Hospitals penalized twice for readmissions, study finds

American Medical Association says the readmission penalty is unnecessary since other other pay-for-performance programs already measure complications such as surgical site infections.

While hospitals are working overtime to cut down on costly post-surgical readmissions, a new study by the American Medical Association suggests that these may not be the best measure for pay-for-performance programs. In fact, they really just punish hospitals twice.

"For a large hospital there are millions of dollars on the line for readmission penalties," said study co-author Dr. Karl Bilimoria of Northwestern University Hospital and Northwestern University. "Some hospitals will have multi-million dollar penalties."

The study suggests that readmissions after surgery are mostly a proxy measure for post-discharge complications. However, the readmission penalty is really unnecessary -- and unfair --  since other other pay-for-performance programs already measure complications such as surgical site infections, the authors said.

"It makes all the sense in the world to avoid readmissions. But sometimes it may be the right thing to do."

"What we found is most of the readmissions after surgery were due to well-known complications that occur at some baseline rate," Bilimoria said. "It's not capturing something new. It seems like a double-jeopardy situation."

The study found readmissions due to complications were predominantly the result of wound infections or surgical site infections.

"We don't have ways to drive that to zero," Bilimoria said.

Also, in any quality measure, penalizing for readmission may force treatment to an outpatient setting, he said.

"It makes all the sense in the world to avoid readmissions," he said.

"But sometimes it may be the right thing to do."

[Also: Medicare penalizes 721 hospitals over medical errors [full list]]

Ryan P. Merkow, MD, of the American College of Surgeons in Chicago, and colleagues examined the reasons, timing and factors associated with unplanned postoperative hospital readmissions within 30 days after surgery.

The study included data from patients undergoing surgery at one of 346 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program between January and December 2012. Readmission rates and reasons were assessed for all surgical procedures and for six operations: bariatric procedures, colectomy or proctectomy, hysterectomy, total hip or knee arthroplasty, ventral hernia repair and lower extremity vascular bypass.

The unplanned 30-day readmission rate for 498,875 operations was 5.7 percent. For the individual procedures, the rate of readmission ranged from 3.8 percent after hysterectomy to 14.9 percent after lower extremity vascular bypass.

The most common reason for unplanned readmission was surgical site infection at 19.5 percent, ranging from 11.4 percent after bariatric surgery to 36.4 percent after lower extremity vascular bypass.

Only 2.3 percent of patients were readmitted for the same complication they had experienced during their hospitalization, according to the study.

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There are ways to lobby for change without throwing out the whole provision, Bilimoria said. As with other pay-for-performance programs, the Centers for Medicare and Medicaid Services has the ability to pick metrics, giving them more flexibility to use judgment that's evidence-based, he said.

Hospitals could have an intermediate care clinic for more advanced care in which a wound could be opened and cleaned, he suggested.

The study said efforts should focus on reducing complication rates overall than simply those that occur after discharge, and this would reduce readmission rates as well.

"Readmissions after surgery may not be an appropriate measure for pay-for-performance programs but rather better suited as measure for hospitals to track internally," the authors said.

Twitter: @SusanMorseHFN