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
Illness Severity Quality of Outpatient Facility Conceptual Framework Poor inpatient quality of care Incomplete Evaluation or Management of Condition Increased Readmission Rates
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
All Readmissions: Medical Factors All values report incident rate ratios for the given risk factor * P < 0.05; ** P < 0.01; *** P < 0.001
All Readmissions: Sociodemographic Factors All values report incident rate ratios for the given risk factor * P < 0.05; ** P < 0.01; *** P < 0.001
Patient Program NICU 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.
ACS Readmissions: Medical Factors All values report incident rate ratios for the given risk factor * P < 0.05; ** P < 0.01; *** P < 0.001
ACS Readmissions: Sociodemographic Factors All values report incident rate ratios for the given risk factor * P < 0.05; ** P < 0.01; *** P < 0.001
Oral Albuterol Inhaled Albuterol Viral antibiotics Facility Characteristics and Readmissions
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)