September 2014, Vol 3, No 6

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Are Hospital Readmissions for Cancer Patients Preventable?

Andrew S. Epstein, MD


Hospital readmissions in cancer patients reflect the high burden of this disease, which is often refractory, and therefore are not reasonably preventable. Consequently, applying readmission penalties to this population, as is being done with noncancer index admissions, is not appropriate, says Andrew S. Epstein, MD.

“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.

The Centers for Medicare and Medicaid Services, in an effort to improve patient care and reduce costs, has initiated the Hospital Readmission 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 that are deemed preventable.

Cancer readmissions are presently not included in the program, but there is concern among oncologists that these could soon be targeted. Because they have not been extensively evaluated, a study was conducted at Memorial Sloan Kettering Cancer Center (MSKCC), New York City, to determine whether or not cancer readmissions might be reasonably preventable.

From a database of 876 cancer patients who had been discharged and then readmitted within 30 days to the Gastrointestinal Oncology Service of MSKCC, Epstein and colleagues randomly selected 50 cases. The admissions occurred between September 2008 and March 2013. Two study authors manually reviewed each case to assess reasons for index admission and readmission, 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,” he said.

“Preventable” was defined prestudy as a readmission that could probably have been avoided by either:

  1. Prolonging the index admission until a realistically attainable medical improvement had occurred, or
  2. Making agreed upon, practical changes in the index admission discharge plan

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

Of the 50 cases, the most common diagnosis categories for either index admission or readmission were infection, pain, or GI issues. 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/family about the index admission discharge plan. While this disagreement 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 Epstein, assistant attending physician, Division of Gastrointestinal Medical Oncology, Department of Medicine at MSKCC.

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 cancer patients are not reasonably preventable in the vast majority of cases. In this population, readmissions are common due to 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,” he said.

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