Micah E. Girotti

Racial Disparities in Readmissions and Site of Care for Major Surgery

BACKGROUND Racial disparities have been described in many surgical outcomes. We sought to examine whether these disparities extend to postoperative readmission rates and whether the disparities are associated with differences in patient mix and/or hospital-level differences. STUDY DESIGN National Medicare beneficiaries undergoing operations in 3 different specialties from 2006 to 2008 were examined: colectomy, hip replacement, and coronary artery bypass grafting (CABG) (n = 798,279). Our outcome measure was risk-adjusted 30-day readmission. We first used logistic regression to adjust for patient factors. We then stratified hospitals into quintiles according to the proportion of black patients treated and examined the differences in readmission rates between blacks and whites. Finally, we used fixed effects regression models that further adjust for the hospital to explore whether the disparity was attenuated after accounting for hospital differences. RESULTS Black patients were readmitted more often after all 3 operations compared with white patients. The unadjusted odds ratio (OR) for readmission for all 3 operations combined was 1.25 (95% CI 1.22 to 1.28) (colectomy OR 1.17, 95% CI 1.13 to 1.22; hip replacement OR 1.20, 95% CI 1.14 to 1.27; CABG OR 1.25, 95% CI 1.19 to 1.30). Adjusting for patient factors explained 36% of the disparity for all 3 operations (35% for colectomy, 0% for hip replacement, and 32% for CABG), but in analysis that adjusts for hospital differences, we found that the hospitals where care was received also explained 28% of the disparity (35% for colectomy, 70% for hip replacement and 20% for CABG). CONCLUSIONS Black patients are significantly more likely to be readmitted to the hospital after major surgery compared with white patients. This disparity was attenuated after adjusting for patient factors as well as hospital differences.

Developing Strategies for Predicting and Preventing Readmissions in Vascular Surgery

The escalating cost burden of hospital readmission has prompted recent nationwide efforts aimed at reducing the incidence of this important quality measure. Because patients undergoing vascular surgery account for a significant proportion of readmissions, vascular surgeons may face reduced reimbursements in the near future if these trends continue. However, risk factors associated with readmission remain poorly defined, and further research is needed to identify interventions that will prevent readmission following vascular procedures. Accordingly, this manuscript will (1) propose a conceptual model to explain the driving forces behind readmissions in vascular surgery, (2) review current evidence directed at identifying risk factors and evaluating interventions to reduce readmissions across different medical and surgical specialties, and (3) identify key areas in patient care where targeted research or interventions may be implemented in vascular surgery.

Health Policy Update: Rethinking Hospital Readmission as a Surgical Quality Measure

The future is here—quality measures now have teeth. Increasingly used as a measure of surgical quality, hospital readmissions have now been translated into financial penalties for hospitals. The Hospital Readmissions Reduction Program contained within the Affordable Care Act went into effect in October 2012, penalizing hospitals up to 3% of their Medicare payments over the next 3 years.1 This policy is expected to expand to surgical diagnoses by 2015. In the context of this increasing policy emphasis, it is worth questioning whether readmissions actually measure quality or whether they instead capture socioeconomic conditions outside the hospital’s control. Additionally, it is debatable that readmission is always a bad outcome. The financial penalty for readmissions also may have unintended consequences and may not be appropriate in all contexts. Above and beyond these concerns that apply in all of health care, there are issues specific to surgical readmissions. Creative solutions must be reached with careful forethought and consideration of all stakeholders.

Hospital Readmissions after Colectomy: A Population-Based Study

BACKGROUND Surgical readmissions will be targeted for reimbursement cuts in the near future. We sought to understand differences between hospitals with high and low readmission rates in a statewide surgical collaborative to identify potential quality improvement targets. STUDY DESIGN We studied 5,181 patients undergoing laparoscopic or open colectomy at 24 hospitals participating in the Michigan Surgical Quality Collaborative between May 2007 and January 2011. We first calculated hospital risk-adjusted 30-day readmission rates. We then compared reasons for readmission, risk-adjusted complication rates, risk-adjusted inpatient length of stay, and composite process compliance across readmission rate quartiles. RESULTS Hospitals with the lowest 30-day readmission rates averaged 5.1%, compared with 10.3% in hospitals with the highest rates (p < 0.01). Despite wide variability in readmission rates, reasons for readmission were similar between hospitals. Compared with hospitals with low readmission rates, hospitals with high readmission rates had higher risk-adjusted complication rates (29% vs 22%, p = 0.03), but similar median lengths of stay (5.5 days vs 5.6 days, p = 0.61). Although measures to reduce complications were associated with lower surgical site infection rates, they were not associated with reduced overall complication or readmission rates. There was wide variation in complication rates among hospitals with similar readmission rates. CONCLUSIONS There is wide variation in hospital readmission rates after colectomy that correlates with overall complication rates. However, the wide variation in complication rates among hospitals with similar readmission rates suggests that hospital complication rates explain little about their readmission rates. Preventing readmissions after colectomy in hospitals with high readmission rates will require more attention to different care processes currently unmeasured in many clinical registries as well as complication prevention.

Hospital morbidity rankings and complication severity in vascular surgery.

INTRODUCTION The American College of Surgeons National Surgical Quality Improvement Program ranks hospitals according to risk-adjusted rates of postoperative complications. However, this approach does not consider the severity or number of complications that occurred. We sought to determine whether incorporating this information would alter hospital rankings. METHODS The study examined data for the 39,519 patients who underwent major vascular surgery in 206 National Surgical Quality Improvement Program hospitals during 2008 to 2009. We categorized postoperative complications as minor or severe and evaluated the extent to which minor and severe complications increased a patients risk of death and prolonged length of stay. We then ranked hospitals on two alternative approaches that included severity or number of complications. We determined the effect of these alternative methods by assessing the proportion of hospitals that moved out of the top and bottom 20% of hospitals compared with standard rankings. RESULTS Compared with patients with minor complications, patients with severe complications had a higher mortality rate (16.2% vs 3.6%; P<.001) and prolonged length of stay (66.7% vs 53.3%; P<.001). Patients with two or more complications also had a higher mortality rate (23.7% vs 6.0%; P<.001) and prolonged length of stay (77.0% vs 50.1%; P<.001) than patients with only one complication. Compared with the current approach for assessing morbidity, ranking hospitals by severe complications resulted in 12 hospitals (29%) moving out of the top 20% and 10 hospitals (24%) moving out of the bottom 20%. A similar degree of reclassification was found when the current rankings were compared with an alternative approach that considered the number of different complications. CONCLUSIONS Although the severity and number of postoperative complications affect mortality and length of stay, and subsequently, hospital rankings, existing measurement systems do not take this into account. Quality measurement platforms should consider weighting complications according to severity and number.