Hospital readmission as a quality measure in surgery.

Abstract

The debate aboutwhether hospital readmissions should be used to measure quality is escalating. The renewed interest in this topic comes fromthe recognition that reducing readmissions is a rare example of the elusive goal of simultaneously improving quality and reducingcosts. TheCenters forMedicare&MedicaidServices (CMS) recentlygavereadmissionmeasures increased importanceby implementing substantial financial penalties through the Hospital Readmissions Reduction Program (HRRP). The HRRP began assessing penaltiesofupto3%ofahospital’s totalMedicarepayments forhospitalswithhigher-than-expected risk-adjusted readmission rates for commonmedical conditions, acutemyocardial infarction, pneumonia, and congestive heart failure.1 Whether hospital readmissions are a good measure of quality for these medical conditions is hotly debated. Many argue against using them because readmissions are not correlated with known quality metrics, such as mortality, volume, or process compliance. Others are concerned that readmissions have more to do with the financial and social resources of the patient than theydowith quality of care.1 Proponents argue that readmissions are not correlated with existing quality metrics because they represent a unique domain of quality—coordination of care. In other words, readmission servesasaproxy forhowwell thehospitalpreparespatients for transitioning from one setting to another. With CMS set to expand these penalties to surgical procedures in 2015, a similar argument has arisen in surgery.2 Many have criticized the use of readmissions in surgical populations, but these criticisms are largely based on the same arguments against using readmissions as quality metrics for medical conditions.2 However, there is emerging evidence that medical and surgical readmissions should be considered separately because they may have different root causes. ArecentstudybyMorrisetal3 inJAMASurgerysupports theview that hospital readmissions may indeed be a valid measure of hospital quality in surgery. Likemanyprior studies, the authors showed that patients who experienced a postoperative complication were at higher risk for readmission.4 Importantly, however, the investigatorswere able to study the timingof the complication. The investigators found that 72% of complications occurred prior to disJAMASURGERY