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Assessing the utility of ICU readmissions as a quality metric: An analysis of changes mediated by residency work-hour reforms.
Chest. 2014 Nov 13;
Authors: Brown SE, Ratcliffe SJ, Halpern SD
Abstract
Background: ICU readmissions are associated with increased mortality and costs; however, it is unclear whether these outcomes are caused by readmissions as opposed to residual confounding by illness severity. An assessment of temporal changes in ICU readmission in response to a specific policy change could help disentangle these possibilities. We sought to determine whether ICU readmission rates changed after 2003 ACGME Resident Duty Hours reform ("reform"), and whether there were temporally corresponding changes in other ICU outcomes.
Methods: We utilized a difference-in-differences approach using Project IMPACT. Piecewise regression models estimated changes in outcomes immediately before and after reform in 274,491 critically ill medical and surgical patients in 151 community and academic U.S. ICUs. Outcome measures included ICU readmission, ICU mortality, and in-hospital post-ICU-discharge mortality.
Results: In ICUs with residents ICU readmissions increased before reform (OR: 1.5 (1.22, 1.84), p<0.01), and decreased after (OR: 0.85 (0.73, 0.98), p=0.03). This abrupt decline in ICU readmissions after reform differed significantly from an increase in readmissions observed in ICUs without residents at this time (difference-in-differences p<0.01). No comparable changes in mortality were observed between ICUs with versus without residents.
Conclusions: The changes in ICU readmission rates after reform, without corresponding changes in mortality, suggest that ICU readmissions are not causally related to other untoward patient outcomes. Instead, ICU readmission rates likely reflect operational aspects of care that are not patient-centered, making them less useful indicators of ICU quality.
PMID: 25393027 [PubMed - as supplied by publisher]