Sydney E S Brown1, Sarah J Ratcliffe2, Scott D Halpern3. 1. Center for Clinical Epidemiology and Biostatistics and Division of Pulmonary, Department of Anesthesiology and Critical Care, University of Pennsylvania. Electronic address: sydneyesbrown@gmail.com. 2. Center for Clinical Epidemiology and Biostatistics and Division of Pulmonary. 3. Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Center for Bioethics, Philadelphia, PA.
Abstract
BACKGROUND: ICU readmissions are associated with increased mortality and costs; however, it is unclear whether these outcomes are caused by readmissions or by 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 Accreditation Council for Graduate Medical Education Resident Duty Hours reform ("reform") and whether there were temporally corresponding changes in other ICU outcomes. METHODS: We used a difference-in-differences approach using Project IMPACT (Improved Methods of Patient Information Access of Core Clinical Tasks). 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 US 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; 95% CI, 1.22-1.84; P < .01), and decreased after (OR, 0.85; 95% CI, 0.73-0.98; P = .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 < .01). No comparable changes in mortality were observed between ICUs with vs 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.
BACKGROUND: ICU readmissions are associated with increased mortality and costs; however, it is unclear whether these outcomes are caused by readmissions or by 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 Accreditation Council for Graduate Medical Education Resident Duty Hours reform ("reform") and whether there were temporally corresponding changes in other ICU outcomes. METHODS: We used a difference-in-differences approach using Project IMPACT (Improved Methods of Patient Information Access of Core Clinical Tasks). 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 US 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; 95% CI, 1.22-1.84; P < .01), and decreased after (OR, 0.85; 95% CI, 0.73-0.98; P = .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 < .01). No comparable changes in mortality were observed between ICUs with vs 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.
Authors: David R Baker; Peter J Pronovost; Laura L Morlock; Romergryko G Geocadin; Christine G Holzmueller Journal: Crit Care Med Date: 2009-11 Impact factor: 7.598
Authors: Jean-Blaise Wasserfallen; Jean-Pierre Revelly; Davide Moro; Nicolas Gilliard; Jacques Rouge; René Chioléro Journal: Intensive Care Med Date: 2004-02-28 Impact factor: 17.440
Authors: Kim J Burchiel; Rowen K Zetterman; Kenneth M Ludmerer; Ingrid Philibert; Timothy P Brigham; Kathy Malloy; James A Arrighi; Stanley W Ashley; Jessica L Bienstock; Peter J Carek; Ricardo Correa; David A Forstein; Robert R Gaiser; Jeffrey P Gold; George A Keepers; Benjamin C Kennedy; Lynne M Kirk; Anai Kothari; Lorrie A Langdale; Philip H Shayne; Steven C Stain; Suzanne K Woods; Claudia Wyatt-Johnson; Thomas J Nasca Journal: J Grad Med Educ Date: 2017-12
Authors: Jungsil Lee; Young Jae Cho; Se Joong Kim; Ho Il Yoon; Jong Sun Park; Choon Taek Lee; Jae Ho Lee; Yeon Joo Lee Journal: J Korean Med Sci Date: 2017-03 Impact factor: 2.153
Authors: Nelleke van Sluisveld; Anke Oerlemans; Gert Westert; Johannes Gerardus van der Hoeven; Hub Wollersheim; Marieke Zegers Journal: BMC Health Serv Res Date: 2017-04-04 Impact factor: 2.655
Authors: Rebecca L Hoffman; Jason Saucier; Serena Dasani; Tara Collins; Daniel N Holena; Meghan Fitzpatrick; Boris Tsypenyuk; Niels D Martin Journal: Int J Qual Health Care Date: 2017-06-01 Impact factor: 2.038