Monday, February 9, 2015

Don't jump to conclusions about that JAMA surgical readmissions paper

On February 3, JAMA published a paper online about readmission rates after surgery. The focus of most tweets was on the most common cause for readmission—surgical site infections (SSIs)—in 19.5% of readmitted patients.

At first glance, this suggests that infection rates after surgery were 19.5%, but that is not so. The paper said that 19.5% of the readmissions were caused by infections.

Of 498,875 total operations reviewed, only 30,270 (6.1%) were readmitted for any reason, and only 5576 (1%) of all patients were readmitted for SSIs.

According to the full text of the paper, the authors had two main points:

One, "because most readmissions were attributable to well-described postoperative complications, readmissions after surgery are mostly a proxy measure for postdischarge complications and in effect penalize hospitals twice [my emphasis] for postoperative complications (ie, other pay-for-performance programs include postoperative complications such as SSI)."

Two, "the majority of hospital readmissions were related to SSI and ileus [non-mechanical failure of bowel peristalsis]. Identifying clinical interventions to reduce the occurrence of these complications to below current levels has been challenging."

An article about the paper in US News quoted an editorial by Lucian Leape who said "system-wide changes need to be made." One such system change, the Surgical Care Improvement Project (SCIP), has been ongoing for more than 10 years.

The paper confirms what I wrote in 2010 about SCIP and other process measures and points out that "Most hospitals in the United States have high adherence rates for the SCIP SSI-prevention process measures; however, compliance with these process measures has not been shown to be strongly associated with reduced SSI rates."

And I am unaware of a conclusive study showing that the incidence of postoperative ileus can be lowered by any intervention.

I agree with the comments of the paper's authors who say, "It is important to note that many readmissions may be unavoidable and are actually the correct course of action for surgical patients. [My emphasis] Many complications should be treated in the inpatient setting, and surgeons should not be deterred from readmitting patients because of concerns about quality measure performance and resulting penalties."

Every effort should be made to lower the infection rates of all procedures. But this paper's results should be viewed not with alarm, but rather as reassurance that the problem is not out of control.


artiger said...

Sounds like some people didn't really read the article. Engage brain before mouth/fingers.

Anonymous said...

Greater than 5500 readmitted. Who is paying for the readmission? The hospital or the patient? Even if it is the patients' insurance, lifetime caps can make that an issue.

Skeptical Scalpel said...

They may have read the article but the emphasis from their tweets was misplaced.

If the patients had insurance, it would have paid. If uninsured, the patient pays. The point is, many readmissions cannot be prevented.

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