these varied greatly depending on the procedure. Still, the authors note that some of these complications, such as dehydration, are worth addressing as there might be opportunities to reduce their occurrence through better communication with patients, patient education, and innovative care redesign.
"Underlying Factors Associated with Hospital Readmission Following Surgery in the United States," is currently available on JAMA's website and will appear in the February 3, 2015 print edition of the journal.
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Journal
JAMA