Penalizing hospitals for patient readmissions after surgery might be ineffective and counterproductive for improving the quality of care, based on new research showing most readmissions are not because of poor care coordination or mismanagement of known issues. According to researchers from Northwestern Medicine and the American College of Surgeons in Chicago, most surgical readmissions happen because of common surgical complications, such as wound infections, that occurred after discharge and more than 97% of the time, were not present during a patient’s hospital stay. The study was published Feb. 3 in JAMA.
“There has been a growing focus on reducing hospital readmissions from policymakers in recent years, including readmissions after surgery,” 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, said in a news release.
“But before this study, we didn’t really understand the underlying reasons why patients were being readmitted to hospitals following surgery.”
A hospital’s rate of all its unplanned patient readmissions, which includes surgical patients, is publicly reported by the Centers for Medicare & Medicaid Services. Also, a hospital’s reimbursement from CMS gets reduced if CMS determines it has too many readmissions within a period of 30 days after a patient’s discharge for certain care, including total hip and knee replacement surgery. This policy, the Readmissions Reduction Program, became effective Oct. 1, 2012, as part of the Affordable Care Act, but initially it focused on readmissions for only heart attack, heart failure and pneumonia. Other surgery types will be added into the program in the future.
To better understand the reasons behind postoperative readmissions, researchers collected data from the American College of Surgeons’ National Surgical Quality Improvement Program from 346 U.S. hospitals for all of 2012. These data specifically included the underlying reason for the readmission based on the medical record, discussions with treating physicians, and the patients themselves — data not available elsewhere, according to the release. Six different surgical procedure types were reviewed based on 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 5.7% of the patient cases had unplanned readmissions. Of those unplanned readmissions, only 2.3% of patients were readmitted because of a complication that occurred during their initial hospital stay.
“These results clearly demonstrate 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,” Bilimoria said in the release. “These complications were new and occurred after the patients were discharged and were recovering at home.”
The study also found the most common cause for unplanned readmissions was surgical-site infections (19.5%), followed by delayed return of bowel function (10.3%). While these two postsurgical complications are the top two causes for readmissions, compliance with available quality measures to reduce these complications often is already high among hospitals in America, and implementing, “policies requiring reductions in readmissions without understanding how to impact improvement could be counterproductive,” the authors wrote.
“Many of the issues that were identified can help hospitals better focus their efforts to continue to reduce potential readmissions,” Bilimoria said in the release. “Our results also highlighted that many of the complications involved in readmissions, such as surgical-site infections, are already well-known and part of other CMS pay-for-performance programs, which means hospitals are effectively being penalized twice for the same complications.”
Other complications the analysis identified as causing readmissions included dehydration or nutritional deficiency, bleeding, an intravenous blood clot and prosthesis or graft issues, but these varied greatly depending on the procedure. Some of these, 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, the authors wrote.
The team also included researchers from the University of Kentucky in Lexington and Harvard School of Public Health in Boston.