- •
Readmission after hospitalization is frequent, costly, and potentially preventable in many instances.
- •
Centers for Medicare & Medicaid Services tracks readmission 30 days after discharge from an acute care admission.
- •
Risk factors for readmission include comorbidities, long hospital length of stay, and postoperative complications.
- •
Hospital profiling studies comparing readmission rates between hospitals should use hierarchical rather than standard logistic regression modeling.
Readmission After Surgery
Section snippets
Key points
Readmission after medical and surgical hospitalization
Most research on readmission has been in the medical population. Among Medicare beneficiaries, 21.0% of patients are readmitted within 30 days after discharge for a medical condition, compared with 15.6% after surgical procedures (Table 1) [2]. Medical patients constitute 77.6% of all readmissions in this population. The diagnoses that account for the highest proportion of all readmissions in patients with Medicare include heart failure (7.6%), pneumonia (6.3%), and chronic obstructive
Defining and measuring readmission
Readmission must be carefully defined to allow meaningful comparisons. In any definition, close attention must be paid to matters of timing, inclusion and exclusion criteria, indication, and location. Some differences exist in how CMS and NSQIP define and track readmission. NSQIP is one of the more widespread programs currently tracking readmission in surgical patients.
CMS tracks readmission 30 days after discharge from an acute care admission [4]. The patient can be discharged to home, a
Hospital Readmissions Reduction Program
As a policy response to financial and quality of care concerns about readmission, the CMS developed the Hospital Readmissions Reduction Program, which imposes financial penalties on hospitals for excess readmission. This program was authorized by the Affordable Care Act in 2010 and became operational in 2013 [16]. CMS’s goal is not to eliminate readmission, which is often clinically appropriate, but rather to reduce it by 20%.
In the CMS program, readmission is broken down by discharge
Statistical issues for hospital profiling on readmission
Much debate surrounds the appropriate statistical modeling of readmission for hospital profiling [12], [17]. First, there is the issue of what factors should go into risk adjustment models. Everyone agrees that preexisting patient comorbidities should be included, because hospitals have no control over this. However, Medicare does not include race or other social characteristics such as income or educational level in their models for the Hospital Readmissions Reduction Program, despite data
Predicting readmission
If readmission could be predicted, providers could potentially design and implement interventions to prevent or reduce it. Because most admissions, and therefore most readmissions, are medical rather than surgical, most work on predicting readmission has been performed using data based on medical patients. In one report, Kansagara and colleagues [22] performed a systematic review of 30 high-quality studies on prediction modeling for readmission. Each of the 30 studies included in the review
Causes and prevention of readmission
As noted, patient-level characteristics such as increasing comorbidities, older age, and lower socioeconomic status are strongly associated with readmission. In reality, factors associated with readmission are likely to be highly complex and multifaceted. The risk of readmission can be impacted by (1) preadmission factors, such as patient demographics, comorbidities, and biologic characteristics, such as extent of disease; (2) health care factors and hospital course, such as whether the patient
Summary
Readmission is a large problem after both medical and surgical admissions. Recent policy changes that include substantial financial penalties have made readmission an important, if not the most important, pay-for-performance program for health care in the United States. The CMS Hospital Readmissions Reduction Program currently applies only to patients with certain medical diagnoses, but it is expanding into orthopedic surgery in 2014, and will likely involve more surgical procedures in the
References (34)
- et al.
Examining reoperation and readmission after hepatic surgery
J Am Coll Surg
(2013) - et al.
Validation of new readmission data in the American College of Surgeons National Surgical Quality Improvement Program
J Am Coll Surg
(2013) - et al.
Risk adjustment in the American College of Surgeons National Surgical Quality Improvement Program: a comparison of logistic versus hierarchical modeling
J Am Coll Surg
(2009) - et al.
Patient readmission and mortality after surgery for hepato-pancreato-biliary malignancies
J Am Coll Surg
(2012) - et al.
Patient readmission and mortality after colorectal surgery for colon cancer: impact of length of stay relative to other clinical factors
J Am Coll Surg
(2012) - et al.
Risk factors for 30-day hospital readmission among general surgery patients
J Am Coll Surg
(2012) - et al.
Medicare readmission rates showed meaningful decline in 2012
Medicare Medicaid Res Rev
(2013) - et al.
Rehospitalizations among patients in the Medicare fee-for-service program
N Engl J Med
(2009) - Report to the Congress: Promoting Greater Efficiency in Medicare. Medicare Payment Advisory Commission. 2007. Available...
2013 Measures Updates and Specifications Report: Hospital-Level 30-Day Risk-Standardized Readmission Measures for Acute Myocardial Infarction, Heart Failure, and Pneumonia (Version 6.0)
(2013)