The Role of Outpatient Facilities in Explaining Variations in Risk-Adjusted Readmission Rates between Hospitals

Department of Pediatrics, Center for Outcomes Research, The Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
Health Services Research (Impact Factor: 2.78). 09/2009; 45(1):24-41. DOI: 10.1111/j.1475-6773.2009.01043.x
Source: PubMed


Validate risk-adjusted readmission rates as a measure of inpatient quality of care after accounting for outpatient facilities, using premature infants as a test case.
Surviving infants born between January 1, 1998 and December 12, 2001 at five Northern California Kaiser Permanente neonatal intensive care units (NICU) with 1-year follow-up at 32 outpatient facilities.
Using a retrospective cohort of premature infants (N=898), Poisson's regression models determined the risk-adjusted variation in unplanned readmissions between 0-1 month, 0-3 months, 3-6 months, and 3-12 months after discharge attributable to patient factors, NICUs, and outpatient facilities.
Prospectively collected maternal and infant hospital data were linked to inpatient, outpatient, and pharmacy databases.
Medical and sociodemographic factors explained the largest amount of variation in risk-adjusted readmission rates. NICU facilities were significantly associated with readmission rates up to 1 year after discharge, but the outpatient facility where patients received outpatient care can explain much of this variation. Characteristics of outpatient facilities, not the NICUs, were associated with variations in readmission rates.
Ignoring outpatient facilities leads to an overstatement of the effect of NICUs on readmissions and ignores a significant cause of variations in readmissions.

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Available from: Dylan S Small, Oct 04, 2015
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    • "Hospital mortality and readmission rates are important indicators of hospital outcomes that are frequently used to assess and publicise hospital and physician performance. They are also often used in health services research to assess issues such as the impact of service organisation (Coyte et al., 2000; Evans and Kim, 2006; Ho and Hamilton, 2000; Lorch et al., 2010), the relationship between hospital inputs and outcomes (Heggestad, 2002; Schreyogg and Stargardt, 2010), the effect of introducing new policies (Evans et al., 2008) and the impact of new technologies (Xian et al., 2011). The idea behind outcome-based quality indicators such as hospital mortality or readmission rates is that, if appropriate adjustment is made for patient case-mix and external environmental factors, then variations in reported levels of such outcome-based quality indicators are likely to be driven by differences in the (unobservable ) quality of hospital services, as reflected in the processes of hospital care and service organisation. "
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    ABSTRACT: Hospital readmission rates are increasingly used as signals of hospital performance and a basis for hospital reimbursement. However, their interpretation may be complicated by differential patient survival rates. If patient characteristics are not perfectly observable and hospitals differ in their mortality rates, then hospitals with low mortality rates are likely to have a larger share of un-observably sicker patients at risk of a readmission. Their performance on readmissions will then be underestimated. We examine hospitals' performance relaxing the assumption of independence between mortality and readmissions implicitly adopted in many empirical applications. We use data from the Hospital Episode Statistics on emergency admissions for fractured hip in 290,000 patients aged 65 and over from 2003 to 2008 in England. We find evidence of sample selection bias that affects inference from traditional models. We use a bivariate sample selection model to allow for the selection process and the dichotomous nature of the outcome variables.
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