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Study: Hospitals Can’t Be Blamed for Many Surgical Readmissions

Fewer than 20% of patients return because of suboptimal care

The Centers for Medicare and Medicaid Services began imposing financial penalties on hospitals in 2015 for higher-than-expected 30-day readmission rates. These penalties are based on the assumption that 30-day readmissions indicate hospital and surgical quality. But a new study from Harborview Medical Center in Seattle, Washington, suggests that many surgery readmissions are not the hospitals’ fault.

Only 18% of surgical patients returned to Harborview because of something doctors could have managed better during the first (index) hospital stay. Many readmissions were related to nonsurgical issues, such as drug abuse or homelessness.

“To be able to affect this rate, there are going to need to be new interventions that require money and a more global care package of each individual patient that doesn’t stop at discharge,” lead author Dr. Lisa McIntyre told Reuters.

The researchers analyzed surgical patients readmitted within 30 days after discharge between July 1, 2014, and June 30, 2015, to identify opportunities for intervention in a cohort that may differ from the hospital’s medical population.

A total of 173 patients (8%) were identified as being unplanned readmissions within 30 days among 2,100 discharges. Of these 173 patients, 91 were men. Common reasons for readmission included 29 patients with injection drug use who were readmitted with soft-tissue infections at new sites (17% of readmissions); 25 with disposition support issues (15%); 23 with infections not detectable during the index admission (13%); and 16 with sequelae of their injury or condition (9%). Sixteen patients were identified as having a likely preventable complication of care (9%), and two were readmitted because of deterioration of medical conditions (1%).

The researchers identified the following risk factors for surgical readmission: female sex (men-to-women risk of readmission odds ratio [OR], 0.5; P < 0.001); the presence of diabetes (OR, 1.7; P = 0.009); sepsis on admission (OR, 1.7; P = 0.03); intensive care unit stay during the index admission (OR, 1.7; P = 0.002); discharge to respite care (OR, 2.3; P = 0.01), and payer status (Medicaid/Medicare versus commercial, OR, 2.0; P = 0.002).

The authors concluded that many surgical readmissions may be unavoidable in the current paradigms of care. While medical comorbidities were contributory, a large number of readmissions in their study were not caused by suboptimal medical care or the deterioration of medical conditions, but by confounding issues, such as substance abuse or homelessness.

In a separate editorial, Drs. Alexander Schwed and Christian de Virgilio of the University of California, Los Angeles, point out that readmitting patients may be viewed as a sound medical decision that is tied to lower risks of death.

“Should such an inexact marker of quality be used to financially penalize hospitals?" they ask. “Health services researchers [need to find] a better marker for surgical quality that is reliably calculable and clinically useful.”

Sources: Reuters; June 20, 2016; and JAMA Surgery; June 15, 2016.

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