Saturday, June 8, 2013

The importance of the patient in quality of outcome, the second P.

Risk Factors for Readmission of Orthopaedic Surgical Patients

As we've been pointing out in recent posts, the outcome of treatment depends on the 4 Ps: the problem, the patient, the provider and the procedure. This study does an excellent job of emphasizing the importance of the patient in determining one of the often measured and important indicators of quality of care: readmission rate. In any 'pay for performance' system, practices associated with lower rates of readmission are likely to be rewarded. A prior study (Jencks et al. in 2009) showed a national rate of thirty-day readmission among Medicare beneficiaries of 19.6%, with an estimated cost of $17.4 billion.

They addressed two questions: What is the incidence of thirty-day readmission for orthopaedic patients and what are the risk factors for readmission? Their study was based on over 3000 orthopaedic surgical admissions to an academic medical center during a two year interval. 73.9% of the readmissions were classified as surgical; of these, thirty-five readmission events (34.3%) were for infection at the surgical site, 14% were for septic arthroplasty, and another 1% for septic arthritis.

They found an unplanned thirty-day readmission rate of 4.2%. Multivariate analysis indicated readmission rate was associated with :

*marital status of ‘‘widowed’’  (OR, 1.846; 95% confidence interval [CI], 1.070 to 3.184; p = 0.03), *African American race (OR, 2.178; 95% CI, 1.077 to 4.408; p = 0.03),  
*American Indian or Alaskan Native race (OR, 3.550; 95% CI, 1.429 to 8.815; p = 0.006)
*Medicaid insurance (OR 1.547; 95% CI, 0.941 to 2.545; p = 0.09) 
*Any intensive care unit stay (OR, 2.356; 95% CI, 1.361 to 4.079; p = 0.002) 
*Longer length of stay ( 5.9 days in the unplanned readmission group compared with 3.6 days for non-readmitted patients (OR, 1.038; 95% CI, 1.014 to 1.062; p = 0.002)). 

As we've pointed out previously, the problem is that patients with these risk factors may be selected against by providers and medical centers concerned about readmission as a metric for quality of care.
As the authors state: "Without sufficient risk adjustment, a medical center that cares for the sicker population is almost ensured to receive poorer “quality” grades and financial penalties. Patients with socioeconomic risk factors for readmission present similar concerns. Without sufficient risk adjustment in these sicker and/or socioeconomically challenged populations, a potential undesired consequence could be selection against these populations for care. Subsequently, these populations may find new difficulties in accessing providers."

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