Reducing Bariatric Readmissions

About two-thirds of the readmissions are preventable, one expert estimates. Identifying patients most at risk for readmission and focusing on best practices proven to keep patients out of the hospital can help.

This article first appeared in the January/February 2016 issue of HealthLeaders magazine.

With a mortality rate of 0.1% and relatively few complications, 30-day readmissions represent the one area in which bariatric surgery programs could improve, says John Morton, MD, director of bariatric surgery at Stanford (California) University School of Medicine and immediate past president of the American Society for Metabolic and Bariatric Surgery. Improving that rate requires identifying patients most at risk for readmission and focusing on best practices proven to keep patients out of the hospital.

About two-thirds of the readmissions are preventable, he says, and the most common reasons for readmission are dietary indiscretions and medication reconciliation.

Focusing on those two causes and other best practices enabled Stanford's bariatric program to reduce its readmission rates from 8% 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," Morton says. "I knew we had a problem, and we started looking at our data to find out what was wrong."

Success key No. 1: Identify at-risk patients
Identifying the patients most at risk of readmission early in the process will go a long way toward lowering readmission rates, Morton says, 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 the age or body mass index is greater than 50. A patient who has an established relationship with a primary care physician is at lower risk, he explains, because that doctor can help coordinate care.

Severity and comorbidities also can put a patient at risk for readmission. A hemoglobin A1c of 10% or the presence of more than three comorbidities should be a readmission warning sign, Morton says. Insurance status also plays a role, with Medicare and Medicaid patients more likely to be readmitted.

"A long case is another factor, because a long time in surgery can be a marker for technical difficulties," he says. "Probably the biggest risk for readmissions is going to be complications at the time of surgery."

Success key No. Key 2: Choose the right setting
Readmission rates also can be affected by where the surgery is performed, Morton notes. Only two of the three common bariatric procedures in the United States can safely be performed in an outpatient setting—the gastric band and, under some circumstances, the sleeve, he says.

"There's a potential for higher readmission rates in ambulatory surgery," Morton says. "There is a certain amount of patient education that takes place in an inpatient setting that may not be happening in ambulatory surgery. That's not to say that an ambulatory surgery center can't do the same level of education, but it's not routinely done."

Any risk factors identified in the patient evaluation should be considered carefully when determining whether outpatient surgery is acceptable or poses too much of a readmission risk for that patient, he says. The more risk factors a patient has, the less likely that outpatient surgery is the right choice.

Success key No. 3: Educate, educate, educate
Pilot projects at Stanford and other bariatric programs have shown that the level of patient education about bariatric surgery and postop requirements has a significant effect on readmissions. 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.

Stanford and other healthcare institutions have standardized their preop education, creating a video that provides consistent messaging. The video includes presentations from a range of disciplines, including nutrition, psychology, and pharmacy. Patients can watch it repeatedly, which Morton says is important not only for the reinforcement but also because patients may be distracted or stressed the first time they watch.

"We give that education when they are an inpatient, and give them a phone call the day after discharge to remind them and answer any questions," he says. "Part of that education process includes discussing their medications and how those may change after surgery."

Realizing that postop education and monitoring was critical to avoiding readmissions, Stanford made the postop phone call more than just a cursory "How are you doing?" Instead, Stanford budgeted nursing time for the calls and set expectations for what information was to be conveyed and collected.

"They're not doing it here and there, between things," Morton explains. "They have dedicated, focused time for doing this because we feel it is that important."

Stanford also sends a letter to the patient's primary care physician after surgery, discussing the patient's postop plan. Morton's team at Stanford found that dietary compliance could be improved, so in addition to pre- and postop education, now the patient also meets with a nutritionist at the two-week follow-up visit."One year we had nine readmissions related to diet, and following the implementation of the nutritionist visit it went to zero," he says. "It had real impact for our practice."

Success key No. 4: Engage pharmacists more
Research has shown that improved coordination with pharmacists—both preop and postop—will lower readmission rates in bariatric surgery, Morton says. About 90% of bariatric procedures in the United States are performed in hospitals accredited through the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program from the American College of Surgeons and the ASMBS, and a hallmark of that program is multidisciplinary care that 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 says. "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."

If the medications are not tapered properly, even a patient who won't need them after surgery can suffer an artificial drop in blood pressure or sugar levels to the point that they require hospitalization, he explains.

At MetroWest Medical Center, which comprises two hospitals and a network of supplementary service centers throughout Boston's western suburbs, when a new bariatric surgery director joined MetroWest Medical Center in Natick, Massachusetts, in 2014, the hospital used that opportunity to improve the bariatric program, notes that program's coordinator, Joanne Prentice, RN, BSN, CBN, CAPA. She met with the bariatric surgery head and discussed the importance of managing medications for comorbidities and pain.

"He asked that I take a detailed list of medications, including information like whether it was coated or long-acting pills, what form the patient was used to," she explains. "We want to be able to manage their comorbidities and not disrupt that ongoing care, but also to provide the pain medications our patients will need. That list is evaluated preop and provided to the hospital staff so that we know what to discharge the patient with."

MetroWest also determined that its bariatric patients' pain management was a leading cause of readmissions. In 2014, MetroWest implemented an initiative designed to make it easier for patients to comply with their discharge instructions regarding all medications.

"All medications, instead of being in pill form, are now in crushed, liquid, or chewable form for the first two or three months postop," Prentice explains. "We realized that patients were having a difficult time with the pills, with swallowing or with the medication upsetting their stomach, and so they weren't taking the pain medications the way they needed to. The resulting pain sometimes led to readmission." The improved partnership with the pharmacy is a primary reason that the readmission rate at MetroWest is low, she says, with no readmissions in the past 16 months.

Stanford also makes sure that the patient's postop medications are available in the clinic at the time of discharge. That helps ensure the patient begins the medications without any delay from going to a pharmacy.

Success key No. 5: Address hydration effectively
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. MetroWest came to the same realization, and now both organizations put more emphasis on hydration during patient education. At both facilities, patients are presented with branded water bottles and taught to carry them at all times.

That effort was to prevent dehydration, but Morton and his team also thought there was a better way to treat it.

"If you just bring them into a clinic or an infusion center, they can be hydrated and sent on their way. They don't require full admission," Morton says. "We make every effort to treat them outside the hospital if they just need hydration, but to do that we have to detect it before the dehydration causes other problems."

The 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.

MetroWest also instituted a plan for hydrating postop patients in its outpatient clinics before they got to the point of needing hospitalization.

"The hydration effort is a good example of how you lower readmissions by looking for those problems that just get worse and cause the patient to spiral down until hospitalization is the only choice," Prentice says. "Patients will have some issues like that after surgery, but the key is to identify them and respond before it gets out of control."