30-Day Readmission Penalties May Disproportionately Affect Safety-Net Hospitals

Timothy M. Pawlik, MD, MPH, MTS, PhD, FACS, FRACS (Hon.)Professor of Surgery and Oncology John L. Cameron M.D. Professor of Alimentary Tract Diseases Chief, Division of Surgical Oncology Program Director, Surgical Oncology Fellowship Director, Johns Hopkins Medicine Liver Tumor Center Multi-Disciplinary Clinic Johns Hopkins Hospital Baltimore, MD 21287MedicalResearch.com Interview with:
Timothy M. Pawlik, MD, MPH, MTS, PhD, FACS, FRACS (Hon.)
Professor of Surgery and Oncology
John L. Cameron M.D. Professor of Alimentary Tract Diseases
Chief, Division of Surgical Oncology
Program Director, Surgical Oncology Fellowship
Director, Johns Hopkins Medicine Liver Tumor Center Multi-Disciplinary Clinic
Johns Hopkins Hospital Baltimore, MD 21287

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Pawlik: In 2012, the Centers for Medicare and Medicaid Services (CMS) introduced the Hospital Readmission Reduction Program (HRRP) whereby hospitals with higher than expected 30-day readmission incur financial penalties. Initially proposed to target readmissions following acute myocardial infarction, pneumonia and congestive heart failure, the program has since expanded to encompass knee and hip replacement surgery with the inclusion of additional surgical procedures anticipated in the near future. Although initial results from the Hospital Readmission Reduction Program have been promising, several concerns have been raised regarding potential limitations in methodological approach; specifically in the ability to adequately risk-adjust and account for variations in patient, provider and disease. As a consequence, many fear that the Hospital Readmission Reduction Program may disproportionately penalize safety-net hospitals as well as hospitals caring for “sicker” and more vulnerable populations.

In the current study we sought to investigate factors associated with the variability in 30-day readmission among a cohort of 22,559 patients discharged following a major surgical procedure at the Johns Hopkins Hospital between 2009 and 2013. Overall, 30-day readmission was noted to be 13.2% varying from 2.1% to 24.8% by surgical specialty / procedure and from 2.1% to 32.9% by surgeon. Non-modifiable patient specific factors such as preoperative comorbidity, insurance status and race / ethnicity, were found to be most predictive of 30-day readmission as well as postoperative factors such as complications and length of stay both of which may also be influenced by preoperative comorbidity. Overall, we noted that 2.8% of the variation in 30-day readmission was attributed to provider-specific factors, 14.5% of the variability was due differences in surgical specialty / procedure while over 84% of the variability in 30-day readmission remained unaccounted for due to non-modifiable patient-specific factors.

MedicalResearch: What should clinicians and patients take away from your report?

Dr. Pawlik: The study reiterates concerns that although a useful metric, penalizing hospitals on 30-day readmission as measured in its current capacity may disproportionately affect hospitals caring for “sicker” patients with greater comorbidity, vulnerable populations as well as safety-net hospitals potentially leading to lower quality of care. Patients, physicians and policymakers should therefore proceed with caution in using these measures to benchmark hospitals as rather than a measure of care quality, readmission appears to be more a function of patient case-mix and non-modifiable patient-specific factors.

MedicalResearch: What recommendations do you have for future research as a result of this study?

Dr. Pawlik: Future research should focus to improve the risk-adjustment methodology employed by the CMS while also incorporating non-modifiable patient-specific factors such as socioeconomic status and factors pertaining to post-discharge care into future iterations of the HRRP.

Citation:

Gani F, Lucas DJ, Kim Y, Schneider EB, Pawlik TM. Understanding Variation in 30-Day Surgical Readmission in the Era of Accountable Care: Effect of the Patient, Surgeon, and Surgical Subspecialties. JAMA Surg. Published online August 05, 2015. doi:10.1001/jamasurg.2015.2215.

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Timothy M. Pawlik, MD, MPH, MTS, PhD (2015). 30-Day Readmission Penalties May Disproportionately Affect Safety-Net Hospitals 

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