The Lynx Group

Most Hospital Readmissions Not Preventable for Patients with Cancer

August 2014, Vol 5, No 6

Chicago, IL—Hospital readmissions in patients with cancer reflect the high burden of this disease, which is often refractory and, therefore, readmission is not reasonably preventable. Consequently, applying readmission penalties to this population, as is being done with noncancer index admissions, is not appropriate, said Andrew S. Epstein, MD, Division of Gastrointestinal Medical Oncology, Memorial Sloan Kettering Cancer Center (MSKCC), at the 2014 American Society of Clinical Oncology meeting.

“The vast majority of readmissions in this population do not represent lapses in care, judgment, or discharge management during the index admission and are not reasonably preventable,” he said.

In an effort to improve patient care and reduce costs, the Centers for Medicare & Medicaid Services has initiated the Hospital Readmissions Reduction Program. This currently applies to certain noncancer index admissions and defines readmission as an admission occurring within 30 days of a discharge. Reimbursement penalties are incurred for readmissions deemed preventable.

Readmissions for cancer are not included in the program, but there is concern among oncologists that these could soon be targeted. This study was conducted at MSKCC to determine whether readmissions for cancer may be reasonably preventable.

From a database of 876 patients with cancer who had been discharged and then readmitted between September 2008 and March 2013 within 30 days to the Gastrointestinal Oncology Service of MSKCC, Dr Epstein and colleagues randomly selected 50 cases. Two study authors manually reviewed each case to assess reasons for index admission and readmission, the nature of the index admission discharge plan, and whether the readmission was preventable.

“We were hypothesizing that our patients with this disease are so sick and vulnerable that the readmissions are not preventable,” Dr Epstein said.

“Preventable” was defined prestudy as a readmission that could probably have been avoided by either prolonging the index admission until a realistically attainable medical improvement had occurred, or by making agreed on practical changes in the index admission discharge plan.

Cases identified as potentially preventable readmissions were then critically reviewed by 3 study authors to reach a consensus.

Of the 50 cases, the most common diagnosis categories for either index admission or readmission were infection, pain, or gastrointestinal issues. The readmission diagnoses differed from index admission diagnoses in 64% of the cases.

In 5 cases, there was disagreement between the care team and the patient or family about the index admission discharge plan. Although the disagreements did not result in preventable readmissions, “it is an extremely important minority of patients to try to deliver care to in the future through…better communication about the risks, benefits, and alternatives of certain treatments or discharge plans,” acknowledged Dr Epstein.

Review of the records revealed the fragile health and/or refractory admitting diagnoses of all patients. Diagnoses may have improved or resolved and then recurred despite appropriate treatment, he indicated.

Only 1 readmission of the 50 cases was found to have been preventable. This readmission involved a patient who was discharged with a recommendation for an outpatient procedure that was not scheduled. The findings indicate that readmissions for patients with cancer are not reasonably preventable in the vast majority of cases. In this population, readmissions are common as a result of the devastating nature of the disease. “We hope that if cancer patients are ever considered for inclusion under this readmission reduction program, these data would refute the inclination to include them,” Dr Epstein said.

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