Study: Penalizing Hospitals for Readmissions Is NOT the Answer

Using data from 346 U.S. hospitals, researchers from Northwestern Medicineand the American College of Surgeons have just published work suggesting that it may be not be useful to penalize hospitals for patient readmissions following surgery. They even learned that it may be counterproductive for improving the quality of hospital care. According to the February 3, 2015 news release, the researchers 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% 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, M.D., M.S., 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.”

The researchers collected data from the American College of Surgeons’ National Surgical Quality Improvement Program for all of 2012. These data did include the underlying reason for why the readmission occurred based on the medical record, discussions with treating doctors, and the patients themselves. This data, according to the news release, are not available elsewhere. Six different surgical procedure types were reviewed based on their clinical and CMS [Centers for Medicare and Medicaid Services] policy relevancy, resulting in a total of 498, 875 separate patient cases being analyzed for the study. Total hip and knee replacement procedures were among the procedures reviewed. Others were bariatric surgery, colectomy or proctectomy, hysterectomy, ventral hernia repair, and lower extremity vascular bypass.

Researchers found that 5.7% of the patient cases had unplanned readmissions. Of those unplanned readmissions, only 2.3% of patients were readmitted due to a complication that occurred during their initial stay in the hospital. The common cause for unplanned readmissions was surgical-site infections at 19.5%, followed by delayed return of bowel function with an overall rate of 10.3%. The study’s add 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.”

Other complications that resulted in readmissions were dehydration or nutritional deficiency, bleeding, an intravenous blood clot and prosthesis or graft issues. 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.

Dr. Bilimoria told OTW, “Readmissions for orthopedic procedures are due to well-known and well accepted risks of surgery, primarily wound infections. Thus readmissions are simply a proxy for complications. Since CMS already measures complications after surgery, measuring readmissions simply penalizes hospitals twice for complications. Readmissions should certainly be avoided where possible but these results question whether there is merit to the tremendous focus on readmissions in pay for performance programs.”