With a mortality rate of 0.1% and relatively few complications, 30-day readmissions represent one area in which bariatric surgery programs could improve, according to an article in the January/February 2016 issue of HealthLeaders magazine.
About two-thirds of bariatric readmissions are preventable, the article says, and the most common reasons for readmission are dietary indiscretions and medication reconciliation. Focusing on those two causes and other best practices enabled the bariatric program at the Stanford University School of Medicine in California to reduce its readmission rates from 8.0% to 2.5% in four years. Stanford's 2008 pilot project on reducing readmissions evolved into the nationwide Decreasing Readmissions Through Opportunities Provided program, which aims to reduce 30-day readmissions nationwide by 20%.
“One thing that got my attention was a letter from an insurer saying that if our admission rate was above 5%, we wouldn't be allowed to participate in the network anymore,” said John Morton, MD, director of bariatric surgery at Stanford. “I knew we had a problem, and we started looking at our data to find out what was wrong.”
Identifying the patients most at risk of readmission early in the process will go a long way toward lowering readmission rates, Morton said, and that can guide whether the procedure is performed inpatient or outpatient. One rule of thumb is the 50/50 rule, which says a patient is at risk for readmission if his or her body mass index is greater than 50. Severity and comorbidities also can put a patient at risk for readmission.
Readmission rates also can be affected by where the surgery is performed, Morton noted. Only two of the three common bariatric procedures in the U.S.––the gastric band and, under some circumstances, the sleeve––can safely be performed in an outpatient setting, he said.
Pilot projects at Stanford and other bariatric programs have shown that the level of patient education about bariatric surgery and postoperative requirements has a significant effect on readmissions, according to Morton. Key points to emphasize are the need to ensure that the patient stays hydrated, knows the right and wrong foods to eat, and avoids advancing the diet too quickly.
Research has also shown that improved coordination with pharmacists—both preop and postop—will lower readmission rates in bariatric surgery, Morton said. Approximately 90% of bariatric procedures in the U.S. are performed in hospitals accredited through the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, and a hallmark of that program is multidisciplinary care, which can include psychologists, nutritionists, and pharmacists.
“Medication reconciliation is particularly important for the bariatric patient because so many of them come in with multiple medical problems and multiple medications,” Morton said. “The nice thing is that after surgery they’re able to discontinue a lot of those medications, but it has to be done in a controlled, systematic way. That’s where the pharmacist can really help out.”
When the Stanford team analyzed its data on readmission rates to find the causes, hydration issues emerged as a leading factor: Patients would become dehydrated after surgery, and that would lead to other complications and hospitalization. Patients at Stanford are presented with branded water bottles and taught to carry them at all times. In addition, a nurse’s phone call after surgery addresses hydration specifically, urging patients to drink water and educating them on how to recognize dehydration so that it can be treated promptly.
Source: HealthLeaders Media; February 11, 2016.