Alberto Montero, MD
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Unnecessary hospital readmissions are costly and inefficient, and the Affordable Care Act (ACA) aimed to reduce them.
The 2010 statute required the federal Centers for Medicare and Medicaid Services to decrease payments to Inpatient Prospective Payment System hospitals with excess readmissions. It identified the diseases most likely to generate readmissions, a list that ranged from heart failure to total knee arthroplasty. The list did not include oncology. While a clear link exists between surgical readmissions and quality, much less is known about the implications of readmission rates in oncology patients. Moreover, less is known about effective strategies to reduce readmission rates in cancer patients
As it turns out, one approach that appears to reduce readmissions in oncology patients involves improving outpatient care transitions (with caveats) according to a Cleveland Clinic study that was featured at the annual meeting of the American Society of Clinical Oncology (ASCO) in Chicago.
The study found that it was possible to reduce 30-day oncology readmissions with a straightforward set of actions that focused on the transition to outpatient care, and that put no patients in jeopardy. The financial ramifications were significant: Each readmission in palliative medicine or general medical oncology was found to cost a mean of $18,365. The observed reduction in admissions of 5.2% would translate into an estimated cost savings of $1.89 million annually.
So why does Medicare not count oncology readmissions as a quality metric? “Probably because the word cancer includes many diseases which are extremely different from one another,” said the study’s lead author, oncologist Alberto J. Montero, MD. “Leukemia and breast cancer are very different. Drivers of admissions and readmissions for these two diseases are quite different.”
The study derived a baseline rate of readmission from the 14-month period between January 2013 and March 2014, and examined interventions that took place from May to December 2014. The three interventions the researchers evaluated were:
Since no additional staff was hired to do conduct the interventions, there were no added costs.
During the 14-month baseline period there were 3,729 combined admissions and 1,003 readmissions — a readmission rate of 26 percent for palliative medicine and 27 percent for general medical oncology.
In the eight-month intervention period, there were 1,694 admissions and 396 readmissions. Call-backs and five-day appointments were monitored with a mean compliance of 77 percent and 70 percent respectively.
During the intervention period, readmission rates in palliative medicine declined by 5 percent, to 21 percent (p = 0.01), a relative risk reduction of 19 percent. General medical oncology readmissions decreased by 3 percent, to 24 percent (p = 0.02, relative risk reduction 11 percent).
While the estimated $1.89 million annual oncology readmission savings in the study cohort “is not trivial, I don’t think it’s startling, especially in the context of the several trillions of dollars we spend annually in the U.S. on healthcare,” said Dr. Montero.
Perspective is important in considering the study’s results, he said. The analysis takes a payer’s perspective of what a reduction in readmission rated would entail as cost savings to Medicare or a private insurer that is paying most of a patient’s hospital bill.
From a hospital’s perspective, “reducing readmissions would represent a revenue loss in the current fee-for-service reimbursement model,” Dr. Montero said. However, with reimbursements likely shifting to bundled-payment models where hospitals receive a fixed amount for care, reducing preventable readmissions would represent an improvement in quality by improving patient outcomes, and at the same time represent hospital cost savings.
Dr. Montero cautioned that some readmissions are preventable and some are not. He said that the most important reason to work on reducing preventable readmissions is that – from patient and quality perspectives – it’s the right thing to do. Cancer patients spend much time coming back and forth from the hospital to get tests and infusions. If we could reduce the need for patients to be readmitted to the hospital, this is time that patients could spend at home with family and friends.
Dr. Montero is a staff physician in the Department of Solid Tumor Oncology at Cleveland Clinic’s Taussig Cancer Institute.