Are Healthcare Professionals Decreasing Patients’ Length of Stay at the Expense of Readmissions? Dr. John Gore Seeks to Improve Quality of Care for Radical Cystectomies
Get Dexur’s Personalized Hospital Specific Presentation on Quality, Safety, Compliance & Education
By: Saparja Nag Dec. 14, 2017
Length of stay and 30-day readmission rate are known to be related but initiatives to decrease total days hospitalized by discharging patients earlier may actually be negatively impacting the overall quality of care. A background article analyzed how 30-day readmissions quantitatively affect overall length of stay, but the clinical implications of these metrics may uncover even more. Dr. John Gore has built his medical profession on not only treating patients in urology and urologic oncology, but also on studying the clinical care processes for these patients. In a previous article, Dr. Gore’s research on 30-day readmissions following urinary diversions was briefly discussed. We checked in with Dr. Gore to see if there had been any advancements in his research.
Dr. Gore’s focus in both his clinical practice and research is to streamline clinical care pathways to improve outcomes for his urology patients, specifically following radical cystectomies. This procedure, which removes the urinary bladder, is known throughout the medical field as one with an intrinsically higher readmission rate. Radical cystectomies involve the removal of the entire bladder and surrounding lymph nodes, which typically includes the prostate and seminal vesicles in men and the uterus, ovaries, fallopian tubes, cervix and part of the vagina in women.
Bladder cancer affects almost exclusively Medicare aged patients, according to Dr. Gore. The removal of the bladder and surrounding structures typically has high early readmission rates, within the first 30 days, mostly due to what is known as failure to thrive. In geriatrics, failure to thrive can include dehydration, urosepsis, and new kidney blockages. Dr. Gore commented that urosepsis is a common effect of the procedure when there is “manipulation of an interposing bowel segment.”
Dr. Gore’s research focuses on seeking ways to “apply evidence-based perioperative pathways to patients undergoing radical cystectomy”, which has roughly a 35% readmission rate within 30 days. A study currently in press used state hospital discharge data to examine sites of readmission for cystectomies. His group found that these procedures are often performed at centers of excellence far from home, resulting in patients being admitted to different hospitals upon readmission. Further, his research discovered that the “risk of failure to rescue is much higher than if the patient was readmitted to the same hospital.”
When asked about recent innovations that have mitigated complications associated with urologic procedures, Dr. Gore commented on a few efforts to enhance recovery following surgery. He said that the focus has been on reducing length of stay without increasing readmissions through a “unified perioperative care pathway” by integrating perioperative processes. Gore emphasized that “the burden of readmission is very high for this procedure”, questioning whether healthcare professionals are prioritizing LOS reduction at the expense of readmissions.
Although some readmissions are unavoidable by nature of the procedure, Dr. Gore acknowledges that this presents a huge burden on the healthcare system and must be addressed. I also asked Dr. Gore about the significance of discharges to skilled nursing facilities (SNFs) and other transitional facilities. There have been some studies on the correlation between readmissions and SNF/transitional facilities but Gore notes that it is difficult to untangle these relationships due to individual patient differences. Patients who are discharged to SNFs or transitional facilities are generally sicker patients who have a tendency to be at a lower baseline of health. A root cause analysis of this strong correlation between discharge to SNF and readmissions would allow for a deeper understanding of the issue.
Dr. Gore mentioned one particular initiative at the University of Southern California that has seen marked improvement in terms of readmission rate. This program, where a home health nurse visit patients a few days after the procedure, has been in place for about four years. Regardless of how the patients report feeling, the nurse administers IV fluids at that time. Preliminary results have shown that readmission rates have decreased dramatically. More information on USC’s Enhanced Recovery After Surgery (ERAS) protocol can be found here.
Dr. Gore’s research on unified perioperative care pathways in urological procedures is essential as the medical field continues to progress. By focusing on the quality of patient’s postoperative care, physicians can serve patients more efficiently. A summary of Dr. Gore’s procedures from the Dexur data between October 2015 and September 2016 can be found below.
| Hospital | Category | Total Medicare Inpatient Discharges with Criteria (October 2015 - September 2016) | Percent of Hospital Share |
|---|---|---|---|
| All | All | 35 | 0.35% |
| All | Urology | 34 | 4.82% |
| University of Washington Medical Center | DRG-658: Kidney & Ureter Procedures for Neoplasm Without CC/MCC | 13 | 59.09% |
ABOUT THE AUTHOR
