October 25, 2011
Closer follow-up and recognizing at-risk patients may improve cardiac and colorectal procedure results
SAN FRANCISCO—Studies have shown that patients returning to the hospital soon after they’ve been discharged may cost Medicare up to billions of dollars each year, but two new studies presented at the 2011 Annual Clinical Congress of the American College of Surgeons could give surgical teams and their patients tools to prevent rehospitalizations.
The findings of these studies can be significant because in October 2012 the Patient Protection and Affordable Care Act begins reducing Medicare payments to hospitals with high readmission rates. The two new studies looked at causes for high rehospitalization rates for cardiac and colorectal surgery and ways for preventing them.
In the first study conducted at Bassett Medical Center in Cooperstown, NY, investigators analyzed about 800 cardiac procedures at the institution over 7½ years through September 2010. Researchers found that when physicians act before discharge to identify risk factors that make patients prone to return to the hospital, they can be preemptive in preventing rehospitalizations. “Based on our analysis, congestive heart failure, chronic lung disease, amount of time on cardiopulmonary bypass, and body-mass index over 40 were independent predictors of readmission,” according to Kelly Bettina Currie, MD, general surgery resident, and lead investigator of the study. The investigators developed a probability calculator that can help predict a specific patient’s risk for rehospitalization. “We feel the model we have developed is applicable to everyday practice for patients who have undergone cardiac surgery,” Dr. Currie said. Moreover, the study team is now collaborating with Columbia University to use a larger database to create a more powerful calculator, according to Dr. Currie.
“If we can identify the population of cardiac surgery patients who are at high risk for readmission, we can focus our resources on this subset of patients to try to prevent readmission,” Dr. Currie explained. Those steps would include follow-up calls within a day of discharge and having at-risk patients see their primary care physician within seven days of discharge, she added.
The second study on preventing readmissions investigated colorectal surgical procedures, for which rehospitalization rates can be as high as 30 to 40 percent, according to lead investigator Andrew M. Ibrahim, BA, the Doris Duke Clinical Research Fellow at Johns Hopkins University School of Medicine, Baltimore. For this study, the researchers focused on almost 11,000 operations to remove part or all of the colon in the Blue Cross/Blue Shield database. “The reason we chose colorectal surgery is because it is notorious for high readmission rates,” Mr. Ibrahim said.
The Johns Hopkins investigators found three major predictors of rehospitalization in this patient group: a severity of illness score in the highest ranges; an infection at the incision site; and the need for a colostomy or ileostomy, according to the study. Strategies they identified for reducing rehospitalizations in these patients are to have physicians, nurses, and social workers coordinate care at discharge; to have patients with infections follow up with their physicians sooner; and to provide more patient education on ostomy care and nutrition, Mr. Ibrahim said.
Despite how Medicare and other payers are tightening rules on rehospitalizations, Mr. Ibrahim noted that some rehospitalizations in colorectal patients are simply unavoidable. “Twenty five percent of the colorectal patients that were readmitted required a reoperation,” Mr. Ibrahim said. “We can probably say on one extreme that if you required a reoperation that was probably a good readmission; and then on the other extreme if we could identify issues of coordination of care at discharge that just weren’t done, that probably represents a preventable readmission,” Mr. Ibrahim said. “Then there’s a much bigger gray zone in the middle that we’re all interested in trying to figure out,” he concluded.
Robert Lancey, MD, FACS, worked with Dr. Currie at Basset Medical Center on developing a risk calculator to identify risk factors that make cardiac patients prone to readmission following their operations.
Elizabeth C. Wick, MD, FACS; Windau T. Mehtsun, MPH; Andrew Shore, PhD; and Martin A. Makary, MD, FACS, MPH, worked with Mr. Ibrahim at Johns Hopkins to identify predictors of rehospitalizations for colorectal patients.