Upstate New York Surgical Quality Initiative

Transcription

1 Upstate New York Surgical Quality Initiative 30-Day Readmissions: A Snapshot of Regional Practice Experience in Colorectal Surgery ACS NSQIP National Conference 10 th Annual Meeting, July 27 th, 2015 Bradley Hensley, Robert Cooney, Nicholas Hellenthal, John Monson, Katia Noyes, Kristin Kelly, Fergal Fleming

2 Disclosures No financial disclosures

3 Why Surgical Readmissions? Significant implications for patients, doctors, hospitals, and insurers By understanding and working to prevent them we have an opportunity to improve patient care and decrease costs

4 Affordable Care Act Section 3025 Section 3025 of the ACA establishes the Readmission Reduction Program and adds paragraph (q) to section 1886 of the Act, which requires the Secretary to apply an adjustment in determining the operating IPPS payment to subsection (d) hospitals (and may be applied to Maryland hospitals under section 1814(b)(3)) that have excess readmissions based on the applicable readmission measures selected by the Secretary. This payment provision was effective for discharges occurring on or after October 1, [Center for Medicare Services Manual System]

5 Hospital Readmissions Reduction Program A reimbursement penalty approach for hospitals that have readmissions deemed excess by CMS Began with 3 specific conditions Acute Myocardial Infarction Heart failure Pneumonia Knee and hip surgery added in 2015

6 Medicare Fee-for-Service Rehospitalization Medicare Claims Analysis (nearly 12 million patients) 19.6% of beneficiaries were rehospitalized within 30 days 15.1% of surgical patients were rehospitalized within 30 days 50.2% had no bill for a visit to a physician s office Estimate cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion New England Journal of Medicine 2009; 360: 1418

7 Medicare Fee-for-Service Rehospitalization Most Common Reasons for Hospitalization for All Surgical Patients 1. Heart Failure (6.0%) 2. Pneumonia (4.5%) 3. GI Problems (3.3%) 4. Septicemia (2.9%) New England Journal of Medicine 2009; 360: 1418

8 Medicare Fee-for-Service Rehospitalization Rates of Rehospitalization within 30 Days after Hospital Discharge New England Journal of Medicine 2009; 360: 1418

9 ReimbursementPenalties 9 Kaiser Health News

10 The Burden of Surgical Readmissions High rates of readmission and excess cost in medical and surgical patients Decreased hospital reimbursement for Pneumonia, MI, CHF and now knee and hip surgery GI Surgery: % of patients - Postoperative complications New England Journal of Medicine 2009; 360: 1418

11 Underlying Reasons Associated With Hospital Readmission Following Surgery in the United States Journal of the American Medical Association Ryan P. Merkow,MD, MS; Mila H. Ju, MD, MS; JeanetteW. Chung, PhD 11.1% all-cause readmission rate for colectomy or proctectomy Most frequent reasons for unplanned readmissions 1. Surgical site infection (25.8%) 2. Ileus or obstruction (18.1%) 3. Dehydration and nutrition (6.7%) 4. Bleeding (4.1%) 5. Venous Thromboembolism (3.2%) JAMA. 2015;313(5):

12 Surgical Readmissions SSIs are the leading reason for surgical readmissions Challenging to identify solutions to reduce SSI rates High adherence rates for SCIP SSI-prevention process measures Adherence has not been strongly associated with reduced SSI rates Other opportunities?

13 Preventing Hospital Readmissions Common Process Breakdowns Associated with Readmissions Care Gaps During Stay Patient safety Medication reconciliation not completed or inaccurate at admission or discharge Patient Factors Lack of understanding of post-discharge plan Lack of understanding of what to watch for, how to respond Non-compliance with elements of post-discharge care Lack of Timely Post-Discharge Care No appointments available or no relationship with PCP Logistics, such as no transportation PCP unaware of hospitalization Communication Delayed or inadequate communication with next provider of care Lacking or inadequate communication with home care provider Global Institute for Emerging Healthcare Practices

14 The Known Unknowns. True rate of readmission/representation following colorectal surgery The actual causes for representation/readmission Can readmissions be prevented? When and what are these opportunities to enhance patient care and reduce unscheduled readmission/representations?

15 Colectomy Readmission Project Goals Identify factors that contribute to readmissions. Identify processes of care that may contribute to reduction of readmissions and improved patient care outcomes.

