872
W. L. Patterson et al. / Surgery for Obesity and Related Diseases 11 (2015) 866–873
[19] Ashton CM, DelJunco DJ, Souchek J, et al. The Association Between the Quality of Inpatient Care and Early Readmission: A MetaAnalysis of the Evidence. Medical Care 1997;35:1044–5. [20] Carlin AM, Zeni TM, English WJ, et al. The Comparative Effectiveness of Sleeve Gastrectomy, Gastric Bypass, and Adjustable Gastric Banding Procedures for the Treatment of Morbid Obesity. Ann Surg 2013;257:791–7. [21] Kwon S, Wang B, Wong E, et al. The Impact of Accreditation on Safety and Cost of Bariatric Surgery. Surg Obes Relat Dis 2013;9:617–22. [22] Nguyen NT, Nguyen B, Nguyen VQ, et al. Outcomes of Bariatric Surgery Performed at Accredited vs. Nonaccredited Centers. J Am Coll Surg 2012;215:467–74. [23] Friedman B, Basu J. The Rate and Cost of Hospital Readmissions for Preventable Conditions. Med Care Res and Rev 2004;61:225–40. [24] Dorman RB, Miller CJ, Leslie DB, et al. Risk for Hospital Readmission following Bariatric Surgery. PLoS ONE 2012;7:e32506.
[25] Goldfield NI, McCullough EC, Hughes JS, et al. Identifying Potentially Preventable Readmissions. Health Care Financing Review 2008;30:75–91. [26] 3 MTM Health Information Systems. Potentially Preventable Readmissions Classification System: Methodology Overview. Document number GRP-139 05/08. May 2008. [27] Saunders J, Ballantyne GH, Belsley B, et al. One year readmission rates at a high volume bariatric surgery center: Laparoscopic adjustable gastric banding, laparoscopic gastric bypass and vertical banded gastroplasty Roux-en-Y gastric bypass. Obesity Surgery 2008;18: 1233–40. [28] Elixhauser A, Syeiner C, Harris D. Co-morbidity measures for use with Administrative Data. Med Care 1998;36:8–27. [29] Hutter MM, Schirmer BD, Jones DB, et al. First Report from the American College of Surgeons Bariatric Surgery Center Network: Laparoscopic Sleeve Gastrectomy has Morbidity and Effectiveness Positioned Between the Band and the Bypass. Ann Surg 2011;254: 410–22.
Editorial
Comment on: Predicting potentially preventable hospital readmissions following bariatric surgery Decreasing the rate of readmissions in bariatric surgery has the potential to improve the delivery of patient care, increase patient satisfaction, and allow for a lower overall cost of care. There are numerous hurdles to truly impact readmission rates. Perhaps the first is to understand the true number of readmissions, and more importantly, those that can be prevented. The authors should be commended in their analysis presented in “Predicting Potentially Preventable Hospital Readmissions Following Bariatric Surgery,” which helps us get closer to understanding that true rate [1]. Additionally, they are carefully responsible with their consistent focus on potentially preventable readmissions as opposed to examining only the total readmission rate. In our program, when we implemented a process to more aggressively capture and understand bariatric readmissions, we witnessed an observer effect with an increase in the number of readmissions in the early months of our analysis. The plethora of definitions of what constitutes a readmission unfortunately confounds the study of this outcome variable. Standardizing the definition of readmissions in the broadest sense will help to identify the true baseline rate. Capturing and classifying all return visits to the hospital—whether an ER visit, 23 hour observation, or actual multiple-midnight stay readmission, as well as capturing patients that present to another hospital is critical to establishing this baseline. In the past, we observed programs that claimed extremely low readmission rates when in fact the readmissions were being admitted to another local hospital or a larger regional tertiary care facility and not being captured as part of the original surgery program data.
