There is an ongoing push to reduce readmission rates in an effort to lower costs and improve quality of care; however, research studies presented at the Society of Gynecologic Oncology's (SGO) 2017 Annual Meeting on Women's Cancer call into question the use of this metric in ovarian cancer surgical procedures.
According to this new data, utilizing readmission rate as a metric of quality of care in ovarian cancer surgeries focuses on short-term outcomes and is not an accurate measure of patient survival long-term.
“Readmission rates might be a valid measure of quality for certain surgeries, where higher readmission rate reflects a higher complication rate,” noted Shitanshu Uppal, MBBS, from the University of Michigan, and author of one of the studies, in a statement. “However, in cancer surgeries, ‘quality of care’ is not only defined by 30-day outcomes, but also by the impact of an appropriate surgery on the patient's overall survival. Sometimes a higher readmission rate after an aggressive surgery to remove all the tumor from the abdomen, which we know translates into a better survival, is worth it.”
Created to discourage repeated hospitalizations among patients with chronic conditions, the 30-day readmission metric is focused on encouraging hospitals to improve their post-acute transition of care and care coordination, according to SGO. Readmission rates have since been integrated into surgical procedures and are now a measure of quality of care in several hospital ranking systems.
The Hospital Readmission Reduction Program (HRRP) was implemented as a part of the Affordable Care Act and allows the CMS to penalize hospitals up to 3 percent of their total reimbursement if a hospital has a high readmission rate compared to similar hospitals.
While the HRRP does not currently include oncologic surgery, given the early success of the program, its expansion to include such procedures is likely to occur, Uppal's team noted. In turn, Uppal cautioned that this penalty has the potential to create a situation where surgeons are pressured to reduce readmission rates, and consequently they adopt procedures that are less aggressive but have a lower readmission rate.
Short- vs. Long-Term
Abstracts 6 & 25
Research conducted by Emma Barber, MD, MS, gynecologic oncologist, and her team at the University of North Carolina at Chapel Hill, sought to “determine the association between primary treatment with neoadjuvant chemotherapy (NACT) or debulking surgery and readmission after surgical hospitalization among stage IIIC epithelial ovarian cancer patients, as well as the association between primary treatment and survival in the same cohort” (Abstract 25).
“As surgeons and gynecologic oncologists, we noticed that many of the quality metrics that are collected about hospitals and providers focus on short-term outcomes,” Barber told Oncology Times. “In oncology, we are always concerned about long-term outcomes such as survival. We were interested if long-term and short-term outcomes were aligned for patients with ovarian cancer receiving surgery.”
Barber and her team identified and examined 26,595 patients with stage IIC epithelial ovarian cancer treated with both chemotherapy and surgery in the National Cancer Database from 2006-2021. Patients included in the study underwent surgery at the facility reporting to the National Cancer Database. “Readmission was defined as readmission to the reporting facility within 30 days of surgery,” according to study authors. “Readmissions were categorized as planned or unplanned per the database.”
“We determined the association between primary treatment with either debulking surgery followed by chemotherapy or neoadjuvant chemotherapy followed by debulking surgery and two outcomes: a short-term outcome of hospital readmission and a long-term outcome of overall survival,” Barber explained.
Of the patients identified by investigators, 15.5 percent (n=4,172) were treated with NACT and 11.3 percent (n=3,052) were readmitted to the same hospital within 30 days of surgery; 57 percent (n=1,742) were unplanned.
Researchers reported that “NACT was associated with a 37 percent reduction in the risk of unplanned readmission (RR 0.63, 95% CI 0.54-0.74) and a 48 percent reduction in the risk of any readmission (RR 0.52, 95% CI 0.46-0.59) compared to primary debulking surgery with adjustment for age, race, insurance, Charlson comorbidity score, and histology.”
“We found that patients who underwent neoadjuvant chemotherapy experienced approximately one-half the rate of 30-day hospital readmission compared with patients who underwent primary debulking surgery,” Barber said. “However, we also found that those patients who received neoadjuvant chemotherapy had inferior survival with a 36 percent increased rate of death.”
Barber noted the study's observational design is a limitation due to the possibility of subject bias. “Patients who receive neoadjuvant chemotherapy differ from those that receive primary debulking surgery in ways that cannot always be measured and adjusted for,” she explained.
Surgical Quality Measures
Understanding the complexity of oncologic procedures, where higher initial morbidity could lead to higher readmission rates, Uppal and his team sought to examine readmission rate as a quality measure in ovarian cancer surgery (Abstract 6).
Analyzing data from the National Cancer Database, researchers identified 36,674 patients with stage III or IV serous ovarian carcinoma undergoing primary debulking surgery between 2004 and 2012.
“We then calculated annualized hospital volume and divided the hospitals into four categories (≤10, 11-20, 21-30, and ≥31 cases/year),” authors wrote. “Case-mix adjustment was done for patient factors (age, race, income, Charlson comorbidity index, and insurance status), tumor factors (stage and grade of disease), and treatment factors (facility type and year of diagnosis).”
Additionally, the team calculated risk-adjusted rates of 30-day readmission, 90-day mortality, rate of adherence to National Comprehensive Cancer Network (NCCN) guidelines, and 5-year overall survival for each hospital.
Findings determined that “hospitals with ≥31 cases/year had the highest risk-adjusted readmission rate. However, these hospitals had significantly lower risk-adjusted 90-day mortality, higher adherence to NCCN guidelines, as well as higher 5-year overall survival rates.”
The authors concluded that while the hospitals with the highest number of ovarian cancer cases achieved higher overall survival and lower 90-day mortality, they could still be “unfairly penalized under the HRRP if 30-day readmission rates are the singular metric by which surgical quality is measured in this patient population.”
Looking to the future, researchers from both studies recognize the importance of ensuring that a focus on readmissions rates does not overshadow the importance of long-term survival outcomes for patients with ovarian cancer.
“What started off as a good intention where we wanted to see what the outcomes were and how we are impacting our patients' lives for better has changed to a metric of ranking and penalizing hospitals,” Uppal noted in statement. “Extending life in the context of a deadly disease like ovarian cancer is important, but a real measure of quality will be the ability to answer the question whether we enabled our patients to achieve their goals or not.”
“For women with ovarian cancer, short-term surgical quality metrics, such as 30-day hospital readmission, may not be aligned with long-term goals such as improved overall survival,” Barber concluded. “Quality metrics for patients with ovarian cancer should be developed to include both short- and long-term outcomes to ensure that we are not incentivizing decreased short-term morbidity at the expense of long-term survival.”
Catlin Nalley is associate editor.
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