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Readmissions as a measure of quality for neonatal intensive care units (NICU) and outpatient practices SA Lorch 1, JH Silber 1, GE Escobar 2, D Small 3.

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Presentation on theme: "Readmissions as a measure of quality for neonatal intensive care units (NICU) and outpatient practices SA Lorch 1, JH Silber 1, GE Escobar 2, D Small 3."— Presentation transcript:

1 Readmissions as a measure of quality for neonatal intensive care units (NICU) and outpatient practices SA Lorch 1, JH Silber 1, GE Escobar 2, D Small 3 1 Center for Outcomes Research, Dept of Pediatrics, The Childrens Hospital of Philadelphia 2 Perinatal Research Center, Kaiser Permanente Medical System, Oakland, CA 3 Dept of Statistics, The Wharton School

2 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

3 Conceptual Framework Poor inpatient quality of care Incomplete Evaluation or Management of Condition Increased Readmission Rates

4 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

5 Conceptual Framework Poor inpatient quality of care Incomplete Evaluation or Management of Condition Increased Readmission Rates Illness SeverityQuality of Outpatient Facility

6 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

7 Patient Population 5 Northern California Kaiser Permanente hospitals 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

8 Exclusion Criteria Major congenital anomalies Need for home ventilation Loss to follow-up within 1 year of discharge –Typically from leaving the Kaiser system

9 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

10 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

11 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.

12 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.

13 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

14 Timing of Readmissions

15 All Readmissions: Medical Factors 0-1 mos0-3 mos3-12 mos Gestational Age < 26 wks8.65***5.43**2.80*** wks6.48***3.36**1.98** wks6.17***2.79** wksReference NEC ***2.60* BPD2.20* Home on oxygen All values report incident rate ratios for the given risk factor* P < 0.05; ** P < 0.01; *** P < 0.001

16 All Readmissions: Sociodemographic Factors 0-1 mos0-3 mos3-12 mos Each sibling at home *** Median Area Income, per $10, Racial/Ethnic StatusReference Asian/Other Black Hispanic WhiteReference Maternal Age < 18 yrs Male Sex All values report incident rate ratios for the given risk factor* P < 0.05; ** P < 0.01; *** P < 0.001

17 All Readmissions: NICU and Outpatient Facilities 0-1 mos0-3 mos3-12 mos NICU measured alone NICU Variation < NICU measured with outpatient facility NICU Variation Outpatient Facility Variation

18 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 NIC U Program

19 ACS Readmissions: Medical Factors 0-1 mos0-3 mos3-12 mos Gestational Age < 26 wks15.66***7.43***2.89** wks15.32***3.13** wks21.01***3.79*** wksReference NEC *** BPD Home on oxygen All values report incident rate ratios for the given risk factor* P < 0.05; ** P < 0.01; *** P < 0.001

20 ACS Readmissions: Sociodemographic Factors 0-1 mos0-3 mos3-12 mos Each sibling at home *1.43*** Median Area Income, per $10, Racial/Ethnic StatusReference Asian/Other Black Hispanic WhiteReference Maternal Age < 18 yrs Male Sex All values report incident rate ratios for the given risk factor* P < 0.05; ** P < 0.01; *** P < 0.001

21 ACS Readmissions: NICU and Outpatient Facilities 0-1 mos0-3 mos3-12 mos NICU measured alone NICU Variation < NICU measured with outpatient facility NICU Variation Outpatient Facility Variation < 0.001

22 Oral AlbuterolInhaled AlbuterolViral antibiotics Facility Characteristics and Readmissions

23 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

24 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

25 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.

26 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.

27 Acknowledgements Funded by MCHB R40 MC00238 Thanks to Marla Gardner and John Greene at Northern California Kaiser Permanente health system.

28 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

29 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)


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