No matter what approach we use, there must be a reasonable attempt by CMS and other payors to determine what are acceptable preventable and total readmission rates [2]. At this point in time, an “acceptable” rate might in fact increase as the entire bariatric community improves its capture of readmission data. We must also be conscious of rewarding a reduction of readmissions. Physician compensation methodologies will all drive certain behaviors, potentially resulting in some unintentional consequences. Could either penalizing readmissions or rewarding a reduction of readmissions actually encourage a healthcare system to prevent a recent postoperative bariatric patient from coming to the hospital when that is indeed the best treatment? I would like to think not, but this is indeed within the realm of possibility. An alternative to penalizing a readmission could be to reward the behaviors that, when employed, can reduce preventable readmissions. One possibility is to incentivize physician, bariatric program, and healthcare system behaviors that allow for the investigation of the root cause of each readmission with a goal of reviewing 100% of readmissions. In this manner, the program can classify the readmission as potentially preventable or nonpreventable. If preventable, the program can then determine if there were any missed opportunities to do better. This multidisciplinary approach should be relatively easy to undertake within the constructs of an MBSAQIP-accredited center of excellence program in bariatric surgery. Readmissions will only be able to be affected through the development of standardized criteria for the definition of
Predicting Preventable Hospital Readmissions / Surgery for Obesity and Related Diseases 11 (2015) 866–873
readmission, honest and accurate case reporting, and thoughtful retrospective analysis of each return to hospital. This has the potential to add important value to the care delivered, drive improvements in the patient experience, and better the outcomes of bariatric surgery.
873
Darren S. Tishler, M.D., F.A.C.S. Department of Surgery, Hartford Hospital, Hartford, Connecticut
References Appendix Supplementary data Supplementary data associated with this article can be found in the online version at doi:10.1016/j.soard.2015.01. 010.
[1] Patterson WL, Peoples BD, Gesten FC. Predicting Potentially Preventable Hospital Readmissions Following Bariatric Surgery. Surg Obes Relat Dis 2015;11(4):866–72. [2] “Health Policy Brief: Medicare Hospital Readmissions Reduction Program,” Health Affairs, November 12, 2013. http://healthaffairs. org/healthpolicybriefs/brief_pdfs/healthpolicybrief_102.pdf.
W. L. Patterson et al. / Surgery for Obesity and Related Diseases 11 (2015) 866–873
[19] Ashton CM, DelJunco DJ, Souchek J, et al. The Association Between the Quality of Inpatient Care and Early Readmission: A MetaAnalysis of the Evidence. Medical Care 1997;35:1044–5. [20] Carlin AM, Zeni TM, English WJ, et al. The Comparative Effectiveness of Sleeve Gastrectomy, Gastric Bypass, and Adjustable Gastric Banding Procedures for the Treatment of Morbid Obesity. Ann Surg 2013;257:791–7. [21] Kwon S, Wang B, Wong E, et al. The Impact of Accreditation on Safety and Cost of Bariatric Surgery. Surg Obes Relat Dis 2013;9:617–22. [22] Nguyen NT, Nguyen B, Nguyen VQ, et al. Outcomes of Bariatric Surgery Performed at Accredited vs. Nonaccredited Centers. J Am Coll Surg 2012;215:467–74. [23] Friedman B, Basu J. The Rate and Cost of Hospital Readmissions for Preventable Conditions. Med Care Res and Rev 2004;61:225–40. [24] Dorman RB, Miller CJ, Leslie DB, et al. Risk for Hospital Readmission following Bariatric Surgery. PLoS ONE 2012;7:e32506.
[25] Goldfield NI, McCullough EC, Hughes JS, et al. Identifying Potentially Preventable Readmissions. Health Care Financing Review 2008;30:75–91. [26] 3 MTM Health Information Systems. Potentially Preventable Readmissions Classification System: Methodology Overview. Document number GRP-139 05/08. May 2008. [27] Saunders J, Ballantyne GH, Belsley B, et al. One year readmission rates at a high volume bariatric surgery center: Laparoscopic adjustable gastric banding, laparoscopic gastric bypass and vertical banded gastroplasty Roux-en-Y gastric bypass. Obesity Surgery 2008;18: 1233–40. [28] Elixhauser A, Syeiner C, Harris D. Co-morbidity measures for use with Administrative Data. Med Care 1998;36:8–27. [29] Hutter MM, Schirmer BD, Jones DB, et al. First Report from the American College of Surgeons Bariatric Surgery Center Network: Laparoscopic Sleeve Gastrectomy has Morbidity and Effectiveness Positioned Between the Band and the Bypass. Ann Surg 2011;254: 410–22.
