From the Journals

Open AAA and peripheral bypass surgery patients among the highest users of post-acute care



The wide disparity among hospitals in their rates of postsurgery discharge to post-acute care (PAC) could be an area of focus for cost containment in Medicare spending, according to the findings of a study that used data from the National Inpatient Sample (NIS) and the Veterans Affairs health system (VA) regarding surgical patients.

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PAC, including skilled nursing facilities and inpatient rehabilitation, accounts for 73% of regional variation in Medicare spending, and studies on hospital variation in this area have typically focused on nonsurgical patients or been limited to Medicare data. However, a high degree of variation also appears to hold for surgical patients, according to the authors of this large database study of more than 4 million patients who had aortic aneurysm repair, peripheral vascular bypass, colorectal surgery, hepatectomy, pancreatectomy, or coronary bypass.

“We found that there is significant variation in use of PAC and rates of home discharge following complex cardiac, abdominal, and vascular surgery,” Courtney J. Balentine, MD, of the University of Alabama at Birmingham and his colleagues wrote in their report in the Journal of Surgical Research.

To explore hospital variation in post-surgery PAC, they evaluated 3,487,365 patients from the NIS (39% were aged 70 years or older, and 60% were men) and 60,666 from the VA (32% were aged 70 years or older, and 98% were men) who had surgery during 2008-2011.

Within the NIS, 631,199 patients (18%) were discharged to PAC facilities, and among the 60,666 veterans, 4744 (7.8%) were discharged to PAC facilities. In addition, hospital rates of discharge to PAC facilities varied from 1% to 36% for VA hospitals and from 1% to 59% for non-VA hospitals, according to the researchers. They found that some VA hospitals were four times more likely to discharge patients to PAC facilities than would be expected from their patients’ characteristics, while others were 90% more likely to send patients home than would be expected, according to Dr. Balentine and his colleagues.

Procedure-specific rates of discharge to PAC facilities from VA hospitals ranged from 2% following endovascular aneurysm repair to 10% after pancreatectomy and peripheral vascular bypass. Among the NIS hospitals, in contrast, rates of discharge to PAC facilities ranged from 6% following hepatectomy to as high as 44% following open aneurysm repair.

“These data could be used to characterize practices that promote more effective recovery from surgery and minimize the need for PAC,” the authors wrote. “Given that skilled nursing facilities and inpatient rehabilitation cost [$5,000]-$24,000 more than treatment at home, even minor reductions in the need for PAC facilities could result in substantial cost savings,” they stated.

“Our findings suggest that there is considerable room for improvement in the use of PAC after surgery and that we still have a long way to go in terms of using PAC to help patients recover and regain their independence,” the researchers concluded.

The authors reported that they had no conflicts of interest.

SOURCE: Balentine CJ et al. J Surg Res. 2018 Oct;230:61-70.

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