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Original Research: Critical Care |

Assessing the Utility of ICU Readmissions as a Quality MetricThe Utility of ICU Readmission as a Quality Metric: An Analysis of Changes Mediated by Residency Work-Hour Reforms

Sydney E. S. Brown, MD, PhD; Sarah J. Ratcliffe, PhD; Scott D. Halpern, MD, PhD
Author and Funding Information

From the Center for Clinical Epidemiology and Biostatistics (Drs Brown and Ratcliffe) and Division of Pulmonary, Allergy, and Critical Care Medicine (Dr Halpern), Perelman School of Medicine at the University of Pennsylvania; Department of Anesthesiology and Critical Care (Dr Brown), University of Pennsylvania; and the Center for Bioethics (Dr Halpern), Philadelphia, PA.

CORRESPONDENCE TO: Sydney E. S. Brown, MD, PhD, University of Pennsylvania School of Medicine, 108 Blockley Hall, 423 Guardian Dr, Philadelphia, PA 19104-6021; e-mail: sydneyesbrown@gmail.com


FUNDING/SUPPORT: This study was supported by the National Heart, Lung, and Blood Institute [F30 HL107020 to Dr Brown] and the Agency for Healthcare Research and Quality [K08 HS018406 to Dr Halpern].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(3):626-636. doi:10.1378/chest.14-1060
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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.

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