December 18, 2013 1:52 am by Jordan Rau | MedCity News
FiDA
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Medicare
has begun tracking the outcomes of hip and knee replacement
surgeries, identifying 95 hospitals where elderly patients were more likely to
suffer significant setbacks. The government also named 97 hospitals where
patients tended to have the smoothest recoveries.
The analysis, which was released last
week, is the latest part of the government’s push to improve quality at the nation’s hospitals
instead of simply paying Medicare patients’ bills. Medicare already assesses
hospital death rates, how consistently hospitals follow basic medical
guidelines and how patients rate their stays. The evaluation of hip and
knee surgery outcomes is significant because for the first time, Medicare is
rating hospitals’ performance on two common elective procedures.
Many patients needing joint replacements
want to know a hospital’s record when choosing where to have the procedure
done. This is not usually the case for treatment of conditions Medicare
has evaluated previously, such as heart attacks.
Of the 95 hospitals
where knee and hip surgery patients experienced difficulties after the
operation, nine were rated having both high readmissions and high complication
rates. Those hospitals were: Froedtert Hospital in Milwaukee; Grant Medical
Center in Columbus, Ohio; Mercy St. Anne Hospital in Toledo, Ohio; Northwestern
Memorial Hospital in Chicago; the Pennsylvania Hospital of the University of
Pennsylvania Health System in Philadelphia; Peterson Regional Medical Center in
Kerrville, Texas; Reston Hospital Center in Reston, Va.; Shannon Medical Center
in San Angelo, Texas, and Southside Regional Medical Center in Petersburg, Va.
Some of those hospitals complained
Monday that Medicare’s assessments were outdated since they covered operations
between July 2009 through
June 2012. A spokeswoman for Shannon Medical Center said the hospital
has improved since then, adding better technology and opening a clinic to
follow up with patients seven days after leaving. A spokeswoman for Southside
Regional Medical Center said that hospital adopted a new treatment model in
2012 for joint and spine patients and that their outcomes have “drastically
improved.”
Medicare
was cautious in how it marked hospitals, only categorizing them as outliers when
their records in hip and knee replacements were statistically different from
the national average.
The overwhelming majority of
hospitals—about 19 out of 20—were branded average, a Kaiser Health News
analysis found.
Table
Out of the 97 hospitals that did better
than average in avoiding either readmissions or complications, 25 were rated as
being better at both measures. Those included some big hospitals such as Sutter
General Hospital in Sacramento, Calif., and the Hospital for Special Surgery in
Manhattan. They also included some local hospitals such Holy Cross Hospital in
Fort Lauderdale, and several physician-owned hospitals that specialize in these
types of surgeries, such as Arkansas Surgical Hospital in Little Rock.
About
600,000 patients in the traditional Medicare program have their hips or knees
replaced each year. The growing popularity of these operations has made them a
more significant expense for Medicare and private insurers.
In 2010, there were 719,000 knee replacements costing nearly $12 billion and
332,000 hip replacements nearly $8 billion, according to the National Center for
Health Statistics.
Medicare
published the new outcomes data on its Hospital Compare
website. While few consumers use that
site, this information may reach a greater audience later on through groups and
publications, such as Consumer
Reports, that tap Medicare’s data in devising their own hospital
ratings.
“With elective procedures, consumers
like to do a lot of research to pick the right doctor and the right hospital,
so this is a good first step,” said Leah Binder, CEO of the Leapfrog Group, a nonprofit funded by
employers that judges hospital quality. However, she said the new ratings would
be of limited use for most patients because the Centers for Medicare &
Medicaid Services judged most hospitals’ performance as normal.
“We know there’s a significant variation
among hospitals, but CMS reports them all as average,” Binder said.
Financial Pressure
Hospitals may soon feel a financial
pinch from the evaluations. Medicare
plans to add hip and knee readmission rates to the criteria it uses when
deciding whether to penalize hospitals each year.
Since October, Medicare has been paying
less than it normally does to 2,225 hospitals
after determining their rates of rebounds for patients with pneumonia, heart
attacks and heart failure were too high, even by a small
amount. Starting in
the fall of 2014, when the joint replacements are to be factored into
the penalty program, hospitals are at risk of losing as much as 3 percent of
Medicare payments for each patient stay.
In its new
evaluation of hip and knee replacement patients, Medicare used two
measures. One was how
often the patients ended up being readmitted to the hospital within 30 days of
discharge. The other was how often they suffered one of eight
complications after the operation. Those included a
heart attack, pneumonia, sepsis or shock within seven days of admission. They
also included bleeding at the site of the surgery, a blood clot in the lung or
death within a month of admission. Medicare also counted mechanical complications with implants and
infections of the joint or wound within 90 days of admission.
