Terry Shih

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.

Does pay-for-performance improve surgical outcomes? An evaluation of phase 2 of the Premier Hospital Quality Incentive Demonstration.

Objective:We sought to determine whether the changes in incentive design in phase 2 of Medicares flagship pay-for-performance program, the Premier Hospital Quality Incentive Demonstration (HQID), reduced surgical mortality or complication rates at participating hospitals. Background:The Premier HQID was initiated in 2003 to reward high-performing hospitals. The program redesigned its incentive structure in 2006 to also reward hospitals that achieved significant improvement. The impact of the change in incentive structure on outcomes in surgical populations is unknown. Methods:We examined discharge data for patients who underwent coronary artery bypass (CABG), hip replacement, and knee replacement at Premier hospitals and non-Premier hospitals in Hospital Compare from 2003 to 2009 in 12 states (n = 861,411). We assessed the impact of incentive structural changes in 2006 on serious complications and 30-day mortality. In these analyses, we adjusted for patient characteristics using multiple logistic regression models. To account for improvement in outcomes over time, we used difference-in-difference techniques that compare trends in Premier versus non-Premier hospitals. We repeated our analyses after stratifying hospitals into quintiles according to risk-adjusted mortality and serious complication rates. Results:After restructuring incentives in 2006 in Premier hospitals, there were lower risk-adjusted mortality and complication rates for both cardiac and orthopedic patients. However, after accounting for temporal trends in non-Premier hospitals, there were no significant improvements in mortality for CABG [odds ratio (OR) = 1.09; 95% confidence interval (CI), 0.92–1.28] or joint replacement (OR = 0.81; 95% CI, 0.58–1.12). Similarly, there were no significant improvements in serious complications for CABG (OR = 1.05; 95% CI, 0.97–1.14) or joint replacement (OR = 1.12; 95% CI, 1.01–1.23). Analysis of the “worst” quintile hospitals that were targeted in the incentive structural changes also did not reveal a change in mortality [(OR = 1.01; 95% CI, 0.78–1.32) for CABG and (OR = 0.96; 95% CI, 0.22–4.26) for joint replacement] or serious complication rates [(OR = 1.08; 95% CI, 0.88–1.34) for CABG and (OR = 0.92; 95% CI, 0.67–1.28) for joint replacement]. Conclusions:Despite recent enhancements to incentive structures, the Premier HQID did not improve surgical outcomes at participating hospitals. Unless significantly redesigned, pay-for-performance may not be a successful strategy to improve outcomes in surgery.

Reliability of readmission rates as a hospital quality measure in cardiac surgery.

BACKGROUND Recent policy interventions have reduced payments to hospitals with higher-than-predicted risk-adjusted readmission rates. However, whether readmission rates reliably discriminate deficiencies in hospital quality is uncertain. We sought to determine the reliability of 30-day readmission rates after cardiac operations as a measure of hospital performance and evaluate the effect of hospital caseload on reliability. METHODS We examined national Medicare beneficiaries undergoing coronary artery bypass graft operations for 2006 to 2008 (n=244,874 patients, n=1,210 hospitals). First, we performed multivariable logistic regression examining patient factors to calculate a risk-adjusted readmission rate for each hospital. We then used hierarchical modeling to estimate the reliability of this quality measure for each hospital. Finally, we determined the proportion of total variation attributable to three factors: true signal, statistical noise, and patient factors. RESULTS A median of 151 (25% to 75% interquartile range, 79 to 265) coronary artery bypasses were performed per hospital during the 3-year period. The median risk-adjusted 30-day readmission rate was 17.6% (25% to 75% interquartile range, 14.4% to 20.8%). Of the variation in readmission rates, 55% was explained by measurement noise, 4% could be attributed to patient characteristics, and the remaining 41% represented true signal in readmission rates. Only 53 hospitals (4.4%) achieved a proficient level of reliability exceeding 0.70. To achieve this reliability, 599 cases were required during the 3-year period. In 33.7% of hospitals, a moderate degree of reliability exceeding 0.5 was achieved, which required 218 cases. CONCLUSIONS The vast majority of hospitals do not achieve a minimum acceptable level of reliability for 30-day readmission rates. Despite recent enthusiasm, readmission rates are not a reliable measure of hospital quality in cardiac surgery.

Using same-hospital readmission rates to estimate all-hospital readmission rates.