Editorial
Comment on: Predicting potentially preventable hospital readmissions following bariatric surgery Decreasing the rate of readmissions in bariatric surgery has the potential to improve the delivery of patient care, increase patient satisfaction, and allow for a lower overall cost of care. There are numerous hurdles to truly impact readmission rates. Perhaps the first is to understand the true number of readmissions, and more importantly, those that can be prevented. The authors should be commended in their analysis presented in “Predicting Potentially Preventable Hospital Readmissions Following Bariatric Surgery,” which helps us get closer to understanding that true rate [1]. Additionally, they are carefully responsible with their consistent focus on potentially preventable readmissions as opposed to examining only the total readmission rate. In our program, when we implemented a process to more aggressively capture and understand bariatric readmissions, we witnessed an observer effect with an increase in the number of readmissions in the early months of our analysis. The plethora of definitions of what constitutes a readmission unfortunately confounds the study of this outcome variable. Standardizing the definition of readmissions in the broadest sense will help to identify the true baseline rate. Capturing and classifying all return visits to the hospital—whether an ER visit, 23 hour observation, or actual multiple-midnight stay readmission, as well as capturing patients that present to another hospital is critical to establishing this baseline. In the past, we observed programs that claimed extremely low readmission rates when in fact the readmissions were being admitted to another local hospital or a larger regional tertiary care facility and not being captured as part of the original surgery program data.
No matter what approach we use, there must be a reasonable attempt by CMS and other payors to determine what are acceptable preventable and total readmission rates [2]. At this point in time, an “acceptable” rate might in fact increase as the entire bariatric community improves its capture of readmission data. We must also be conscious of rewarding a reduction of readmissions. Physician compensation methodologies will all drive certain behaviors, potentially resulting in some unintentional consequences. Could either penalizing readmissions or rewarding a reduction of readmissions actually encourage a healthcare system to prevent a recent postoperative bariatric patient from coming to the hospital when that is indeed the best treatment? I would like to think not, but this is indeed within the realm of possibility. An alternative to penalizing a readmission could be to reward the behaviors that, when employed, can reduce preventable readmissions. One possibility is to incentivize physician, bariatric program, and healthcare system behaviors that allow for the investigation of the root cause of each readmission with a goal of reviewing 100% of readmissions. In this manner, the program can classify the readmission as potentially preventable or nonpreventable. If preventable, the program can then determine if there were any missed opportunities to do better. This multidisciplinary approach should be relatively easy to undertake within the constructs of an MBSAQIP-accredited center of excellence program in bariatric surgery. Readmissions will only be able to be affected through the development of standardized criteria for the definition of
Predicting Preventable Hospital Readmissions / Surgery for Obesity and Related Diseases 11 (2015) 866–873
readmission, honest and accurate case reporting, and thoughtful retrospective analysis of each return to hospital. This has the potential to add important value to the care delivered, drive improvements in the patient experience, and better the outcomes of bariatric surgery.
873
Darren S. Tishler, M.D., F.A.C.S. Department of Surgery, Hartford Hospital, Hartford, Connecticut
References Appendix Supplementary data Supplementary data associated with this article can be found in the online version at doi:10.1016/j.soard.2015.01. 010.
[1] Patterson WL, Peoples BD, Gesten FC. Predicting Potentially Preventable Hospital Readmissions Following Bariatric Surgery. Surg Obes Relat Dis 2015;11(4):866–72. [2] “Health Policy Brief: Medicare Hospital Readmissions Reduction Program,” Health Affairs, November 12, 2013. http://healthaffairs. org/healthpolicybriefs/brief_pdfs/healthpolicybrief_102.pdf.
