Our model improves the detection of concerning symptoms after radical cystectomy by optimizing the timing and number of outpatient encounters. By understanding how to design better outpatient followup care for patients treated with radical cystectomy we can help reduce the readmission burden for this population.
Background
The Hospital Readmissions Reduction Program reduces payments to hospitals with excess readmissions for three common medical conditions and recently extended its readmission program to surgical patients. We sought to investigate readmission intensity as measured by readmission cost for high-risk surgeries and examine predictors of higher readmission costs.
Materials and Methods
We used the Healthcare Cost and Utilization Project's State Inpatient Database to perform a retrospective cohort study of patients undergoing major chest (aortic valve replacement, coronary artery bypass grafting, lung resection) and major abdominal (abdominal aortic aneurysm repair [open approach], cystectomy, esophagectomy, pancreatectomy) surgery in 2009 and 2010. We fit a multivariable logistic regression model with generalized estimation equations to examine patient and index admission factors associated with readmission costs.
Results
The 30-day readmission rate was 16% for major chest and 22% for major abdominal surgery (p<0.001). Discharge to a skilled nursing facility was associated with higher readmission costs for both chest (OR 1.99; 95% CI 1.60-2.48) and abdominal surgeries (OR 1.86; 95% CI 1.24-2.78). Comorbidities, length of stay, and receipt of blood or imaging was associated with higher readmission costs for chest surgery patients. Readmission >3 weeks after discharge was associated with lower costs among abdominal surgery patients.
Conclusions
Readmissions after high-risk surgery are common, affecting about one in six patients. Predictors of higher readmission costs differ among major chest and abdominal surgeries. Better identifying patients susceptible to higher readmission costs may inform future interventions to either reduce the intensity of these readmissions or eliminate them altogether.
Few would disagree that patient-centered care involves asking open-ended questions, acknowledging patient emotions, and engaging in mutual dialogue about decision-making and next steps. When this communication occurs, it is typically during an in-person clinic consultation. Traditional medical education emphasizes this approach to clinical encounters because it is presumed to be more empathetic, especially when disclosing bad news.Delivering bad news happens every day in oncology practice. Numerous studies demonstrate that patients cope with a range of emotions when receiving bad news.1 For patients, waiting for in-person communication of biopsy results may lead to apprehension of physicians. Compounding the issue, the ability to acutely process bad news in the office worsens under emotional duress and ensuing medical jargon. If practitioners remain cognizant of the limitations of communicating biopsy results at in-person consultations, their efforts may better support delivery of patient-centered care. Telemedicine approaches can potentially relieve much of the anxiety associated with in-person consultations while delivering bad news in a timely, compassionate, and patient-centered manner. With increasing clinical time constraints and the shock of hearing a cancer diagnosis in person, telemedicine encounters can facilitate more meaningful future in-person discussions of complex therapeutic options and their adverse effects. Initial telemedicine communication of biopsy results (eg, telephone or video teleconference) can offer patients time to absorb their diagnosis and take greater advantage of their next in-person consultation.The initial in-person office visit to communicate malignant biopsy results is arguably less interactive than expected. Patients are not only trying to absorb devastating news but also engage in challenging conversations. On the other hand, communication of biopsy results through telecommunication can serve as a buffer to the initial in-person visit and provide time for patients to process the results alone or with family. Furthermore, telecommunication can augment medical decision aids to allow for more meaningful conversations upstream of the office visit.A number of patient decision aids, such as pamphlets and web-based tools, serve as adjuncts to traditional counseling. In a systematic review of 115 randomized clinical trials, decision aids had the largest and most consistent benefit in increasing patients' knowledge of options and outcomes and helping patients feel more comfortable in their choices. A potential concern in delivering biopsy information through nontraditional methods is physician discomfort in relaying lifealtering news without the familiarity of an in-person visit. This issue likely has more to do with the status quo rather than what patients tend to prefer. With proper training and practice, physicians could become adept at using telecommunication tools. Certain patients may still prefer to have biopsy results delivered through a traditional in-person consultation. To ...
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