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Society of Gynecologic Oncology
Foundation for Women’s Cancer
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Hospital readmission metrics are not an ideal measure in ovarian cancer cases
Surgeons should focus on long-term outcomes
National Harbor, MD (March 12, 2017) – To reduce costs and improve quality of care, the Centers for Medicaid and Medicare Services (CMS) has made reducing readmission rates a priority, yet research studies presented today at the Society of Gynecologic Oncology’s 2017 Annual Meeting for Women’s Cancer question the use of the metric in surgeries performed in patients with ovarian cancer. The presentations find that readmission rate as a metric of quality of care in ovarian cancer surgeries focuses on short-term outcomes but is not an ideal measure of patient survival in the long run.
Two separate studies presented by lead researchers, Shitanshu Uppal, MBBS, and Emma Barber, MD, MS, SGO Members and gynecologic oncologists, focus on how certain surgeries may lead to high readmission rates for ovarian cancer patients, but these procedures likely benefit patients in the long-term as reflected by an overall increase in survival rates.
Historically, the 30-day readmission metric was created to discourage repeated hospitalizations in patients with chronic medical conditions. These actions were largely focused on encouraging hospitals to improve their post-acute transition of care and care coordination. Over time, readmission rates have made their way in the surgical world and are now a measure of quality of care in several hospital ranking systems.
“Readmission rates might be a valid measure of quality for certain surgeries, where higher readmission rate reflects a higher complication rate,” said Dr. Uppal from the University of Michigan. “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. 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.”
The Affordable Care Act (ACA) created the Hospital Readmission Reduction Program to allow the CMS to penalize hospitals up to 3 percent of their total reimbursement if a hospital has a high readmission rate compared to similar hospitals. However, this penalty has the potential to create a situation where surgeons are pressured to reduce readmission rates, and consequently they adopt procedures which are less aggressive but have a lower readmission rate, Dr. Uppal said.
For example, in research conducted by Dr. Barber and her research team at the University of North Carolina at Chapel Hill, women who received chemotherapy prior to surgery (neoadjuvant chemotherapy) instead of surgery followed by chemotherapy (primary debulking) as initial treatment, had a 36 percent increased rate of death, yet they had half the rate of readmission. In contrast, those who received the surgery first had a higher survival rate, but also a higher readmission rate.
“These overarching policies are going to incentivize gynecologic oncologists to do more chemotherapy before surgery (neoadjuvant chemotherapy),” said Dr. Barber, “This is an example where a well-meaning policy for the broad population has unintended consequences for the smaller ovarian cancer community.” Hospitals are likely to incentivize patterns of care, such as neoadjuvant chemotherapy, that decrease readmission rates, yet these care patterns do not always lead to a better survival rate for ovarian cancer patients.
In Dr. Uppal’s research, his team analyzed data from the National Cancer Database (NCDB) and focused on women diagnosed between 2004 and 2013 with high-grade serous ovarian carcinoma. The team divided the hospitals into four categories based on their annual case volumes and compared the 30-day readmission rate to other measures of quality of care.
They found, in ovarian cancer surgery, hospitals with the highest volume of cases (surgeries) per year more often delivered care consistent with national guidelines and achieved higher overall survival. But these same hospitals, had a higher readmission rate compared to those hospitals treating ovarian cancer patients rarely.
Both of these studies highlight that hospital readmission rates are only short-term outcomes, and in both, readmission rates were not reflective of the most important metrics in cancer care, long-term survival.
“What started off as a good intention where we wanted to see what the outcomes were and how we are impacting our patients’ lives for better has changed to a metric of ranking and penalizing hospitals,” Uppal said.
For Uppal, the more meaningful outcome is patient-reported outcomes merged with overall survival. The current studies do not have these metrics.
“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,” he said.
The Society of Gynecologic Oncology (SGO) is a 501(c) (6) national medical specialty organization of physicians and allied health care professionals who are trained in the comprehensive management of women with malignancies of the reproductive tract. For more information, go to https://www.sgo.org/.