Assessing the utility of ICU readmissions as a quality metric: an analysis of changes mediated by residency work-hour reforms.
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.
Center for Clinical Epidemiology and Biostatistics and Division of Pulmonary, Department of Anesthesiology and Critical Care, University of Pennsylvania. Electronic address: sydneyesbrown@gmail.com.
Sydney E S
SES
Brown
Center for Clinical Epidemiology and Biostatistics and Division of Pulmonary.
Sarah J
SJ
Ratcliffe
Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Center for Bioethics, Philadelphia, PA.
Scott D
SD
Halpern
D000368:Aged; D000369:Aged, 80 and over; D016638:Critical Illness / Q000401:mortality / Q000628:therapy*; D005260:Female; D018166:Health Care Reform / Q000639:trends*; D062489:Health Impact Assessment; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D007396:Internship and Residency / Q000706:statistics & numerical data*; D008297:Male; D017063:Outcome Assessment, Health Care; D010359:Patient Readmission / Q000706:statistics & numerical data*; D010561:Personnel Staffing and Scheduling / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000592:standards*; D012044:Regression Analysis; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D015996:Survival Rate; D016526:Workload / Q000706:statistics & numerical data*