The
quality of joint implants has been under scrutiny for several years. Some of the
surgical devices have been plagued by quality problems, especially
among artificial hips made of interlocking metal parts. The friction
created by these joints can create metal debris that damages the
surrounding flesh and bone. Two manufacturers have recalled their devices since
2010.
Problems Are Declining
Nationwide, the number of readmissions
following hip and knee replacement surgeries has been dropping, but not as
quickly as readmission rates for heart attack, heart failure or pneumonia
patients, according to a Medicare-commissioned study by the
Yale New Haven Health Services Corporation Center for Outcomes Research and
Evaluation.
Dr. Eric Coleman, an expert on
readmissions at the University of Colorado Anschutz Medical Campus, said some hospitals are trying to
prevent joint replacement patients from returning by educating them ahead of
the surgeries about how to take care of themselves and warning signs of
problems. This program provides “a chance to walk you through what to
expect, what your family would expect, how to arrange your home,” Coleman said.
“In most of the cases of readmission reductions, we’re still very reactive.”
Hospitals’ clientele appears to play
some role in how they fared after these surgeries. The outcomes for hip and knee replacements tend to be
slightly worse for hospitals that serve a high proportion of Medicaid patients,
according to the Yale study. The study also found that hospitals where more than one out of every five
patients were African-American tended to have slightly higher complication and
readmission rates than did hospitals with no black Medicare patients.
However, the report noted, some of these hospitals serving large numbers of
Medicaid or black patients also performed very well.
These kind of
racial and economic disparities in readmissions have long troubled
health policy experts. Some hospitals mostly cater to prosperous
patients who have the money, resources and education to get necessary
post-surgical care after discharge. But safety net hospitals often have a
harder time ensuring that low-income, less educated people follow the often
complex instructions about how to recover from a major surgery or
hospitalization.
In
Medicare’s new analysis, on average, hip and knee patients had a 5.4 percent
chance of having to return to the hospital. Nationally, the average
complication rate for patients after hip and knee replacement surgery was 3.4
percent. One hospital, Beaumont Health System
in Royal Oak, Mich., had a mixed record: Patients there were more likely to be
readmitted but less likely to suffer serious complications.
Hospital-Wide Readmissions Published
The government also last week released
its first ratings of how often Medicare patients of all diagnoses returned to
hospitals within 30 days. That “all cause”
measure is more encompassing than Medicare’s appraisals based on
heart attack, heart failure and pneumonia. A number of prominent experts,
including Congress’ Medicare Payment Advisory Commission, have been pushing for
this measure to be used in setting financial penalties for hospitals.
Medicare’s analysis found that 16
percent of Medicare patients ended up returning to a hospital within 30 days
between July 2011 through June 2012. Again rates varied significantly.
At 364
hospitals, or 8 percent, patients were more likely than average to return
within a month, the data show. These included the Cleveland Clinic, as well as
the clinic’s hospital in Weston, Fla.; both of Johns Hopkins’s hospitals in
Baltimore; and New York-Presbyterian Hospital in Manhattan.
Medicare did not count cases where the
patient was scheduled to return to the hospital, such as when a lung cancer
patient was admitted for pneumonia and later came back for a chemotherapy
treatment that had been planned. Medicare calculated that patients were less
likely than average to end up back for any reason at 315 hospitals, or 7
percent of the nation’s total.
Nancy Foster, an executive with the
American Hospital Association, said that tracking hospital-wide readmissions
was of limited value to hospitals that wanted to do better. “Most of the
interventions you would use are built and targeted around particular
conditions,” she said. “You have to know what’s driving patients back into the
hospital to address the problem. When you get this lump of all-cause
readmissions, you don’t know what to go after.”
KHN reporters Ankita Rao and Marissa
Evans contributed.
Public
reporting of CMS patient outcome data from joint replacement surgery has been a
'grown-up Christmas wish' for the last 5 years! Patient harm from lax
oversight of implants has cost us our humanity, needless suffering of patients
and their family members, trust in our government and care providers and a substantial
chunk of healthcare spending. Simply compiling the CMS data and making
that information available to researchers like Consumers Union Safe Patient
Project will clarify the true risks and benefits of implanted medical devices.
The legal system unfairly entitles Pharma and the medical device
industry, so preventing harm is essential to patient safety. My
blog/personal story: http://fida-advocate.blogspot.com
