Patients with ovarian cancer who were treated at the highest volume centers had superior overall survival but also higher readmission rates compared with lower volume hospitals, casting doubt on the value of this measure for patients with cancer.
Explaining the findings, lead investigator Shitanshu Uppal, MBBS, from the University of Michigan, noted that "certain readmissions are appropriate and necessary. Certain surgeries need 'appropriate aggression' and result in a high readmission rate. 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.”
Medicare estimated that readmissions within the first 30 days after discharge were responsible for $17.4 billion in costs in 2004, making it a major concern for health care delivery. In general, 30-day readmission rates vary across the country, with the highest rates (20.2% to 23.2%) seen on the East coast and in the Mid-West.
To address this, many hospitals put readmission prevention programs in place to avoid fees under the Hospital Readmissions Reduction Program that was created by the Affordable Care Act. Although this program had good intentions, it could lead to the use of less aggressive and by consequence less effective procedures, Uppal noted.
“Readmission rates might be a valid measure of quality for certain surgeries, where higher readmission rate reflects a higher complication rate,” he said. “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."
Readmission rates after a major cancer surgery were generally in the 10% to 15% range for patients of all ages; however, when looking at those ≥65 years, the 30- to 90-day readmission rate jumps to 20% to 50%. In ovarian cancer specifically, the rates across all ages were 10% to 20%, Uppal noted.
Independent predictors of disease-specific survival in ovarian cancer include hospital and physician volume and the ability to effectively cytoreduce. In general, the best outcomes are seen at hospitals with ≥20 ovarian cancer surgeries per year and with physicians who see ≥10 patients per year (P <.0001).
To look at readmissions, the study explored data from the National Cancer Database. The analysis included 44,079 patients who were diagnosed with stage III or IV high-grade serous carcinoma between 2004 and 2013. All patients were undergoing cytoreductive surgery. Risk was adjusted using several sociodemographic and treatment factors.
Most patients (40.44%) were treated at institutions that had ≤10 cases per year. These patients were distributed across 875 hospitals. There were 13 hospitals that saw ≥31 cases per year (10.46% of patients). Overall, 127 hospitals fell into the 11 to 20 cases/year range (35.64% of patients) and 29 saw 21 to 30 cases/year (13.46% of patients).
The 30-day mortality rate was near 2% across all centers, with a slightly lower rate at hospitals with ≥31 cases/year. Similar findings were seen for 90-day mortality rates, at nearly 5.5% for all, except for the ≥31 cases/year centers, which was near 4.5%.
Partially explaining this trend, Uppal noted that treatment that was adherent to the NCCN guidelines was highest in the ≥31 cases/year hospitals. The adherence rates were 78%, 78%, 80%, and 85%, in the ≤10, 11-20, 21-30, and ≥30 cases/year hospitals, respectively.
In contrast with these numbers, however, readmission rates were highest in the hospitals with ≥31 cases/year. The 30-day readmission rate at the ≥31 cases/year hospital was 10% compared with 7% in the ≤10 cases/year group and 8% in the 11 to 20 and 21 to 30 cases/year hospitals.
Uppal noted that many of the cases examined did not contain quality of life measures or patient-reported outcomes. Moreover, it was difficult to determine from the dataset if all readmissions represented a "failed discharge" or simply a necessary step. In ovarian cancer specifically, he noted, readmission rates may not tell the full story.
“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,” said Uppal.
Uppal S. Hospital Readmission as a Quality Measure in Ovarian Cancer Surgery. Presented at: The Society of Gynecologic Oncology Annual Meeting on Women’s Cancer; National Harbor, Maryland; March 12-15, 2017.