Higher Readmission Rates After Surgery Not Always Bad in Ovarian Cancer
National Harbor, MD—A higher readmission rate after surgery had a significant association with improved survival for patients with ovarian cancer, according to 2 studies reported at the 2017 Society of Gynecologic Oncology meeting.
An analysis of data for 44,079 women who underwent primary debulking surgery for ovarian cancer showed that high-volume centers had the highest overall survival and lowest 90-day mortality. However, the high-volume centers also had the highest 30-day readmission rate.
The second study, involving 26,595 women with stage III epithelial ovarian cancer, showed that neoadjuvant chemotherapy followed by interval surgical debulking led to a 37% reduction in the risk for unplanned readmission compared with upfront debulking surgery. Primary debulking, however, was associated with a 36% lower risk for all-cause mortality.
Taken together, the studies suggested that the use of a 30-day readmission rate as a principal quality metric—as allowed by the Hospital Readmission Reduction Program (HRRP)—may penalize centers that achieve superior outcomes in gynecologic oncology surgery, investigators of the 2 studies concluded.
“Readmission rates might be a valid measure of quality for certain surgeries, where readmission rate reflects a higher complication rate,” said Shitanshu Uppal, MBBS, Assistant Professor of Obstetrics and Gynecology, University of Michigan, Ann Arbor. “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 of the tumor from the abdomen, which we know translates into better survival, is worth it,” he noted.
Extension of HRRP rules to oncologic surgery could lead to the unintended consequence of “incentivizing gynecologic oncologists to do more chemotherapy before surgery,” said Emma Barber, MD, a gynecologic oncology fellow, University of North Carolina, Chapel Hill, and principal investigator in the second study.
“This is an example where a well-meaning policy for the broad population has unintended consequences for the smaller ovarian cancer community,” she added.
Established by the Affordable Care Act, the HRRP authorizes the Centers for Medicare & Medicaid Services to impose a penalty of as much as 3% of total Medicare or Medicaid reimbursement on hospitals that have higher 30-day readmission rates than similar hospitals. The penalty has the potential to pressure surgeons into performing less aggressive procedures associated with lower readmission rates, said Dr Uppal.
The Readmission Rates Conundrum
To examine outcomes and readmission rates for patients with ovarian cancer, Dr Uppal and colleagues queried the National Cancer Database to identify women treated for stage III or IV epithelial ovarian cancer from 2004 to 2013. Centers that provided care for the patients were stratified by annual ovarian cancer surgery case volume—≤10, 11-20, 21-30, and ≥31 cases annually.
Investigators adjusted for case-mix and treatment-related factors. Outcomes of interest were 30-day readmission rate, 30- and 90-day mortality, adherence to the National Comprehensive Cancer Network (NCCN) guidelines, and 5-year overall survival.
The data showed that the highest-volume hospitals had a 30-day risk-adjusted readmission rate of approximately 10%, compared with approximately 7% to 8% for the other case-volume categories. High-volume hospitals had a 30-day mortality rate of <2%; hospitals in the other 3 categories had a 30-day mortality exceeding 2%. The 90-day mortality was slightly more than 4% for the high-volume hospitals versus approximately 5% for the other categories.
Adherence to the NCCN guidelines was highest among the high-volume hospitals. A preliminary analysis of 5-year survival showed an advantage for high-volume centers.
Asked whether all readmissions reflect a “failed discharge,” Dr Uppal answered, “Certain readmissions are appropriate and necessary. Certain surgeries need ‘appropriate aggression’ and result in a higher readmission rate.”
Patients receiving neoadjuvant chemotherapy accounted for 15.5% (N = 4172) of the total study population. Overall, 11.3% (N = 3052) of patients were readmitted to the treating hospital within 30 days of surgery, and 57% of readmissions were unplanned.
Primary debulking surgery was associated with a readmission rate of 12.5% and an unplanned readmission rate of 6.8%. The rates for neoadjuvant chemotherapy were 6.5% and 4.5%, respectively, both of which were significantly different from readmission rates after primary debulking surgery.
The survival analysis favored primary debulking, because patients who had surgery as initial treatment had a median overall survival of 47 months compared with 36 months for the group that received neoadjuvant chemotherapy (P <.001).
“Policies that prioritize decreased readmission rates inherently encourage neoadjuvant chemotherapy over primary debulking surgery,” said Dr Barber. “Policies and incentive programs for ovarian cancer patients should incorporate both short- and long-term outcomes,” she added.