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Ninety Day Readmissions of Bundled Valve Patients: Implications for Healthcare Policy
Michael S Koeckert, Eugene A Grossi, Mathew R Williams, Gary Kalkut, Didier F Loulmet, Elias A Zias, Michael. Querijero, Aubrey C Galloway
NYU School of Medicine, New York, NY

OBJECTIVE: Medicare's Bundle Payment for Care Improvement (BPCI) Model 2 bundles the cost of valve surgery into 90-day episodes of care (EOC) which include the operative cost, in-patient stay, physician fees, post-acute care, and any readmission during the 90-day EOC. As we undergo a national review of recent healthcare initiatives, there is little data to understand the appropriateness of such financial models. To explore this risk-bearing, we analyzed our BPCI patient's outcomes and EOC thru 90 days to understand the financial impact and sustainability of the bundle payment system for valve patients.
METHODS: We previously implemented management strategies including pre-surgical risk stratification, standardized post-discharge management led by cardiac nurse practitioners (CNP) and post-discharge emergency department triage protocols. For the first 30 postoperative days the CNP's maintain weekly contact, use telemedicine, and attempt to guide any post-discharge encounters (PDE); when possible <48hr hospital observation was utilized instead of full readmission. All PDEs were tracked prospectively. The Medicare master claims data was incorporated to provide details of all (internal and external) 30-90 readmissions. We analyzed all bundled readmissions as tabulated by Medicare, for all BPCI valve patients from 10/13 (start of risk sharing phase) through 12/15.
RESULTS: Analysis included 376 BPCI valve patients - 202 open surgical valves and 174 transcatheter aortic valves (TAVR). TAVR patients were older (83.6 vs 73.8 years; p=0.001) and had higher STS predicted risk (7.1% vs 2.8%; p=0.001). Readmissions were categorized as early (<=30 days) or late (31-90 days). Overall, 18.6% of patients (70/376) had one or more readmission within 90-days. Readmissions were more common among TAVR patients (22.4% (39/174) vs 15.3% (31/202), p=0.05). While there was no difference between early readmission claims, TAVR patients had significantly higher late readmissions and greater late claims cost. See Table. Those patients having an early readmission were at no higher risk of subsequent late readmission (2/20; 10.0%) for open valves, but more likely to have subsequent late-readmission (8/21; 38.1%) for TAVR (p=0.04). Univariate analysis revealed that older age (81.4 vs 77.9 years; p=0.02), diabetes (46.7% vs 21.6%; p=0.05), and having two falls in the 6 months prior to surgery (13.3% vs 5%; p=0.08) were associated with late readmission.
CONCLUSION: Significant bundle dollars are consumed by readmissions; particularly in TAVR, where early readmission predicts late readmission. Identifying high-risk patients may allow targeting resources for optimized late outpatient management. Alternatively, late readmissions in high-risk patients may represent chronic disease management and this group may not be appropriate for prolonged EOC risk sharing. These data question the appropriateness of such a national strategy.

All Bundle Valves
(n=376)
Open Valves
(n=202)
TAVR
(n=174)
p-value
Patients with any Readmission70 (18.6%)31 (15.3%)39 (22.4%)0.05
Patients with Early Readmission41 (10.9%)20 (9.9%)21 (12.1%)0.65
Patients with Late Readmission39 (10.4%)13 (6.4%)26 (14.9%)0.03
>1 Early readmits8 (2.1%)3 (1.5%)5 (2.9%)0.28
>1 Late readmits10 (2.7%)5 (2.5%)5 (2.9%)0.81
Early readmit dollars Mean[sum]$14,138 [$579,665]$14,437 [$288,741]$13,853 [$290,924]0.77
Late readmit dollars Mean[sum]$14,179 [$553,018]$10,740 [139,628]$15,899 [$413,389]0.01


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