Readmissions after complex cancer operations vary with institution type and patient cohort

May 31, 2016

CHICAGO: Readmission rates after complex cancer operations tend to be higher in hospitals that are considered to be vulnerable because they serve as safety nets in their communities or have a high number of Medicaid patients. Reasons for higher readmission rates are highly complex and involve socioeconomic and hospital institutional characteristics. Payment programs that penalize hospitals for high readmission rates without understanding these issues could stress already financially threatened institutions, according to authors of a new study published online in the Journal of the American College of Surgeons in advance of print publication.


Clinical quality improvement efforts as well as federal payment policies have sought to reduce hospital readmissions to improve the quality of patient care and decrease Medicare program spending. A review of Medicare claims by the Medicare Payment Advisory Commission (MedPAC) in 2005 found that 5 to 79 percent of readmissions could potentially have been prevented and saved $12 billion in Medicare spending.1


Findings such as these led to creation of the Medicare Hospital Readmissions Reduction Program (HRRP) in the Affordable Care Act, which penalizes hospitals that have higher than expected readmission rates. HRRP currently covers four common medical conditions--pneumonia, heart failure, acute myocardial infarction, and chronic obstructive pulmonary disease (COPD), along with two joint replacement operations (knee and hip). The program will expand in 2017 and begin including coronary artery bypass grafting (CABG) procedures.2


While the American College of Surgeons has publicly recognized that high readmission rates may reflect lower quality care and lead to unnecessary spending, ACS has emphasized that readmissions may be related to many factors, including the complexity of the medical condition as well as patients' socioeconomic status and compliance. ACS has urged HRRP to take such factors into consideration so hospitals are not penalized because of factors that are beyond their control.3


In the present study, researchers found that patient factors were primary drivers of higher readmission rates to vulnerable hospitals after cancer operations. These results further support the need for incorporating socioeconomic variables into the determination of HRRP payments especially for hospitals that already serve a disproportionate number of disadvantaged patients.


"Patient conditions and hospital infrastructure make vulnerable hospitals prone to higher readmissions from the outset. Policymakers need to be aware of the drivers that lead to higher readmissions at these hospitals so payment penalties do not push financially strained hospitals into further hardship," said Young Hong, MD, lead study investigator, MedStar-Georgetown Surgical Outcomes Research Center and Georgetown University Medical Center, Washington, D.C.


The researchers evaluated the care of 110,857 adult patients who had one of seven major or complex cancer procedures between January 1, 2004, and September 30, 2011, in one of 355 hospitals in the state of California. The researchers compared readmission rates for 311 non-vulnerable hospitals, 13 safety net hospitals, 31 high Medicaid institutions, and five hospitals that were both safety net and high Medicaid institutions. Patients underwent cancer resection procedures to remove the esophagus, stomach, pancreas, liver, prostate, lung, or kidney.


The 30-day readmission rates were 14 percent for safety net hospitals, 13 percent for high Medicaid hospitals, and 14 percent for safety net and high Medicaid institutions. Ninety-day readmission rates were 20 percent for safety net hospitals, 22 percent for high Medicaid hospitals, and 21 percent for high Medicaid and safety net hospitals. In contrast, the readmission rates for non-vulnerable hospitals were 11 percent at 30 days and 17 percent at 90 days.


Patients having cancer operations at vulnerable hospitals were more likely to live in low income areas (28 percent vs. 17 percent), have Medicaid (27 percent vs. 5 percent), and be admitted via the emergency department for their index procedure (15 percent vs 9 percent) than those who had their operations at non-vulnerable hospitals.


Patient cohorts differed in various types of vulnerable hospitals. The proportion of Hispanic patients was much higher (41 percent) at high Medicaid hospitals than at safety net (24 percent) or high Medicaid and safety net institutions (25 percent). High Medicaid and safety net institutions had a higher percentage of Medicaid patients (41 percent) than either of the other categories of vulnerable hospitals (27 percent for safety net hospitals and 24 percent for high Medicaid hospitals).


The vast majority of safety net and high Medicaid plus safety net institutions were teaching centers (85 percent and 100 percent, respectively), while 47 percent of high Medicaid hospitals had teaching programs.


"This study showed that the reasons behind higher readmissions may depend on the type of vulnerable hospital, given their varying patient populations and hospital characteristics," said Chaoyi Zheng, MS, statistician for the study group.


Findings from this study reinforce ACS's position that measures for determining financial penalties associated with hospital readmissions should focus on patient subgroups and socioeconomic factors.


"Different hospitals have different patient mixes, and if that is not factored in, HRRP reductions in payment may further marginalize financially vulnerable hospitals," said corresponding study author Waddah B. Al-Refaie, MD, FACS, chief of surgical oncology, MedStar Georgetown University Hospital.
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In addition to Drs. Al-Refaie and Hong and Ms. Zheng, other study authors include Elizabeth Hechenbleikner, MD; Lynt B. Johnson, MD, FACS; and Nawar Shara, PhD.

This study was originally presented at the Western Surgical Association 123rd Scientific Session, November 2015.


"FACS" designates that a surgeon is a Fellow of the American College of Surgeons.



Citation: Vulnerable Hospitals and Cancer Surgery Readmissions: Insights into the Unintended Consequences of the Patient Protection and Affordable Care Act. Journal of the American College of Surgeons. DOI: http://dx.doi.org/10.1016/j.jamcollsurg.2016.04.042

1 Medicare Hospital Readmission Reduction Program. Health Affairs, Nov 12, 2013 http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=102.
2 Hospital Readmissions Reduction Program Overview. QualityNet (HCQIS). Available at: http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228772412458 . Accessed May 27, 2016.
3Hoyt DB. American College of Surgeons letter to Andrew Slavitt, Centers for Medicare & Medicaid Services. June 15, 2015. Available at: https://www.facs.org/~/media/files/advocacy/regulatory/fy2016%20ipps%20comments.ashx. Accessed May 23, 2016.


About the American College of Surgeons

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 80,000 members and is the largest organization of surgeons in the world. For more information, visit http://www.facs.org(.)

American College of Surgeons

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