New findings presented at the 2009 Clinical Congress of the American College of Surgeons have revealed that readmission to a hospital after standard surgical treatment for colon cancer is far more common than suspected for elderly patients.
Results from the first study to determine nationwide readmission rates following colectomy [surgical removal of malignant disease and part of the colon] in the Medicare population revealed that nearly one in nine patients over the age of 65 was readmitted within 30 days.
The study also showed that readmission was strongly linked with mortality. Sixteen per-cent of the patients who were readmitted died within a year compared with only seven percent of patients who were not readmitted died. "We cannot say that because these patients were readmit-ted therefore they have higher rates of death. But we can say there is a remarkably strong associ-ation between readmission and mortality that deserves further study," according to David Yu Greenblatt, MD, MSPH, a resident in general surgery at the University of Wisconsin, Madison.
The study departed from the typical outcome analysis of surgical care, which examines such factors as immediate postoperative outcomes, overall mortality, or cancer-free survival. "Most surgeons have tended to think that readmission is not a terribly serious outcome. They treat the patient for whatever circumstance caused readmission and send them home. In recent years, as researchers have focused on health care costs, readmissions have generated more interest," Dr. Greenblatt explained. The Centers for Medicare and Medicaid is, in fact, requiring hospitals to track readmission rates for a number of medical conditions, such as congestive heart failure and pneumonia.
In an attempt to begin to shed light on postoperative readmissions, Dr. Greenblatt and his colleagues targeted the largest population of surgical patients and the most widely performed general surgical procedure. Colon cancer is the third most common cancer diagnosis and the third leading cause of mortality in the United States. "Colectomy is not an extremely chal-lenging operation that should be done only in specialized academic centers. It is an operation that is done all over the country in community hospitals by surgeons in private practice as well as in big academic medical centers. So we''re not talking about a few hundred patients per year. We''re talking about thousands of patients every year who are undergoing this operation and then being readmitted for one reason or another. Any impact we can make on reducing the readmission rate of this population would translate into real benefits in terms of expenditures and positive patient outcomes," he explained.
The study included 42,375 Medicare beneficiaries who underwent colectomy for stage I to III colon cancer between 1992 and 2002. A total of 4,662 patients were readmitted within 30 days, usually for ileus [temporary interruption of intestinal function after abdominal surgery], bowel obstruction, or infection. "The causes of readmission seem to be due to consequences
of surgical care that we know from other research are modifiable. So we are not observing a phenomenon that we can''t do anything about. We have identified a real problem and provided some preliminary information that hopefully we and other researchers can use to develop inter-ventions that will decrease the rate of readmission and translate into better outcomes, such as improved survival," said Dr. Greenblatt.
Initial efforts could be directed at the most common reasons for readmission identified in the study, which are clinical conditions that can be prevented. "Various authors and investi-gators have looked at readmissions in patient populations and tried to develop interventions to decrease them. Up until now, all of those efforts have been based on older literature from single institutions that have not been able to find out what happens to patients if they are admitted later to another institution. The data in our study allowed us to follow the same individual patients as they went from one hospital to another. So we could begin to get the big picture from a national level data source and identify the variables to focus attention on. Our results hopefully will provide valuable information in the ongoing effort to develop processes of care that can reduce the problems that lead to readmission," Dr. Greenblatt said.
Maureen A. Smith, MD, MPH, PhD; Erin S. O''Connor, MD; Noelle K. LoConte, MD; Jinn-Ing Liou, MS, MBA; and Sharon M. Weber, MD, FACS, participated in the study.