By Scott Howe
With appendicitis readmissions rates at some hospitals as high as 30 percent for children with severe disease, a group of children’s hospitals has started handing out comparative performance report cards to grade the way they diagnose and treat the condition. The quarterly reports are tools for hospitals to examine their performance across the entire scope of appendicitis care, prioritize quality improvement efforts and establish best practices.
According to Shawn Rangel, MD, a surgeon at Boston Children’s Hospital, the report cards grew out an effort to "understand high rates of preventable readmissions for complicated appendicitis." A few years ago, Rangel and his colleagues began comparing appendicitis readmission rates at hospitals in the Children’s Hospital Association. The researchers found that the rate of kids readmitted within 30 days ranged from a low of 5 percent to a high of 30 percent for children with severe (ruptured) appendicitis.
The high rates are "disturbing," Rangel says, because appendectomy is the most common abdominal surgical emergency in children with some 80,000 cases reported in the U.S. each year. What’s more, hospitalizations associated with care of children with appendicitis are among the most costly for surgical procedures performed at pediatric hospitals. In 2010, the 42 hospitals in the Pediatric Health Information System (PHIS) database reported inpatient costs of nearly $150 million for appendectomies, with charges to the health care system nearly three times that. Readmissions add significantly to these costs.
For children’s hospitals, "preventable readmissions for appendicitis is one of our biggest Achilles’ heels," Rangel states. "Appendicitis patients, for the most part, are previously healthy kids," he explains. "They receive complex care, but when they leave the hospital they should be cured. There should be zero kids bouncing back, and those who do reflect a failure in our current system to identify the most effective means of identifying and treating recurrent intra-abdominal infections at an early stage."
So, why are there so many readmissions? A recent study by Rangel and his colleagues pinned the blame on a lack of standardization in care. "Our study looked at resource utilization not just readmission," he says. "When we looked at all the things that are classically part of caring for kids with appendicitis, we saw massive variation across institutions," he says. "From when the patient hits the emergency room and how they get diagnosed, to what happens in the operating room, to the way care is managed after the operation, we saw no standardization."
For example, Rangel’s study found different approaches to diagnostic imaging in the emergency room. "There is variation in who gets a CT and who gets an ultrasound," he says. "There is also variation in how centers use their ultrasound and in how confident clinicians are that what they see on the ultrasound is real."
"For straightforward appendicitis, the greatest variation is in what’s done in the OR," Rangel reports. He points to differences in equipment, like staplers, and "different approaches to how you operate and remove the appendix." The inconsistencies continue after the operation is over. The study found "dramatic variation" in the use of PICC lines, imaging to detect abscesses in the postoperative period and use of total parenteral nutrition (TPN), a costly and potentially dangerous form of nutrition given intravenously.
"Appendicitis patients, for the most part, are previously healthy kids. There should be zero kids bouncing back."
All of these inconsistencies lead to lower-quality, higher-priced care. To help address the problem and provide hospitals with insight into where they can prioritize their quality improvement efforts, the CHA Appendectomy QI Project was launched.
Involving 31 hospitals from the CHA, the project uses comparative performance reporting and peer networking with the goal of driving QI on a national level through knowledge-sharing and best practice dissemination from high-performing hospitals. Information from member hospitals is used to create the quarterly appendicitis report cards, which can be used to prioritize quality improvements at individual hospitals. In addition, the reports lead member hospitals to share knowledge in an effort to determine best practices.
The report card features the following data:
- diagnostic imaging use (CT and ultrasound)
- PICC line utilization
- TPN utilization
- readmission and revisit (ED) rates
- costs (index admission and total)
- hospital days per cure
Rangel suggests that the data from the report cards will establish benchmarks for appendicitis care and help establish practice standards around both diagnosis and treatment. This, he says, will directly address the cost concerns surrounding appendicitis readmissions, among others, and drive needed quality improvements.
"There’s been an increased focus in recent years on readmissions," he says, "not only because they’re very expensive but because the quality metrics that are part of the Affordable Care Act will lead to more public reporting." No hospital, he states, wants to wear the "scarlet letter" of being a high-readmission rate "outlier."