Experts warn against readmissions as sole quality measure in ovarian cancer
NATIONAL HARBOR, MD. – For patients with ovarian cancer, focusing solely on hospital readmission rates as a quality measure might worsen long-term outcomes while unfairly penalizing the best hospitals, suggest the results of two analyses of the National Cancer Database presented at the annual meeting of the Society of Gynecologic Oncology.
Hospitals with the highest ovarian cancer caseloads had the best rates of overall survival and postsurgical mortality, but also had the highest rates of readmission within 30 days after postsurgical discharge, reported Shitanshu Uppal, MBBS, of the obstetrics and gynecology department at the University of Michigan in Ann Arbor.
A separate analysis linked neoadjuvant chemotherapy with significantly fewer readmissions, but also with significantly worse overall survival compared with primary debulking surgery, reported Emma L. Barber, MD, of the University of North Carolina at Chapel Hill.
“Policies that prioritize decreased readmission rates inherently encourage neoadjuvant chemotherapy over primary debulking surgery,” Dr. Barber stressed. She recommended that policies and incentive programs incorporate both short- and long-term outcomes for patients with ovarian cancer.
Thirty-day hospital readmissions cost Medicare $17.4 billion in 2004 alone, noted Dr. Uppal. Research shows that almost one in seven patients is readmitted to the hospital within 30 days of discharge after major surgery, and that high-volume hospitals with low surgical mortality rates have lower surgical readmission rates than other hospitals do (N Engl J Med. 2013;369:1134-42).
Accordingly, the Centers for Medicare and Medicaid Services limits reimbursements if hospitals exceed 30-day readmission thresholds after surgeries for certain conditions, including acute myocardial infarction, heart failure, pneumonia, chronic obstructive pulmonary disease, coronary artery disease, and total hip and total knee arthroplasty. For now, these procedures do not include primary or interval debulking, but hospitals do monitor readmission rates, in general, as part of the Hospital Readmission Reduction Program, Dr. Barber noted.
Studies of ovarian cancer have shown postsurgical readmission rates of 10%-20%, Dr. Uppal said. To evaluate readmissions as a quality metric in this setting, he and his associates identified patients diagnosed with stage III or stage IV high-grade serous carcinoma between 2004 and 2013 who underwent cytoreductive surgery as primary treatment. More than 44,000 patients meeting these criteria were treated at hospitals that handled anywhere from under 10 to more than 30 cases annually.
The overall rate of unplanned readmissions was 6.2% (95% confidence interval, 5.2%-6.4%), and patients resembled each other clinically and demographically, irrespective of hospital caseload, Dr. Uppal said. After adjustment for other risk factors for readmission, including higher-stage disease, hospitals that treated more than 30 cases of ovarian cancer per year had significantly higher 30-day readmission rates than did the lowest-volume hospitals – nearly 10%, compared with about 7.5% (adjusted odd ratio, 1.25; 95% CI, 1.1-1.5; P less than .05). However, high-volume hospitals had the lowest 30-day and 90-day mortality rates (P less than .05), the highest rate of 5-year overall survival (adjusted hazard ratio, 0.83; 95% CI, 0.78-0.88; P less than .05), and a significantly higher frequency of adherence to NCCN guidelines compared with low-volume hospitals.
“Not all readmissions reflect a failed discharge,” Dr. Uppal emphasized. “Certain readmissions may be appropriate and necessary, and some surgeries merit appropriate aggression and result in a high readmission rate.”
The study by Dr. Barber included data from nearly 27,000 patients who underwent chemotherapy and surgery for stage IIIC epithelial ovarian cancer at Commission on Cancer–accredited institutions between 2006 and 2012. The overall 30-day readmission rate was 11%, and 57% of readmissions were unplanned. About 16% of patients received neoadjuvant chemotherapy followed by interval debulking surgery, and the rest underwent primary debulking surgery, Dr. Barber said.
Rates of 30-day readmissions were 6.5% after neoadjuvant chemotherapy with interval debulking, compared with 12% after primary debulking. Neoadjuvant chemotherapy was associated with a 48% drop in the risk of readmission and with a 37% decrease in the chances of unplanned readmission after the researchers controlled for age, race, insurance status, comorbidities, and histology, Dr. Barber said. However, primary debulking significantly increased the chances of survival at next follow-up (HR, 1.36; 95% CI, 1.29-1.42; P less than .001). Median overall survival was 47 months with primary debulking surgery and 37 months with neoadjuvant chemotherapy (P less than .001).
These findings show how broad health policies that are not designed for specific patient subgroups can create unique, unintended, and undesirable incentives and consequences, Dr. Barber said. Unfairly penalizing high-volume hospitals by concentrating solely on readmissions, rather than taking a more holistic view of cancer care, could inadvertently encourage the use of less aggressive debulking surgeries and increase the use of neoadjuvant therapies in cases where primary debulking is more appropriate, Dr. Uppal added.
Dr. Barber and Dr. Uppal acknowledged no external funding sources and reported having no conflicts of interest.