Association Between Postop Complication and Readmission
Association Between Postop Complication and Readmission
Objective: To estimate the effect of preventing postoperative complications on readmission rates and costs.
Background: Policymakers are targeting readmission for quality improvement and cost savings. Little is known regarding mutable factors associated with postoperative readmissions.
Methods: Patient records (2005–2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Risk factors, procedure, and 30-day postoperative complications were determined from ACS-NSQIP. The 30-day postoperative readmission and costs were determined from Medicare. Occurrence of a postoperative complication included surgical site infections and cardiac, pulmonary, neurologic, and renal complications. Multivariate regression models predicted the effect of reducing complication rates on risk-adjusted readmission rates and costs by procedure.
Results: The 30-day postoperative readmission rate was 12.8%. Complication rates for readmitted and nonreadmitted patients were 53% and 16% (P < 0.001). Patients with a postoperative complication had higher predicted probability of readmission and cost of readmission than patients without a complication. For the 20 procedures accounting for the greatest number of readmissions, reducing ACS-NSQIP complication rates by a relative 5% could result in prevention of 2092 readmissions per year and a savings to Medicare of $31.0 million per year. Preventing all ACS-NSQIP complications for these procedures could result in prevention of 41,846 readmissions per year and a savings of $620.3 million per year.
Conclusions: This study provides substantial evidence that efforts to reduce postoperative readmissions should begin by focusing on postoperative complications that can be reliably and validly measured. Such an approach will not eliminate all postoperative readmissions but will likely have a major effect on readmission rates.
Hospital readmission is a persistent and costly occurrence. A study of Medicare beneficiaries hospitalized in 2009 reported a 30-day readmission rate of 12.7% for surgical patients and 16.1% for medical patients and unplanned hospital readmissions were estimated to cost Medicare $17.4 billion in 2004. To encourage physicians and hospitals to reduce readmissions, the Centers for Medicare and Medicaid Services (CMS) began publicly reporting 30-day readmission rates for certain medical diagnoses in 2009. In addition, recent legislation provided for a hospital readmissions reduction program, in which hospital reimbursement is linked to performance. As a result, in October 2012, CMS began penalizing hospitals for excessive readmissions related to these medical diagnoses. The scope of the hospital readmission public reporting and pay-for-performance program is scheduled to expand in 2015 and it is speculated that elective surgical procedures will be among the additional diagnoses included. Finally, the Partnership for Patients, led by the Secretary of Health and Human Services and CMS, has set a goal of reducing all hospital readmissions by 20% by the end of 2013.
There are a variety of reasons why a surgical patient may be readmitted. Some admissions may be planned (ie, chemotherapy or elective surgery) or unplanned but likely unrelated to the surgery performed (ie, trauma). However, the potentially preventable readmissions are those that are unplanned and likely related to or a direct consequence of events from the initial hospitalization. This category of readmissions includes those occurring for medical reasons such as an exacerbation of a preoperative comorbidity like congestive heart failure or diabetes, and readmissions resulting from postoperative complications.
In this study, we describe the population of patients being readmitted within 30 days of surgery and then examine the association between the occurrence of a postoperative complication and a readmission. Complications were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and include surgical site infections as well as cardiac, pulmonary, neurologic, and renal complications. The hypothesis was that patients with an ACS-NSQIP postoperative complication would have a higher risk-adjusted probability of 30-day postoperative readmission compared with patients without an ACS-NSQIP postoperative complication. Finally, we estimated the effect that reducing ACS-NSQIP postoperative complication rates may have on reducing readmission rates and costs. Studies suggest that hospitals participating in ACS-NSQIP can successfully reduce rates of postoperative complications by 9% to 13%; however, the effect of these quality improvement efforts on hospital postoperative readmission rates has not been documented.
Abstract and Introduction
Abstract
Objective: To estimate the effect of preventing postoperative complications on readmission rates and costs.
Background: Policymakers are targeting readmission for quality improvement and cost savings. Little is known regarding mutable factors associated with postoperative readmissions.
Methods: Patient records (2005–2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Risk factors, procedure, and 30-day postoperative complications were determined from ACS-NSQIP. The 30-day postoperative readmission and costs were determined from Medicare. Occurrence of a postoperative complication included surgical site infections and cardiac, pulmonary, neurologic, and renal complications. Multivariate regression models predicted the effect of reducing complication rates on risk-adjusted readmission rates and costs by procedure.
Results: The 30-day postoperative readmission rate was 12.8%. Complication rates for readmitted and nonreadmitted patients were 53% and 16% (P < 0.001). Patients with a postoperative complication had higher predicted probability of readmission and cost of readmission than patients without a complication. For the 20 procedures accounting for the greatest number of readmissions, reducing ACS-NSQIP complication rates by a relative 5% could result in prevention of 2092 readmissions per year and a savings to Medicare of $31.0 million per year. Preventing all ACS-NSQIP complications for these procedures could result in prevention of 41,846 readmissions per year and a savings of $620.3 million per year.
Conclusions: This study provides substantial evidence that efforts to reduce postoperative readmissions should begin by focusing on postoperative complications that can be reliably and validly measured. Such an approach will not eliminate all postoperative readmissions but will likely have a major effect on readmission rates.
Introduction
Hospital readmission is a persistent and costly occurrence. A study of Medicare beneficiaries hospitalized in 2009 reported a 30-day readmission rate of 12.7% for surgical patients and 16.1% for medical patients and unplanned hospital readmissions were estimated to cost Medicare $17.4 billion in 2004. To encourage physicians and hospitals to reduce readmissions, the Centers for Medicare and Medicaid Services (CMS) began publicly reporting 30-day readmission rates for certain medical diagnoses in 2009. In addition, recent legislation provided for a hospital readmissions reduction program, in which hospital reimbursement is linked to performance. As a result, in October 2012, CMS began penalizing hospitals for excessive readmissions related to these medical diagnoses. The scope of the hospital readmission public reporting and pay-for-performance program is scheduled to expand in 2015 and it is speculated that elective surgical procedures will be among the additional diagnoses included. Finally, the Partnership for Patients, led by the Secretary of Health and Human Services and CMS, has set a goal of reducing all hospital readmissions by 20% by the end of 2013.
There are a variety of reasons why a surgical patient may be readmitted. Some admissions may be planned (ie, chemotherapy or elective surgery) or unplanned but likely unrelated to the surgery performed (ie, trauma). However, the potentially preventable readmissions are those that are unplanned and likely related to or a direct consequence of events from the initial hospitalization. This category of readmissions includes those occurring for medical reasons such as an exacerbation of a preoperative comorbidity like congestive heart failure or diabetes, and readmissions resulting from postoperative complications.
In this study, we describe the population of patients being readmitted within 30 days of surgery and then examine the association between the occurrence of a postoperative complication and a readmission. Complications were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and include surgical site infections as well as cardiac, pulmonary, neurologic, and renal complications. The hypothesis was that patients with an ACS-NSQIP postoperative complication would have a higher risk-adjusted probability of 30-day postoperative readmission compared with patients without an ACS-NSQIP postoperative complication. Finally, we estimated the effect that reducing ACS-NSQIP postoperative complication rates may have on reducing readmission rates and costs. Studies suggest that hospitals participating in ACS-NSQIP can successfully reduce rates of postoperative complications by 9% to 13%; however, the effect of these quality improvement efforts on hospital postoperative readmission rates has not been documented.
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