16 Transition of Care Following Surgery

17 Readmission Post Colectomy Project Readmission focused variable design ~ colorectal resections 2013/2014 Analysis Quality improvement 2014/2015 Evaluation of measures ~ colorectal resections 2015/2016

18 UNYSQI Colectomy Database July 2013-June 2014 Diverse range of clinical practice (urban vs. rural, academic vs. community) All colorectal resections captured by NSQIP sampling Standard NSQIP variables plus readmission-specific variables

19 Readmission after Colectomy Variables: Payment Source Ostomy type Ileus/Obstruction Anastomotic Leak Date of Anastomotic Leak IR procedure Date of IR procedure Date of Reoperation Reoperation CPT codes Ancillary staff involvement Date of surgical outpatient appointment(s) ED and Observation visits Readmission ICD-9 Readmission reason Readmission length of stay

20 Ensuring data completion-auditing % of cases with missing custom fields data Initial Project New Project 1st Audit 2nd Audit

21 Methods Exclusion criteria: Death prior to discharge, LOS>30 days Primary endpoint: 30-day readmissions Secondary endpoints: ED visits, 30-day re-presentation Bivariate analysis of patient, hospital and operative factors Multivariable logistic regression

22 Elective cases: 66.2% (417/630) Operative Factors Resection site: Colon only: 77.0% (485/630) Colon + Rectum: 23.0% (145/630) Operative Indication: Cancer: 34.0% (214/630) Diverticular disease: 24.6% (155/630) IBD: 6.5% (41/630) Other: 34.9% (220/630) Laparoscopic Surgery: 49.2% (310/630)

23 Postoperative Re-presentation ED Visits 69/97 Rate: 71.1% Readmitted 48/69 Rate: 69.6% All acute representations 97/630 Rate: 15.4% Directly Readmitted 28/97 Rate: 28.9% Home 21/69 Rate: 30.4% Overall readmission rate: 12.1%

24 Reasons for Readmission Reason Percentage Nausea/Vomiting 17.0% Wound complication 12.8% Pain 11.7% Medical (Renal, Pulm, Cardiac, VTE) 11.7% Ileus/Obstruction 10.6% Dehydration 9.6% Failure to thrive/malaise/ Fatigue 6.4% Change in ostomy output (increase/ decrease) 6.4% Sepsis/SIRS 4.3% OSI 4.3% Bleeding/Anemia 4.3% Social 1.1%

25 Bivariate Results: Factors Associated with 30-Day Readmissions Patient Factors Bleeding Disorder Diabetes Mellitus Disseminated Cancer Renal Comorbidity Smoker in Past Year Operative Factors ASA Class (3, 4 & 5) Non-Elective Surgery Open Surgery Ostomy Type: No Ostomy Colostomy Ileostomy Post-Operative Factors No Scheduled Follow-Up Physical/Occupational Therapy Social Work Involvement No Readmission (n=554; 87.9%) 26 (4.7) 70 (12.6) 24 (4.3) 5 (0.9) 95 (17.1) 292 (52.8) 180 (32.5) 271 (48.9) 397 (71.7) 76 (13.7) 81 (14.6) 112 (20.2) 213 (38.4) 157 (28.3) Readmission (n=76; 12.1%) 8 (10.5) 18 (23.7) 7 (9.2) 3 (3.9) 21 (27.6) 52 (68.4) 33 (43.4) 49 (64.5) 43 (56.6) 14 (18.4) 19 (25.0) 29 (38.2) 37 (48.7) 31 (40.8) P-value <

26 Multivariable Analysis 4.5 Adjusted Odds Ratio Diabetes Smoker Ileostomy No Scheduled Follow-Up

27 Possible QI targets Optimize Diabetic Management

28 Scheduled Follow-Up Appointments Schedule follow-up at the time surgery is booked Contact outpatient office to schedule follow-up prior to discharge Have the office reach out to the patient after discharge to schedule an appointment

29 Possible QI targets Ostomy care pathway Optimize Diabetic Management

30 Ostomy Care Pathways Ileostomy patients are scheduled for pre and post-op visits Stoma marking Education on appliances and ostomy care Prevention of dehydration teaching Infusing protocols

31 Ostomy Care Pathways Protocol for management of the high output stoma patient High output: >1200 ml/24 hours First line therapy: Loperamide 4 mg QID, 30 minutes before meals Second line therapy: Codeine mg QID, 30 minutes before meals. Third line therapy : Lomotil mg TID or QID max dose 20 mg. Forth line therapy: Tincture of opium (Codeine ORtincture of opium, but not both) Fifth line therapy: Antisecretory agents (Octreotide, omeprazole, cimetidine and cholestyramine)

32 Ostomy Care Pathways Streamlining wound ostomy care nursing documentation Improve documentation Streamline communication Standardize teaching Working with Home Care Agencies Reinforcing protocols

33 Possible QI targets Ostomy care pathway Smoking Cessation Programs Optimize Diabetic Management

34 Smoking Cessation Programs Very Brief Advice 1 to 3 minutes is EFFECTIVE (40% increase) Clinician advice alone is EFFECTIVE More counseling is even more effective e.g., 30 minutes can be 90% increase SO: Time spent at point of care - PLUS - Multiple providers - PLUS - Telephone Quitline Counselors

35 Final Thoughts Multifactorial etiology, many of which are non-modifiable Gaps in data need to be closed Tangible QI initiatives include: Pre-operative smoking cessation programs Enhance discharge planning Dedicated ostomy care pathway Optimize diabetic management

36 Acknowledgements UNYSQI SCRS & Surgeon Champions Stacey Esposito Excellus Michelle Vielhauer Marybeth McCall ACS NSQIP Craig Miller Emma Malloy Steve Merzlak, James Wadzinski URMC Margaret Odhner Amy Matroniano