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Readmissions as a measure of quality for neonatal intensive care units (NICU)
and outpatient practices
SA Lorch1, JH Silber1, GE Escobar2, D Small3
1 Center for Outcomes Research, Dept of Pediatrics, The Children’s Hospital of Philadelphia
2 Perinatal Research Center, Kaiser Permanente Medical System, Oakland, CA
3 Dept of Statistics, The Wharton School
Background
• There is increased interest in measuring the quality of inpatient care by insurers, public agencies, and patients.
• One proposed measure: risk-adjusted readmission rates
Conceptual Framework
Poor inpatient quality of care
Incomplete Evaluation or Management of Condition
Increased Readmission Rates
Prior Work
• Conflicting data in literature– Ashton (1995): Meta-Analysis, 13 studies
• OR 1.55 for readmission if care received at hospital with sub-standard quality
• Wide range of metrics and time frame for readmissions
– More recent literature did not find this association
• Congestive Heart Failure• Myocardial Infarction
Conceptual Framework
Poor inpatient quality of care
Incomplete Evaluation or Management of Condition
Increased Readmission Rates
Illness Severity Quality of Outpatient Facility
Goals of Study
• Aim 1: Determine the role of NICUs in predicting variations in risk-adjusted readmission rates
• Aim 2: Determine how this role changes when site of outpatient care is accounted for
• Aim 3: Define characteristics of facilities associated with high risk-adjusted readmission rates
Patient Population
• 5 Northern California Kaiser Permanente hospitals
• 1998-2001• Gestational age < 32 weeks at
delivery• Survive to hospital discharge• Received care at 1 of 32 outpatient
clinics affiliated with the Kaiser Permanente health system
Exclusion Criteria
• Major congenital anomalies
• Need for home ventilation
• Loss to follow-up within 1 year of discharge– Typically from leaving the Kaiser
system
Study Definitions• Readmission
– Any unplanned rehospitalization within specified time period
• Ambulatory-care Sensitive Condition– Any readmission for condition “sensitive” to
care provided in outpatient setting• Pneumonia• Asthma• Cellulitis• Failure-to-Thrive
• Time Frame: 0-1 month; 0-3 months; 3-12 months
Data Collection
• Neonatal data– Neonatal Minimal Data Set: prospective
collection of 250 clinical variables, including• Maternal history• Birth history• Complications occurring in NICU
• Outpatient data– Cost Management Information System tracked
all resources used in the outpatient setting, including
• medications and laboratory studies• readmissions, outpatient visits, and emergency room
visits– Demographic data used to define area-level
socioeconomic data based on zip code
Facility Characteristics
• Outpatient facility assigned to child based on site of usual care for well-child visits.
• Characteristics:– Use of oral albuterol (poor quality)– Use of inhaled albuterol for asthma symptoms
(good quality)– Use of antibiotics for viral illness (poor quality)
• Facilities divided into high or low quality for each characteristic.
Statistical Analysis
• Multivariable poisson regression models
• 2 sets of models– Fixed NICU effects included alone (Aim 1)– Random outpatient effects added to the
fixed NICU effects (Aim 2)
• Random outpatient effects accounts for smaller numbers of patients at a given outpatient center.
Demographics
• 892 infants at 5 NICUs and 32 outpatient facilities• Each NICU discharged to 9-17 outpatient facilities• Each outpatient facility received infants from 1-3
NICUs• Gestational Age 29.5 ± 2.2 wks• Racial/Ethnic Distribution:
– 45.5% White non-Hispanic– 20.5% Hispanic– 11.2% Black– 22.8% Asian or Multi-Racial
• 16.6% with BPD, 1.8% with NEC
Timing of Readmissions
Time of Readmissions
0
10
20
30
40
50
60
70
1 2 3 4 5 6 7 8 9 10 11 12
Months after Discharge
Nu
mb
er o
f R
ead
mis
sio
ns
All Readmissions: Medical Factors
0-1 mos 0-3 mos 3-12 mos
Gestational Age
< 26 wks 8.65*** 5.43** 2.80***
27-28 wks 6.48*** 3.36** 1.98**
29-30 wks 6.17*** 2.79** 1.00
31-32 wks Reference Reference Reference
NEC 2.43
3.55*** 2.60*
BPD 2.20* 1.17 1.21
Home on oxygen 0.75 1.36 1.39
All values report incident rate ratios for the given risk factor * P < 0.05; ** P < 0.01; *** P < 0.001
All Readmissions: Sociodemographic Factors
0-1 mos 0-3 mos 3-12 mos
Each sibling at home 1.13 1.06 1.34***
Median Area Income, per $10,000
0.98 1.03 0.95
Racial/Ethnic Status Reference Reference Reference
Asian/Other 1.01 0.84 0.99
Black 1.15 1.53 1.18
Hispanic 1.22 0.79 0.91
White Reference Reference Reference
Maternal Age < 18 yrs 1.24 0.70 1.65
Male Sex 0.96 1.21 1.14
All values report incident rate ratios for the given risk factor * P < 0.05; ** P < 0.01; *** P < 0.001
All Readmissions: NICU and Outpatient Facilities
0-1 mos 0-3 mos 3-12 mos
NICU measured alone
NICU Variation 0.24 0.02 < 0.001
NICU measured with outpatient facility
NICU Variation 0.25 0.10 0.07
Outpatient Facility Variation
1.00 1.00 0.011
Example of Attributable Variation: All readmissions 0-3 months
Area of each circle represents the proportional amount of variation attributed to each group of factors.
