Hospital readmissions after cardiac surgery: Is it a game worth playing?
2014; Elsevier BV; Volume: 149; Issue: 3 Linguagem: Inglês
10.1016/j.jtcvs.2014.11.069
ISSN1097-685X
Autores Tópico(s)Hip and Femur Fractures
ResumoSee related article on pages 850-7. See related article on pages 850-7. In their study in this issue of the Journal, “Uniform Standards Do Not Apply to Readmission Following Coronary Artery Bypass Surgery: A Multi-Institutional Study,” Lancey and colleagues1Lancey R. Kurlansky P. Argenziano M. Coady M. Dunton R. Greelish J. et al.Uniform standards do not apply to readmission following coronary artery bypass surgery: A multi-institutional study.J Thorac Cardiovasc Surg. 2015; 149: 850-857Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar have highlighted several issues that limit the utility of the 30-day readmission rate as a suitable measure of quality when used as a pay for performance metric and call into question the practicality of its role in subsequent hospital reimbursement. Hospital readmissions are an obvious target for Medicare because they are costly to the health care system, accounting for more than $12 billion dollars per year, and pose significant hardship and inconvenience to patients. As a metric for scrutiny, the 30-day readmission rate is easily obtained, granular, and easy to measure.2Maniar H. Bell J. Moon M.R. Meyers B.F. Marsala J. Lawton J.S. et al.Prospective evaluation of patients readmitted after cardiac surgery: analysis of outcomes and identification of risk factors.J Thorac Cardiovasc Surg. 2014; 147: 1013-1018Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar It is, however, not an ideal metric in isolation. A higher occurrence of readmission after an index admission is not necessarily representative of suboptimal care. In heart failure, for example, readmissions have been associated with lower 30-day mortality. A readmission penalty in this scenario would, in fact, penalize a hospital with lower mortality but whose subsequent greater number of discharged patients would be eligible for readmission.3Gorodeski E.Z. Starling R.C. Blackstone E.H. Are all readmissions bad readmissions?.N Engl J Med. 2010; 363: 297-298Crossref PubMed Scopus (178) Google Scholar Moreover, the Medicare Payment Advisory Commission has stated that only 13% of readmissions are likely preventable, suggesting that even among specialties with readmission rates as high as 15% to 20%, only a small percentage of patients will benefit from strategies specifically addressing readmission. Similar to other readmission studies of cardiac surgical patients, the patients in this series were readmitted most commonly as a result of infection, arrhythmia, or an exacerbation of congestive heart failure. The date of readmission was typically within the first 2 weeks after discharge. Lancey and colleagues have additionally illustrated the difficulties that exist in identifying which specific comorbidities predispose toward readmission, and they have alluded to the importance of socioeconomic issues that must be considered in any future investigation of readmission. Patients with lesser financial means and health insurance are not medically savvy, are less compliant with medications, and, not surprisingly, are more likely to return to the hospital. Unfortunately, it is the hospitals that care for the economically disadvantaged that are usually less able to direct resources to prevent readmission and thus in turn are at greater risk and probably less able to tolerate future Medicare penalties.2Maniar H. Bell J. Moon M.R. Meyers B.F. Marsala J. Lawton J.S. et al.Prospective evaluation of patients readmitted after cardiac surgery: analysis of outcomes and identification of risk factors.J Thorac Cardiovasc Surg. 2014; 147: 1013-1018Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 4Joynt K.E. Jha A.K. Thirty-day readmissions—truth and consequences.N Engl J Med. 2012; 366: 1366-1369Crossref PubMed Scopus (378) Google Scholar, 5Li Z. Armstrong E.J. Parker J.P. Danielsen B. Romano P.S. Hospital variation in readmission after coronary artery bypass surgery in California.Circ Cardiovasc Qual Outcomes. 2012; 5 (Erratum in: Circ Cardiovasc Qual Outcomes. 2012;5:e104): 729-737Crossref PubMed Scopus (56) Google Scholar Although the appropriateness of the 30-day readmission metric remains controversial, it stands to remain a significant data point within pay for performance strategies, which can affect 1% to 2% of total hospital Medicare reimbursement. If the 30-day readmission rate and specifically its reduction are to be feasible and practical, targeting specific patient subgroups predisposed toward readmission and incorporating strategies that involve intervention within the first 2 weeks after discharge would seem to be paramount.2Maniar H. Bell J. Moon M.R. Meyers B.F. Marsala J. Lawton J.S. et al.Prospective evaluation of patients readmitted after cardiac surgery: analysis of outcomes and identification of risk factors.J Thorac Cardiovasc Surg. 2014; 147: 1013-1018Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar As demonstrated in this study, readmission rates for even a single procedure such as CABG vary greatly between hospitals, and any proposed strategic interventions must be developed in the context of local hospital culture. It is, moreover, generally agreed that although reducing the readmission rate is an immediate priority to avoid financial penalty, the strategies that incorporate continuity of care, care transitions, access to primary care, and ultimately improved population health itself will be most effective in the long term. A transition from penalties to an incentive model for the latter is being considered and would likely achieve a reduction in readmissions and do so in a manner that provides lasting patient benefit and more physician buy-in.6Brown J.R. Sox H.C. Goodman D.C. Financial incentives to improve quality: skating to the puck or avoiding the penalty box?.JAMA. 2014; 311: 1009-1010Crossref PubMed Scopus (20) Google Scholar Uniform standards do not apply to readmission following coronary artery bypass surgery: A multi-institutional studyThe Journal of Thoracic and Cardiovascular SurgeryVol. 149Issue 3PreviewReducing hospital readmissions is a national priority, with coronary artery bypass graft (CABG) surgery slated for upcoming reimbursement decisions. Clear understanding of the elements associated with readmissions is essential for developing a coherent prevention strategy. Patterns of readmission vary considerably based on diagnosis. We therefore sought to clarify the factors most clearly associated with 30-day readmission following CABG surgery in an academically affiliated community hospital network. Full-Text PDF Open Archive
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