How to Address an Inappropriately high Readmission Rate?

Transcription

1 How to Address an Inappropriately high Readmission Rate? Joe Sharma, MD Associate Professor of Surgery NSQIP Surgical Champion Medical Officer CDC/DHPQ

2 Disclosure Slide No COI and no disclosures.

3 OBJECTIVES 1. Identify risk factors associated with readmissions. 2. Learn a QI cycle for decreasing readmissions.

4 Readmission rate : is it a problem? Medicare patients discharged from a hospital 20 %are re-hospitalized within 30 days 34% are re-hospitalized in 90 days. In 480,000 surgical patients in 3000 hospitals 13% readmission rate In 2013, CMS readmission penalties total of 2,213 hospitals about $280 million

5 General/Vascular Site : Hospital X / th decile 20% 5 th decile 15% 1 st decile -13%

6 Procedures and Readmission Rates Risk Factors for 30-Day Hospital Readmission among General Surgery Patients Michael T Kassin, MD, Rachel M Owen, MD, Sebastian D Perez, MSPH, Ira Leeds, BS, James C Cox, PhD, Kurt Schnier, PhD, Vjollca Sadiraj, PhD, John F Sweeney, MD, FACS

7 In 2012, ACS NSQIP included 374 adult hospitals, accounting for approxi- mately 10% of all hospitals and 30% of operations per- formed in the United States. Underlying Reasons Associated With Hospital Readmission Following Surgery in the United States Ryan P. Merkow, MD, MS; Mila H. Ju, MD, MS; Jeanette W. Chung, PhD; Bruce L. Hall, MD, PhD, MBA; Mark E. Cohen, PhD; Mark V. Williams, MD; Thomas C. Tsai, MD, MPH; Clifford Y. Ko, MD, MS, MSHS; Karl Y. Bilimoria, MD, MS

8 Risk of Readmission

9 Complications and Readmission Rates Underlying Reasons Associated With Hospital Readmission Following Surgery in the United States Ryan P. Merkow, MD, MS; Mila H. Ju, MD, MS; Jeanette W. Chung, PhD; Bruce L. Hall, MD, PhD, MBA; Mark E. Cohen, PhD; Mark V. Williams, MD; Thomas C. Tsai, MD, MPH; Clifford Y. Ko, MD, MS, MSHS; Karl Y. Bilimoria, MD, MS

10 Overall SSI 19.5% Ileus 10.3% Bariatric Ileus 24.5% Colectomy SSI 25.8% Ileus 18.1% Bleeding 6.7%

11 Analysis Individual Factors Team Factors Patient Factors Readmission?????? Environment Rules and Policy Organization

12 Drilling-down on Readmission Risk (Pre-existing conditions) Pre-existing conditionsand Readmissions in Colectomy Steroid Hypertension Cancer COPD Smoker Functional Status Diabetes Pre-existing conditionsand Readmissions in Vascular Diabetes Renal Failure Pre-existing conditionsand Readmissions Thyroidectomy Renal Failure In most risk models surgery related medical conditions played a greater role in readmissions.

13 Drilling-down on Readmission Risk (Complications) CV Renal Readmis sions Pulmonary Infectious CNS

14 The problem of READMISSIONS for Hospital X Readmission O/E ratios are high and the hospital is an outlier vs. Readmission rates have been low/mid and now there is an increase. Examination of SAR and Run Chart

15 Pinpointing the problem of Readmission General 1/12-12/12 7/12-6/13 1/13-12/13 7/13-6/14 1/14-12/14 7/14-6/15 Morbidity Cardiac Pneumonia Unplanned Intubation Vent > 48hrs VTE Renal Failure UTI SSI Sepsis

16 Readmission reduction areas of potential intervention Preoperative Intraoperative Postoperative Screening OSA HTN DM Pulmonary Pre-existing Comorbid Dyspnea Cancer Renal Failure Elective Surgery Cancellation Postponement with optimization ERAS Risk Assessment Special Populations NSQIP risk calculator (Reduction of Complications) WHO Checklist SSI Prevention Anesthesia Considerations Low Tidal Volume Ventilation Anesthetic Choices Fluid limitation Hyperglycemia control Operative Technique ERAS ERAS Multimodal Analgesia Fluid restriction Oral Intake Ambulation Lung expansion Education Nursing Follow-up High risk population Patient Registry Telemonitoring Discharge Planning Hospital alignment with community

17 Strategy for Readmission Reduction Reduce the risk of readmission Preop, reduce complications Identify high risk population Ileostomy patients at EUH Teaching Signs of dehydration Dedicated nurse follow-up and access Infusion center

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21 Where to focus in Readmission improvement? Depends (Targets will vary) Overall Process Improvements Preoperative screening Identifying high risk populations : life-line ERAS Reduction of Ileus Specific SSI Prevention Ileus Prevention Dehydration Prevention