Referring a patient to an acute care facility following major cardiac, joint, and spine surgery rather than the patient’s own home may not always be necessary, according to findings of a new self-examining study from NYU Langone Medical Center.

According to researchers, an approach to post-surgery care that the institution implemented two years ago—which included sharply reducing post-hospital referrals to acute care facilities—showed no corresponding increase in readmission rates. The study appears in the November 23 edition of JAMA Internal Medicine.

In 2012, NYU Langone began participating in a Medicare pilot program under the Affordable Care Act called Bundled Payment for Care Improvement. Under this program, hospitals and physicians deliver all services for an episode or “bundle” of care in return for a single lump sum payment. An episode of care typically includes a hospital stay plus a 90-day recovery period.

One intervention NYU Langone pursued as part of this program was to send more patients home for post-surgery recovery rather than to a facility like a skilled nursing facility. The program covered patients undergoing three procedures: cardiac valve replacement, major joint replacement of the lower extremity, or spinal fusion.

“NYU Langone is committed to payment and care models that reduce time in facilities for our patients as well as the costs associated with those stays,” said Andrew Brotman, MD, senior vice president and vice dean for clinical affairs and strategy and chief clinical officer at NYU Langone. “We are pleased this study shows that our efforts to be nimble with the care we provide are paying off for our patients.”

The researchers examined Medicare claims data on 4,664 patients for a nearly 3-year baseline period before the program began, a period during the program’s preparation, and a “risk-bearing” period after the program launched.

They found that NYU Langone achieved a drop of 49 percentage points in patients discharged to post-acute care facilities after cardiac valve surgery and a drop of 34 percentage points for those undergoing lower extremity joint replacement surgery, with no corresponding increase in readmission rates. Readmission rates were similarly stable in patients undergoing spinal fusion, for whom post-acute care facility rates were unchanged. The study was not able to evaluate outcomes like functional status or whether the patients fully recovered from surgery.

The study raises questions about spending on some types of post-acute care, according to senior author Leora Horwitz, MD, MHS, associate professor in the Department of Population Health and director of the Center for Healthcare Innovation and Delivery Sciences at NYU Langone. Currently, Medicare spends $59 billion annually on these post-hospital services.

“As clinicians, we often feel that discharging patients to an acute rehabilitation facility may help them recover better and prevent them from returning to the hospital,” Dr. Horwitz said. “But we did not see any increase in readmissions after our clinicians began sending more patients directly home. These results may give surgeons greater confidence in discharging patients directly home instead of to a facility, where care is more costly and potentially more disruptive to the lives of patients and families.”

According to Joseph D. Zuckerman, MD, the Walter A.L. Thompson Professor of Orthopaedic Surgery and chair of the department of orthopaedic surgery at NYU Langone, “The results of this study are incredibly positive for our patients. When patients can recover after an orthopaedic procedure in the comfort of their own home with no increased risk of medical complications, it is a win-win situation for them and for us.”

Besides Dr. Horwitz, other researchers involved in the study were Keith S. Goldfeld, DrPH, of the Department of Population Health, Wei-yi Chung, MS, ASN, of the Department of Population Health and the Center for Healthcare Innovation and Delivery Sciences (CHIDS), and Saul B. Blecker, MD, MHS, of the Department of Population Health, CHIDS, and the Department of Medicine, all based at NYU Langone Medical Center, as well as Lindsey E. Jubelt, MD, MS, formerly of NYU Langone Medical Center.

The data for this project were provided through the Centers for Medicare and Medicaid Services (CMS) Bundled Payment for Care Improvement (BPCI) Contract #2106-105 000. Dr. Blecker was supported by the Agency for Healthcare Research and Quality (AHRQ) grant K08HS23683. Dr. Horwitz was supported by AHRQ grant R01HS022882.

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Allison Clair
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