Looking beyond metrics to prevent readmissions
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Hospital quality metrics are defined as a group of standards CMS developed to quantify patient outcomes and health care processes.
We seem to be inundated with metrics, but the common ones are length of stay, 30-day readmission rates and mortality rates, to name a few.
A metric should be a well-defined measurement that is used to analyze, monitor and optimize health care processes in order to increase patient satisfaction. Perhaps the definition should add “the metric needs to be collected accurately.”
I’m sure your cancer centers see metrics as specific key performance indicators. It shouldn’t surprise anybody that the five key performance indicators for many, if not all, health care organizations are people, quality, time, growth and financial performance.
Measures of success
So-called hospital key performance indicators monitor the quality of health care provided by the hospital and measure the overall success of the business. Indeed, hospitals are a business.
The list seems to be endless. There is bed occupancy rate, staff-to-patient ratio, average treatment charge, claims denial rate, and average insurance claim processing time and cost, among others. It’s basically metric overload.
I have a hard time wrapping my hands around 30-day readmissions for patients with cancer. The observed readmission rate is the percentage of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days. It is equal to the count of 30-day readmissions divided by the count of index hospital stays.
The average all-cause hospital-wide readmission rate for U.S. hospitals is 15.5%, with rates ranging from 11.5% to 21.2%, according to data from 4,100 hospitals in the Definitive Healthcare HospitalView product.
Cancer care is complex and in most cases a readmission within 30 days of hospitalization can be justified. Index admissions are excluded from the readmission measure if the patient was discharged against medical advice (AMA) and/or the patient was admitted for a primary psychiatric diagnosis, for rehabilitation or for medical treatment of cancer. However, reducing hospital readmissions — especially those that result from poor inpatient or outpatient care — has long been a health policy goal because it represents an opportunity to lower health care costs, improve quality and, just as importantly, increase patient satisfaction.
Variations to consider
We must remember that the availability of services and types of facilities vary significantly across the United States. This comes into play because the physician and staff must take into account several factors beyond medical determinants to avoid readmission. These include patient cognitive status, activity level and functional status. There is also the nature of the patient’s home and its suitability for the patient’s conditions, which can be impacted by factors such as the presence of stairways, cleanliness, availability of family or companion support, ability to obtain medications and access to services in the community to assist with ongoing care.
Solomon and colleagues demonstrated this in a study published in JCO Oncology Practice. Using a merged longitudinal data set of New York state hospital discharges and vital records, they measured 30-day readmissions for anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia and sepsis among patients with metastatic cancer between 2012 and 2014. The 30-day readmission rate was 24.5%, with 11.9% (n = 565) of readmissions potentially preventable.
Results showed an association of potentially preventable readmissions with discharge home with services. The authors stated that this finding suggests services supplied may not be sufficient to address the health needs of the patient. Home care models offering more clinical support and anticipatory guidance have the potential to enhance patient-centered care and outcomes while reducing costs associated with potentially unnecessary readmissions. Interestingly, the authors also concluded that despite efforts, no standardized definition of potentially preventable medical admissions exists.
What can we do?
Preventing avoidable hospitalizations is more complicated than one might expect. It appears that the most consistent readmission risk factors among patients with cancer tend to be a mix of unmodifiable social demographic factors and clinical characteristics, such as age, social determinants of health, type and stage of cancer, and associated comorbidities. Associated comorbidities are even more critical today as patients with cancer are living longer. All these factors might be infeasible to overcome indirectly with intensive supplemental post-discharge care.
I would imagine none of this is news to my colleagues. The subject matter demonstrates the inexact science we are dealing with. However, I see no solution except to do the best job we can with the resources each of us has to avoid unnecessary readmissions, some of which are unavoidable despite our efforts in the face of no standard definition of preventable admissions.
Stay safe.
References:
- Alper E, et al. Hospital discharge and readmission (UpToDate). Available at: www.uptodate.com/contents/hospital-discharge-and-readmission. Updated Aug. 18, 2022. Accessed Dec. 28, 2022.
- Definitive Healthcare. Critical access hospitals with the highest readmission rates. Available at: www.definitivehc.com/resources/healthcare-insights/critical-access-hospitals-readmission-rates. Accessed Dec. 28, 2022.
- Finkelstein A, et al. N Engl J Med. 2020;doi:10.1056/NEJMsa1906848.
- Solomon R, et al. J Oncol Pract. 2019;doi:10.1200/JOP.18.00500.
For more information:
Nicholas J. Petrelli, MD, FACS, is Bank of America endowed medical director of ChristianaCare’s Helen F. Graham Cancer Center & Research Institute and associate director of translational research at Wistar Cancer Institute. He also serves as Associate Editor of Surgical Oncology for HemOnc Today. He can be reached at npetrelli@christianacare.org.
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