Patient
NICU
Program
ACS Readmissions: Medical Factors
0-1 mos 0-3 mos 3-12 mos
Gestational Age
< 26 wks 15.66*** 7.43*** 2.89**
27-28 wks 15.32*** 3.13** 1.72
29-30 wks 21.01*** 3.79*** 0.72
31-32 wks Reference Reference Reference
NEC 2.44 2.25 2.80***
BPD 2.10 1.12 1.78
Home on oxygen 0.59 1.33 0.81
All values report incident rate ratios for the given risk factor * P < 0.05; ** P < 0.01; *** P < 0.001
ACS Readmissions: Sociodemographic Factors
0-1 mos 0-3 mos 3-12 mos
Each sibling at home 1.04 1.27* 1.43***
Median Area Income, per $10,000
0.96 0.99 0.90
Racial/Ethnic Status Reference Reference Reference
Asian/Other 1.44 0.97 0.80
Black 1.31 1.91 1.13
Hispanic 1.21 0.80 1.03
White Reference Reference Reference
Maternal Age < 18 yrs 1.35 0.64 2.64
Male Sex 0.54 0.84 0.68
All values report incident rate ratios for the given risk factor * P < 0.05; ** P < 0.01; *** P < 0.001
ACS Readmissions: NICU and Outpatient Facilities
0-1 mos 0-3 mos 3-12 mos
NICU measured alone
NICU Variation 0.63 0.06 < 0.001
NICU measured with outpatient facility
NICU Variation 0.63 0.24 0.41
Outpatient Facility Variation
0.50 1.00 < 0.001
Oral Albuterol Inhaled Albuterol Viral antibiotics
Facility Characteristics and Readmissions
0.5
11
.52
2.5
33
.54
Inci
dent
Ra
te R
atio
All 0-1 All 0-3 All 3-12 ACS 0-1 ACS 0-3 ACS 3-12
Limitations
• Data from one health system– NICUs and outpatient facilities with
different practices and outcomes
• No direct information on family income and socioeconomic status
• Cohort more homogeneous than other NICUs, especially academic centers
Conclusions
• Patient-level factors were the primary determinants for readmissions after NICU discharge.
• NICU measured alone:– Significant variations between sites.
• NICU measured with outpatient facilities:– No independent variation between NICUs
Conclusions
• Outpatient facility characteristics associated with poor quality are also associated with higher readmission rates:– High oral albuterol use: 0-3 mos and 3-12 mos– High antibiotic use: 3-12 mos
• Time frame does matter when examining readmission rates.
Implications for Policy
• Readmission rates appear to measure the quality of outpatient facilities, not inpatient hospitals.
• Associations with NICU typical sites of outpatient care to which a NICU discharges.
Acknowledgements
• Funded by MCHB R40 MC00238
• Thanks to Marla Gardner and John Greene at Northern California Kaiser Permanente health system.
Why Study NICUs and Premature Infants?
• Prematurely-born infants are uniformly admitted to NICUs.
• Relatively consistent discharge practices based on development of physiologic skills and weight gain.
• Readmission rates after discharge are high, but do not occur in all patients.– Allows for variation among NICUs and
outpatient settings
Deficits in Literature
• Many conditions do not have validated admission criteria
• Wide variations in time frame– Which time frames are valid?
• No control for site of outpatient care• Ignoring these factors may lead to
faulty assessment of the care provided by inpatient services, such as neonatal intensive care units (NICUs)