Readmission rates after gynecologic surgery may not be a valid measurement of quality care

Surgeons should focus on long-term outcomes for the treatment of ovarian cancer rather than hospital readmission rates after surgery, according to two studies presented at the Society of Gynecologic Oncology’s Annual Meeting on Women’s Cancer.

Surgery may lead to high readmission rates; however, surgery also can translate to improved survival in patients with ovarian cancer. Thus, hospital readmission rates may not be the best metric to assess high-quality care.

Because readmission rates are a quality-of-care measure used in hospital ranking systems, researchers evaluated the short-term effects of hospital readmission metrics, as well as long-term survival outcomes of patients.

Hospital readmission metrics

The Hospital Readmission Reduction Program was created under the Affordable Care Act to allow CMS to penalize hospitals up to 3% of their total reimbursement if a hospital had a high readmission rate compared with similar hospitals.

“However, this penalty has the potential to create a situation where surgeons are pressured to reduce readmission rates, and consequently they adopt procedures which are less aggressive but have a lower readmission rate,” Shitanshu Uppal, MBBS, assistant professor of obstetrics and gynecology at the University of Michigan, said in a press release.

Uppal and colleagues used the National Cancer Data Base to identify 36,674 patients with stage III or stage IV serous ovarian carcinoma who underwent primary debulking surgery to examine the use of hospital readmission rate as a quality measure.

“Readmission rates might be a valid measure of quality for certain surgeries, where [a] higher readmission rate reflects a higher complication rate,” Uppal said in the release. “However, in cancer surgeries, ‘quality of care’ is not only defined by 30-day outcomes, but also by the impact of an appropriate surgery on the patient’s OS. Sometimes, a higher readmission rate after an aggressive surgery to remove all the tumor from the abdomen, which we know translates into a better survival, is worth it.”

Researchers divided hospitals into four categories based on volume: 10 or fewer cases per year, 11 to 22 cases per year, 21 to 30 cases per year, and 31 or more cases per year.

Hospitals with more than 31 cases per year demonstrated the highest risk-adjusted readmission rate. However, these hospitals showed a lower risk-adjusted 90-day mortality, higher adherence to National Comprehensive Cancer Network guidelines and a greater rate of 5-year OS.

“What started off as a good intention — where we wanted to see what the outcomes were and how we are impacting our patients’ lives for better — has changed to a metric of ranking and penalizing hospitals,” Uppal said. “Extending life in the context of a deadly disease like ovarian cancer is important, but a real measure of quality will be the ability to answer the question whether we enable our patients to achieve their goals or not.”

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Long-term outcomes

Health systems are incentivized to decrease postoperative readmissions; however, it is unknown if these incentives are aligned with goals of improved long-term survival.

Emma L. Barber, MD, MS, and colleagues identified 26,595 women with stage III epithelial ovarian cancer treated with chemotherapy and surgery who were registered in the National Cancer Data Base to determine the association between treatment options and hospital readmission, as well as OS. Researchers compared outcomes of patients who received neoadjuvant chemotherapy followed by surgery with those who underwent primary debulking, or surgery followed by chemotherapy.

In total, 15.5% of patients were treated with neoadjuvant chemotherapy and 11.3% were readmitted to the same hospital within 30 days of surgery. Fifty-seven percent of those readmissions were unplanned.

Compared with primary debulking surgery, neoadjuvant chemotherapy appeared to be associated with a 37% reduction in the risk for unplanned readmission (RR = 0.63; 95% CI, 0.54-0.74) and a 48% reduction in the risk for any readmission (RR = 0.52; 95% CI, 0.46-0.59).

However, chemotherapy also increased risk for death of all causes by 36% (HR = 1.36; 95% CI, 1.29-1.42).

“These overachieving policies are going to incentivize gynecologic oncologists to do more chemotherapy before surgery,” Barber said in a press release. “This is an example where a well-meaning policy for the broad population has unintended consequences for the smaller ovarian cancer community.” – by Kristie L. Kahl

References:

Barber EL, et al. Abstract 6. Presented at: Annual Meeting on Women’s Cancer; March 12-15, 2017; National Harbor, MD.

Uppal S, et al. Abstract 24. Presented at: Annual Meeting on Women’s Cancer; March 12-15, 2017; National Harbor, MD.

Disclosure: HemOnc Today could not confirm the researchers’ relevant financial disclosures at the time of reporting.