Faced with increasing pressure to reduce hospital admissions and readmissions, oncologists across the country are investigating why their patients are hospitalized and how hospital use can be minimized.
In North Carolina, for example, radiation oncologists have found that nearly one-fifth of their patients have unanticipated admissions, and now they want to figure out how to reduce that level.
In Pennsylvania, physicians are learning why readmitted cancer patients think they were unable to make a successful transition from hospital to home.
And in Texas, researchers are studying how hospital readmissions should be measured and understood.
These and other projects presented at the American Society of Clinical Oncology's Quality Care Symposium spring from the recognition that payers and policymakers increasingly equate hospital admissions with failed outpatient care. So far, the focus has been primarily on a handful of specialties other than oncology and hematology. But it is only a matter of time until oncologists are evaluated—and paid—in relation to their patients' use of hospital beds.
That is why Ronald Walters, MD, Associate Vice President of Clinical Operations at The University of Texas MD Anderson Cancer Center, encourages oncologists to help determine the difference between appropriate and inappropriate hospital use.
“It's amazing how many doctors don't think there's anything they can do about this,” he said. “Either it's going to happen to you, or you are going to be a part of the process. And it's much better to be part of the process.”
The attempt to reduce hospital use is part of a gargantuan effort to replace America's hospital-centric acute-care system with an outpatient-centered prevention-oriented one.
Under the payment system in place for the last several decades, hospitals have been paid to keep their beds full. Recognizing the perverse financial incentives at play, public and private payers started nudging hospitals nearly a decade ago to take responsibility for helping their newly discharged patients avoid a return trip to an inpatient bed. The thinking is that many readmissions are preventable if patients have medicine, follow-up appointments, and support needed to recuperate at home.
‘Nudge Became a Shove’
Last October that nudge became a shove when the Medicare program began levying financial penalties against hospitals that have high readmission rates. More than 2,000 hospitals are currently being penalized with a reduction in Medicare payments for every patient they treat during the entire fiscal year.
In the first year of the government's Readmission Reduction Program, the Medicare program is looking at 30-day readmission rates for three conditions: heart attack, heart failure, and pneumonia—and the maximum penalty is a one percent reduction in pay. But the magnitude of the penalties will grow to three percent by fiscal year 2015, and the number of conditions that Medicare considers will also increase.
Because of the complexity of cancer care, Medicare will probably not target oncology readmissions in the immediate future. But other forces are also bringing attention to bear on hospital use. Hundreds of accountable care organizations have recently signed contracts with the Medicare program or private payers that incentivize physicians to provide care as inexpensively as possible while still meeting certain quality criteria. Meanwhile, as oncology practices adopt the medical home model, they will be offered contracts that reward them for limiting hospital visits whenever possible (OT, 12/10/12).
“One of the most expensive costs for a cancer patient is hospitalizations,” said Lee N. Newcomer, MD, UnitedHealthcare's Senior Vice President of Oncology Services. “We all focus on drugs, but in point of fact, drugs are only about 26 percent of the costs of taking care of a cancer patient and hospital care is about 53 percent.”
Readmission Rates in Radiation Oncology
At the University of North Carolina at Chapel Hill, researchers sought to understand which radiation oncology patients are at high risk of being hospitalized during or shortly after completing treatment, and why.
“The motivation was to see if we can look at our own experience to identify a patient who was especially vulnerable to not handling treatment well and needing admission,” said Ronald C. Chen, MD, MPH, a radiation oncologist at the UNC Lineberger Comprehensive Cancer Center “Then, potentially as a next step, we may be able to identify such patients early and help provide supportive services to help these patients get through treatment better.”
In the study he reported, he and his colleagues reviewed the electronic medical records of all 1,114 patients who had radiation therapy in 2010 to see how many had unanticipated admissions within 90 days of their first treatment. The result—that 19 percent of patients were admitted—was a surprise, Chen said.
“I would have thought that it was much lower. This is an issue that we need to pay attention to as a cancer community.”
