Hospital Readmission: a false marker of surgical quality?

Readmission involves a patient requiring unplanned readmission to hospital after they’d been discharged from hospital. In the surgical specialties, it is assumed that readmission to hospital indicates a failure of previous treatment, a complication secondary to surgery, or a consequence of an error.

In the United States hospitals that “incur” unplanned readmissions face financial penalties. In Australia, a growing number of insurers will not financially cover the second hospital episode (readmission), leaving hospitals responsible for covering these costs.

Recently, a group of investigative journalist published a hospital ranking system naming and shaming the best and the worst hospitals and doctors. Their data were based on administrative data sets that are currently used for medical billing but typically not used to evaluate clinical outcomes.

A presentation at the Annual Meeting on Women’s Cancer in Washington, DC, from the 10 to 14 March 2017, shared data on the rate of hospital readmission and whether it is a valid measure of quality in gynaecological cancer surgery.

The study also used an administrative data set and included patients with stage 3 and 4 ovarian cancer treated at US hospitals from 2004 to 2013. Medical and sociodemographic factors were captured. Unplanned readmissions were correlated with hospital ovarian cancer case volume.

The majority of ovarian cancer cases were operated on in low-volume hospitals treating less than 10 patients a year. Only 8 per cent all patients were treated by a specialist in a high-volume hospital. Overall, the rate of unplanned readmission within 30 days of surgery was 6 per cent.

Factors associated with unplanned readmission were stage-4 disease, neoadjuvant chemotherapy and the hospital volume. Paradoxically, patients who had treatment in a high-volume hospital had a higher rate of readmissions.

However, patients who had treatment in a high-volume hospital also had the best survival. High-volume hospitals also were more likely to adhere to national guidelines on ovarian cancer treatment.

More importantly, patients who had treatment in a high-volume hospital had a 17% better chance of surviving their ovarian cancer, compared to low and mid-volume hospital.

What does all this mean?  Dr Uppal from Michigan, who presented this study on behalf of his co-authors, said that patients in high-volume hospitals will have more aggressive surgery, resulting in a higher rate of postoperative complications. Sometimes these complications present after the patient was discharged from hospital.

Furthermore, case-based hospital funding and financial pressures on hospitals create incentives to discharge patients early and some patients could have been discharged too early.

In my personal clinical experience as a gynaecological oncologist, unplanned readmissions are also more likely noted in elderly patients with poor social support. Sometimes, elderly and medically compromised patients find it difficult to adjust to life at home.

In summary, evidence is emerging that unplanned readmission is not an appropriate quality indicator for the care patients receive.

 

Note: SurgicalPerformance does capture unplanned readmission to hospital. Gynaecologists can compare their readmission rates with their peers in trusted confidentiality.