Readmission rates for spine surgery are high in some hospitals, which will become a significant burden as insurance companies and Medicare stop paying for readmissions separately within the episode of care. Many departments are considering new initiatives to reduce readmission rates, and surgeons should play a role in these decisions.
"I think the most important step is for surgeons to start the conversation," says Alpesh A. Patel, MD FACS, spine surgeon and Associate Professor in the Department of Orthopaedic Surgery at Northwestern University School of Medicine in Chicago. "Surgeons should be more involved in these discussions. We are seeing them at the hospital level, but hospitals need to partner with surgeons to make these initiatives truly effective."
Here are five steps to reduce readmission after spinal procedures.
1. Identify risk factors for readmissions. The first step after you decide to lower readmission rates is to identify the risk factors. Isolate cases where the patient was readmitted and pinpoint the most common reasons at your hospital.
"Understand what the current readmission profile looks like at the hospital and look at the hospital records to comprehend cost implications of readmissions," says Dr. Patel. "Really hone in on the most important risk factors and partner with others to eliminate them. For example, if there are several readmissions because of infections, you'll need to partner with the hospital on a stronger infection control policy."
Some of the most common risk factors for readmissions across the country include:
• Medical comorbidities
• Age of the patient
• Type of procedure performed (open vs. minimally invasive)
• Number of levels fused
• Pain control
• Infection
Don't just rely on the ICD-9 coding data or hospital billing records; really examine patient records for readmissions to conduct a root cause analysis.
2. Develop new protocols to minimize the issues. Partner with other specialists to develop new protocols that minimize common issues leading to readmissions. For example, if the majority of readmissions are due to poor pain control, develop a better pain protocol for patients postoperatively.
"Identify the root cause of the readmissions and enact steps to reduce the risk," says Dr. Patel. "It requires partnering with the hospital and other specialists to make sure everyone is one the same page. Define upfront what the issues are and then develop the protocols to eliminate readmissions."
The team of physicians should also define their targets and how they'll measure progress going forward.
3. Gain physician buy-in. Everyone should be on the same page when developing and implementing new protocols to reduce readmissions at the hospital. If even one surgeon or specialist isn't onboard, the entire initiative will fall apart.
"If you have one physician who doesn't do it, there might not be any change because of that outlier," says Dr. Patel. "In addition to understanding the clinical need to reduce readmissions, physicians need to get on board with protocol changes. This takes time and planning, but if there is a good financial reason to push forward it will happen."
If someone is weary of changing the process, show them the quality and cost data associated with readmissions for spinal procedures. This can make a big impact on convincing surgeons change is appropriate and necessary.
4. Enact the changes. Make the protocol changes and then track your results for at least six months to see whether progress has been made. Capture accurate data from before the change to really see how the changes impact readmission rates.
"As surgeons, our key role is oftentimes being a good team player in these initiatives, but we also need to play the role of patient advocate to lead these initiatives," says Dr. Patel. "Surgeons who are employed are familiar with working with the hospitals hand-in-hand, but this may be a new endeavor for surgeons who are not employed. Look at the hospital as a partner in the care for your patients and understand why it's important for patient care and financial implications to make the commitment and time to reduce readmission."
Throughout the protocol development and implementation process, set aside enough time to spend on administrative details with hospital leaders. This should take a few hours per month after the initial changes are made.
5. Track your progress. There are several parties that will be interested in the results of your initiatives if you are able to reduce readmission rates. You can show patients, referring providers and insurance companies your results to support your commitment to better patient care.
"Lowering readmissions means patients are getting better quality upfront," says Dr. Patel. "Tie that to a cost reduction and show third party payors that you are a cost-effective option. With bundled payments, readmissions aren't paid for, so it could be good practice for future initiatives."
The value of efforts to reduce readmissions will become greater if readmissions are considered losses instead of gains, as they will be in the future with pay-for-performance.
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