BACKGROUND Since October of 2012, Medicares Hospital Readmissions Reduction Program has fined 2,200 hospitals a total of

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

500 million. Although the program penalizes readmission to any hospital, many institutions can only track readmissions to their own hospitals. We sought to determine the extent to which same-hospital readmission rates can be used to estimate all-hospital readmission rates after major surgery. STUDY DESIGN We evaluated 3,940 hospitals treating 741,656 Medicare fee-for-service beneficiaries undergoing CABG, hip fracture repair, or colectomy between 2006 and 2008. We used hierarchical logistic regression to calculate risk- and reliability-adjusted rates of 30-day readmission to the same hospital and to any hospital. We next evaluated the correlation between same-hospital and all-hospital rates. To analyze the impact on hospital profiling, we compared rankings based on same-hospital rates with those based on all-hospital rates. RESULTS The mean risk- and reliability-adjusted all-hospital readmission rate was 13.2% (SD 1.5%) and mean same-hospital readmission rate was 8.4% (SD 1.1%). Depending on the operation, between 57% (colectomy) and 63% (CABG) of hospitals were reclassified when profiling was based on same-hospital readmission rates instead of on all-hospital readmission rates. This was particularly pronounced in the middle 3 quintiles, where 66% to 73% of hospitals were reclassified. CONCLUSIONS In evaluating hospital profiling under Medicares Hospital Readmissions Reduction Program, same-hospital rates provide unstable estimates of all-hospital readmission rates. To better anticipate penalties, hospitals require novel approaches for accurately tracking the totality of their postoperative readmissions.

Reliability of surgeon-specific reporting of complications after colectomy.

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.

Is Reference Pricing the Next Big Thing in Payment Reform

OBJECTIVE We sought to determine the reliability of surgeon-specific postoperative complication rates after colectomy. BACKGROUND Conventional measures of surgeon-specific performance fail to acknowledge variation attributed to statistical noise, risking unreliable assessment of quality. METHODS We examined all patients who underwent segmental colectomy with anastomosis from 2008 through 2010 participating in the Michigan Surgical Quality Collaborative Colectomy Project. Surgeon-specific complication rates were risk-adjusted according to patient characteristics with multiple logistic regression. Hierarchical modeling techniques were used to determine the reliability of surgeon-specific risk-adjusted complication rates. We then adjusted these rates for reliability. To evaluate the extent to which surgeon-level variation was reduced, surgeons were placed into quartiles based on performance and complication rates were compared before and after reliability adjustment. RESULTS A total of 5033 patients (n = 345 surgeons) undergoing partial colectomy reported a risk-adjusted complication rate of 24.5%. Approximately 86% of the variability of complication rates across surgeons was explained by measurement noise, whereas the remaining 14% represented true signal. Risk-adjusted complication rates varied from 0% to 55.1% across quartiles before adjusting for reliability. Reliability adjustment greatly diminished this variation, generating a 1.2-fold difference (21.4%-25.6%). A caseload of 168 colectomies across 3 years was required to achieve a reliability of more than 0.7, which is considered a proficient level. Only 1 surgeon surpassed this volume threshold. CONCLUSIONS The vast majority of surgeons do not perform enough colectomies to generate a reliable surgeon-specific complication rate. Risk-adjusted complication rates should be viewed with caution when evaluating surgeons with low operative volume, as statistical noise is a large determinant in estimating their surgeon-specific complication rates.

Medicare's Acute Care Episode Demonstration: Effects of Bundled Payments on Costs and Quality of Surgical Care

With increasing national interest to simultaneously lower costs and improve quality, payers are exploring innovative policy initiatives targeted at health care payment reform. The majority of these initiatives shift financial responsibility from the payer to the provider (ie, hospitals and clinicians): bundled payments and accountable care organizations both involve negotiating a lump-sum payment from the payer to be appropriated at the discretion of the provider. Health care systems are incentivized to provide efficient care, as they keep any money they do not use and must provide extra resource utilization at a loss. Although most are familiar with some of these payment reforms, many surgeons have not heard of the latest innovation (and perhaps the most promising to date): reference pricing. Under this policy, patients (rather than providers) share the burden of financial responsibility. Early demonstrations of reference pricing have resulted in large savings in health care spending. In this context, surgeons must become familiar with reference pricing and its implications, as the policy will likely grow in scope in the near future.

Health Policy Research in Surgery

OBJECTIVE To evaluate whether participation in Medicares Acute Care Episode (ACE) Demonstration Program-an early, small, voluntary episode-based payment program-was associated with a change in expenditures or quality of care. DATA SOURCES/STUDY SETTING Medicare claims for patients who underwent cardiac or orthopedic surgery from 2007 to 2012 at ACE or control hospitals. STUDY DESIGN We used a difference-in-differences approach, matching on baseline and pre-enrollment volume, risk-adjusted Medicare payments, and clinical outcomes to identify controls. PRINCIPAL FINDINGS Participation in the ACE Demonstration was not significantly associated with 30-day Medicare payments (for orthopedic surgery: -

Large Databases Used for Outcomes Research

358 with 95 percent CI: -