The most common reasons for admissions were pain (19% of admissions), gastrointestinal toxicity (18%), and respiratory distress (15%). Certain categories of patients were at a higher risk of being admitted to the hospital than others:
- 30 percent of patients treated with palliative intent were admitted vs. 14 percent of patients treated with curative intent;
- 23 percent of patients receiving concurrent chemotherapy were hospitalized, compared with 18 percent of patients with radiotherapy alone;
- 37 percent of patients who had a recent admission before starting radiation were readmitted; and
- Patients on their second or third course of radiation had higher admission rates than those on their first course.
The findings underscore the importance of making nutrition services, pain management, and other support services available to patients early in their treatment, Chen said. “This presents an opportunity for us in the oncology community to identify patients who are at risk for not tolerating treatment well and to think about using supportive services more frequently and earlier in this patient population.”
What Patients Think
Reducing unnecessary 30-day readmissions is one of the overarching goals of the University of Pennsylvania Health System's Blueprint for Quality, and oncology patients account for at least 25 percent of readmissions. That is why Tracey L. Evans, MD, a medical oncologist at the Abramson Cancer Center, teamed with internist Shreya Kangovi, MD, who is researching potentially avoidable readmissions, to learn what brings oncology patients back to a hospital bed.
As part of a larger survey of patients readmitted to the hospital within 30 days of a discharge, 197 oncology patients were surveyed to see why the patients thought they needed to return. More than 45 percent of readmitted oncology patients cited challenges during the transition from hospital to home, including difficulty with activities of daily living, such as eating and dressing; feeling that they were unprepared for discharge; and difficulty complying with prescribed medications.
Those findings suggest that oncologists must consider the patient's post-discharge care as closely as they consider inpatient treatment, Kangovi said. “As oncologists, we might think that we made patients better from whatever they came into the hospital with, but the fact is that a lot of these patients are not able to function well at home and they just end up coming right back in.”
To help patients succeed at home, the University of Pennsylvania started a quality improvement project to increase the likelihood that patients have a follow-up appointment with their physician within seven days of discharge. Unit secretaries are responsible for contacting the physician's office to schedule the appointment; Evans said 60 percent of patients now have appointments within seven days, up from 25 percent when the project started.
Another finding from the survey: Uninsured and Medicaid patients were significantly more likely than others to attribute their readmission to factors other than deteriorating health. For example, they were five times more likely to cite difficulty obtaining medications. “Could we help these patients get their medications at the time they are discharged?” Kangovi asked. “Without that, it does make sense that many of them are going to end up right back in the hospital.”
What Does ‘Good’ Look Like?
As the health care industry puts hospital use under a microscope, one measure—the 30-day all-cause readmission rate—is emerging as a way to evaluate the quality of care. When it comes to oncology and hematology patients, Walters, an MD Anderson Associate Vice President, wants to stop that thinking in its tracks.
Walters, who participates in quality-measurement initiatives by the Centers for Medicare & Medicaid Services and the National Quality Forum, and his colleagues analyzed 52,097 oncology admissions at MD Anderson over a two-year period. Nearly 33 percent of patients were readmitted within 30 days of a discharge.
While that is a high readmission rate compared with national averages—the University Health Consortium, a large group of academic medical centers and their affiliated hospitals, reports 15 percent—it reflects MD Anderson's patient population. A full 46 percent of the MD Anderson readmissions were leukemia, lymphoma, and stem cell patients who, by virtue of their illness and treatment, are prone to neutropenic admissions; another 42 percent of patients were readmitted for planned chemotherapy or immunotherapy.
Indeed, the researchers categorized only 3.6 percent of the readmissions as “preventable, unexpected, and unplanned.” Thus, they concluded that a 30-day all-cause readmission rate is not an appropriate indicator of the quality of care delivered to cancer patients at an academic cancer hospital.
That finding makes the point that the quality and efficiency measures must be carefully developed and used appropriately, Walters said. But it does not make the point that readmission rates are irrelevant as a quality measure.
“There's no such thing as a perfect measure, but you still have to have measures, and you have to have a way to compare people the best you can,” he said. “It doesn't do any good to sit on the sideline and complain about being scored on readmissions. We must try to influence that from the beginning to make sure we find the best possible readmission measure.”