Authors: Emily Jane Woo
Publish Date: 2015/11/09
Volume: 474, Issue: 3, Pages: 848-849
Abstract
The author certifies that she or any member of her immediate family has no funding or commercial associations eg consultancies stock ownership equity interest patent/licensing arrangements etc that might pose a conflict of interest in connection with the submitted articleHealthcare quality can be difficult to measure and assess in ways that respect the expertise of individual physicians while simultaneously applying objective standards Hospital readmission during the first 30 days after orthopaedic surgery is discrete and quantifiable yet different definitions of what constitutes planned and unplanned readmission can result in different estimates of rates Evaluating the reasons for readmission may elucidate areas of need and identify opportunities for improvementThe authors of the current study reviewed hospital readmissions after orthopaedic operations at their institution Their analysis—which encompasses all orthopaedic subspecialties during a 2year period and includes both surgical and medical readmissions—adds to our knowledge Not surprisingly a patient’s baseline health status and the length of stay during the index hospitalization are each associated with an increased risk of readmission However other risk factors such as receiving treatment on the orthopaedic trauma service or being discharged to a skilled nursing facility are not as obvious Even if risk factors cannot be modified their presence can alert clinicians to the elevated risk of readmission and prompt closer followup such as an outpatient appointment within 48 hours of discharge Moreover poor agreement among clinical institutions hospitals and Medicare regarding the definition of planned readmission reveals important differences in the way that patient services are classified and prioritizedA policy aimed at merely reducing readmissions—without understanding the reasons and risk factors—could compromise patient safety Financial penalties such as denial of payment for a readmission that an insurer deems unnecessary and administrative penalties such as inclusion on a list of providers who have aboveaverage rates of readmission—might lead some physicians to try to manage complications on an outpatient basis even when clinical judgment indicates that the patient needs to be admitted Some surgeons might hesitate to operate on patients with complex orthopaedic conditions and those with multiple medical comorbidities Therefore while the reduction of readmissions is important it is equally crucial to ensure that the question is approached sensibly and appropriately Furthermore the discrepancies among clinical hospital and Medicare definitions of planned readmission suggest that physicians administrators and insurers need to evaluate key components of postoperative management and identify areas of disagreement By unifying their efforts these stakeholders can collaborate in order to attain a common objective improving patient care while containing costsThis topic deserves further research and additional risk factors should be examined First as the authors acknowledge admissions to other facilities were not captured If a substantial percentage of patients reside more than an hour from the index hospital and seek emergency care at a different facility then the number of unplanned admissions may be underestimated Second the total operative time might have predictive value in terms of surgical factors such as the complexity of the procedure and the severity of the underlying condition as well as medical factors such as possible effects of prolonged anesthesia on pulmonary and hemodynamic function during the early postoperative period Third the involvement of attending physicians should be assessed At the institution of Bernatz et al all patients are seen by an attending physician every day during the entire hospitalization However at some teaching facilities orthopaedic inpatients have no contact with any attending physician and are managed by unsupervised junior residents Ensuring that faculty physicians are physically present and personally involved in patient management might reduce the risk of readmission and other poor outcomes Fourth for the more challenging subpopulations—such as trauma patients and individuals who will be discharged to skilled nursing facilities—additional analyses should focus on the range and intensity of services that they needTreating numbers is easy treating people requires thought and planning Simply reducing readmissions could be literally fatal Understanding the reasons for rehospitalization is an important first step The different perspectives of clinicians policymakers and insurers could be an asset with their combined experience and complementary strengths these stakeholders can together develop an integrated approach to improve healthcare quality and patient safety
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