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A Hidden Cause of Readmissions Comes to Light

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   February 13, 2014

Serious complications resulting from surgery are only now attracting attention as a cause for hospital readmissions. That may be because some surgeries will soon be included in Medicare's 3% readmissions penalty algorithm.

Amidst all the frenzy to prevent 30-day readmissions, some hospital teams may be surprised to learn that they've been neglecting an important and apparently hidden source of these preventable costs.

That source of readmissions is serious complications from surgery.

And it is only now attracting attention, perhaps some surgeries are now included in the 3% readmissions penalty algorithm, and more are anticipated.

A report out this week shows a surprisingly high number of surgical patients developing these complications, such as a venous thromboembolism (VTE) or infection, after discharge. Many of these patients require a return to the hospital for life-saving and expensive care, researchers at the University of Alabama Birmingham have discovered.

Such complications are known and reported, but the focus has been mainly on complications discovered during the initial hospital stay.

"The thing that surprised us most was the proportion of complications that were happening after the hospitalization," a large share of which resulted in the patient's return, explains Mary Hawn, chief of gastrointestinal surgery at the University of Alabama Birmingham and the senior author of the report, published online in Wednesday's JAMA Surgery.

"If we're just using the end of the index hospitalization to assess our rates of complications, we're going to miss a lot of these complications that are likely attributable to that surgical procedure," she says.

Rarely Tracked
What's more, the precise reasons why those patients are being readmitted are rarely tracked and quantified, at least not with the intensity that national efforts to prevent readmissions in patients with medical conditions such as heart failure, pneumonia, and heart attack have been to date.

Public reporting that would shed light on these complications is largely absent. Medicare's Hospital Compare mainly shows rates of complications from surgery that occurred before the patient was discharged, not after, Hawn says.

Her study looked at 59,273 major surgical procedures—such as orthopedic, vascular, or gastrointestinal—performed at 112 VA hospitals from January, 2005 to August 2009. It found that 22.6% of these surgical patients developed a serious complication, and nearly one-third of those, or 28.1%, occurred after discharge.

Almost 12% of patients developed complications so severe, they could not be treated in an outpatient setting and had to return to the hospital for an inpatient stay.

Complications included:

  • Surgical site infections that weren't apparent at the time of discharge respiratory complications that required a ventilator or resulted in pneumonia, stroke or coma
  • Venous thromboembolism
  • Urinary tract infections
  • Renal failure or kidney infection

Most surgical readmissions the research discovered were due to infections, discovered when patients develop a fever or redness of the surgical wound a week or two after hospital discharge, Hawn says.

Since four years have passed since data collection ended, might hospitals have begun to launch more aggressive efforts to prevent post-discharge surgical complications? Hawn says she doesn't think so.

"Hospitals now have 95%, 96%, and 97% adherence to these process measures, or even higher. And yet surgical patients are still getting VTEs and infections, and still being readmitted," she says.

A Tough Task
Hawn says it's crucial for hospitals to be more diligent about preventing these surgical complications. But that's a labor-intensive task. Patients who develop these complications may not be readmitted to the same hospital where they had the surgery. Hospitals usually learn how many of their patients get readmitted, but Hawn says most hospitals do not have a system to track the reasons why. Was it due to a fall, or something related to the surgery? There's often no way a hospital can know without a huge amount of effort they don't have the resources to make.

Another problem with the system, she says, are the surgical care improvement project or SCIP process measures that are now included in Medicare's value-based purchasing program. These prompt hospitals to perform blood cultures and administer antibiotics to patients undergoing surgery to prevent infections or blood clots.

"But it's really hard to show that adhering strictly to these processes of care is able to have any real influence on reducing these infections or VTE events," Hawn says. That's because the measures themselves have been "dumbed down," and lack specificity.

For example, the VTE SCIP measure to prevent pulmonary embolism or deep vein thrombosis, "is a very blunt measure. It looks at the first or second day to see if the patient got VTE prophylaxis. It doesn't look at whether they got it for the entire hospitalization, or whether they got it after discharge, or whether they were stratified into a high risk group."

She adds that while these measures are written in a way to make them simple for hospital surgical teams to report, they don't measure whether the team "tailored the measure to the complexity of the patient."

In an invited commentary, Elizabeth Hechenbleikner, MD, and Elizabeth Wick, MD, surgeons at Johns Hopkins Hospital, agreed, saying that these measures "are more complex to execute well than it may seem."

Hawn says the "focus needs to be on really assessing readiness and criteria for discharge, figuring out who the high risk patients are, and maybe doing more wrap-around services with those patients, with home health, and see if those strategies an reduce complications."

She adds, "We need to study every readmission of a surgical patient in the light of their previous admission, and ask, 'Okay. Was there something— anything—we could have done differently?' "

All-Cause Readmission Rates
The Centers for Medicare & Medicaid Services tracks readmissions of patients with heart failure, pneumonia, and heart attack, and punishes hospitals with higher rates by reducing reimbursement by up to 3% of their total base Medicare payment. Starting this October, CMS says, excess readmissions for patients with chronic obstructive pulmonary disease, another medical condition, will be added, as well as total hip and knee procedures, the first surgeries in the algorithm.

Hospitals will soon begin reporting to Medicare their all-cause readmission rates. And officials at CMS have proposed including in the penalty those patients readmitted after coronary artery bypass surgery, bariatric surgery, and vascular surgery, although those procedures are not yet in the readmissions reduction program.

I asked Hawn if quality improvement organizations would push back on her claim that hospitals aren't working hard enough to reduce readmissions among their surgical patients.

Hawn stuck to her guns. "There are probably some out there that are [working hard enough] but I don't think every organization is doing it. It's very resource-intensive. And I don't think they're doing much work around surgery because it's such a diverse group of patients and conditions, with very different complications and reasons for readmissions."

Besides, Hawn says, "they're all mainly focused on the medical conditions now, because that's where the money is at risk now."

That is soon going to change.


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