The Utility of ICU Readmission as a Quality Indicator and the Effect of Selection

Objectives: Intensive care readmission rates are used to signal quality, yet it is unclear whether they represent poor quality in the transition of care from the ICU to the ward, patient factors, or differences in survival of the initial admission. This study aims to measure the selection effect of surviving the initial ICU admission on readmission rates. Design: Retrospective cohort study of adult patients admitted to ICUs participating in the Case Mix Program database from the Intensive Care National Audit Research Centre. Settings: The study includes 262 ICUs in the United Kingdom. Patients: The study includes 682,975 patients admitted to ICUs between 2010 and 2014. Interventions: None. Measurements and Main Results: The study includes 682,975 patients admitted to ICUs in the United Kingdom. There were 591,710 patients discharged alive, of which 9,093 (1.53%) were readmitted within the first 2 days of ICU discharge. Post-ICU admission hospital mortality and ICU readmission were poorly correlated (r = 0.130). The addition of a selection model resulted in a weaker correlation (r = 0.082). Conclusions: ICU readmission performed poorly as a performance metric. The selection process by which only patients who survive their index admission are eligible for readmission has a significant effect on ICU readmission rankings, particularly the higher ranked ICUs. Failure to consider this selection bias gives misleading signals about ICU performance and leads to faulty design of incentive schemes. These data derive from the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme Database. The Case Mix Programme is the national comparative audit of patient outcomes from adult critical care coordinated by ICNARC. For more information on the representativeness and quality of these data, please contact ICNARC. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of Intensive Care National Audit and Research Centre. Dr. Maharaj contributed to conception and design. All authors contributed to analysis and interpretation and drafting the article for important intellectual content. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/29S62lw). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: Ritesh.maharaj@kcl.ac.uk Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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