Evaluating Hospital Readmissions for Persons With Serious and Complex Illness: A Competing Risks Approach

Abstract

Hospital readmission rate is a ubiquitous measure of efficiency and quality. Individuals with life-limiting illnesses account heavily for admissions but evaluation is complicated by high-mortality rates. We report a retrospective cohort study examining the association between palliative care (PC) and readmissions while controlling for postdischarge mortality with a competing risks approach. Eligible participants were adult inpatients admitted to an academic, safety-net medical center (2009-2015) with at least one diagnosis of cancer, heart failure, chronic obstructive pulmonary disease, liver failure, kidney failure, AIDS/HIV, and selected neurodegenerative conditions. PC was associated with reduced 30-, 60-, and 90-day readmissions (subhazard ratios = 0.57, 0.53, and 0.52, respectively [all p < .001]). Hospital PC is associated with a reduction in readmissions, and this is not explained by higher mortality among PC patients. Performance measures only counting those alive at a given end point may underestimate systematically the effects of treatments with a high-mortality rate.

Keywords

hospital readmissions mortality palliative care retrospective studies

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References

Adelson

Paris

Horton

J. R.

Hernandez-Tellez

Ricks

Morrison

R. S.

Smith

C. B.

(2017). Standardized criteria for palliative care consultation on a solid tumor oncology service reduces downstream health care use. Journal of Oncology Practice, 13, e431-e440. doi:10.1200/jop.2016.016808

Aldridge Carlson

M. D

. (2013). Research methods priorities in geriatric palliative medicine. Journal of Palliative Medicine, 16, 838-842. doi:10.1089/jpm.2013.9492

Austin

P. C.

(2009). Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Statistics in Medicine, 28, 3083-3107. doi:10.1002/sim.3697

Austin

P. C.

Fine

J. P.

(2017). Accounting for competing risks in randomized controlled trials: A review and recommendations for improvement. Statistics in Medicine, 36, 1203-1209. doi:10.1002/sim.7215

Bakitas

Tosteson

Lyons

Hull

. . . Dragnev

K. H.

(2014, April). The ENABLE III randomized controlled trial of concurrent palliative oncology care. Paper presented at the ASCO Annual Meeting, Chicago, IL.

Brooks

J. M.

Ohsfeldt

R. L.

(2013). Squeezing the balloon: Propensity scores and unmeasured covariate balance. Health Service Research, 48, 1487-1507. doi:10.1111/1475-6773.12020

Calton

B. A.

Alvarez-Perez

Portman

D. G.

Ramchandran

K. J.

Sugalski

Rabow

M. W.

(2016). The current state of palliative care for patients cared for at leading US cancer centers: The 2015 NCCN Palliative Care Survey. Journal of National Comprehensive Cancer Network, 14, 859-866.

Center to Advance Palliative Care. (2018). National Palliative Care Registry. Retrieved from https://registry.capc.org/

Centers for Disease Control and Prevention. (2017). National death index. Retrieved from https://www.cdc.gov/nchs/ndi/index.htm

10.

Centers for Medicare & Medicaid Services. (2017a). Hospital Readmissions Reduction Program (HRRP). Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

11.

Centers for Medicare & Medicaid Services. (2017b). Measure methodology reports. Retrieved from http://www.qualitynet.org/dcs/ContentServer?cid=1219069855841&pagename=QnetPublic%2FPage%2FQnetTier4&c=Page

12.

Centers for Medicare & Medicaid Services. (2018, November). Hospital compare preview reports. QualityNet. Retrieved from https://www.qualitynet.org/

13.

Chuang

Kim

Blank

A. E.

Southern

Fausto

(2017). 30-Day readmission rates in patients admitted for heart failure exacerbation with and without palliative care consultation: A Retrospective cohort study. Journal of Palliative Medicine, 20, 163-169. doi:10.1089/jpm.2016.0305

14.

Dartmouth Atlas. (2017). Inpatient days per decedent during the last six months of life, by gender and level of care intensity for 2014. Retrieved from https://atlasdata.dartmouth.edu/

15.

Donoghoe

M. W.

Gebski

(2017). The importance of censoring in competing risks analysis of the subdistribution hazard. BMC Medical Research Methodology, 17, 52. doi:10.1186/s12874-017-0327-3

16.

Earle

C. C.

Ayanian

J. Z.

(2006). Looking back from death: The value of retrospective studies of end-of-life care. Journal of Clinical Oncology, 24, 838-840. doi:10.1200/JCO.2005.03.9388

17.

Elixhauser

Steiner

Harris

D. R.

Coffey

R. M.

(1998). Comorbidity measures for use with administrative data. Medical Care, 36, 8-27.

18.

Ewing

Rogers

Barclay

McCabe

Martin

Todd

(2004). Recruiting patients into a primary care based study of palliative care: Why is it so difficult? Palliative Medicine, 18, 452-459.

19.

Ferrell

B. R.

Temel

J. S.

Temin

Alesi

E. R.

Balboni

T. A.

Basch

E. M.

. . . Smith

T. J.

(2017). Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice guideline update. Journal of Clinical Oncology, 35, 96-112. doi:10.1200/jco.2016.70.1474

20.

Fingar

K. R.

Barrett

M. L.

Elixhauser

Stocks

Steiner

C. A.

(2015). Trends in potentially preventable inpatient hospital admissions and emergency department visits. Retrieved from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb195-Potentially-Preventable-Hospitalizations.pdf

21.

Gade

Venohr

Conner

McGrady

Beane

Richardson

R. H.

. . . Della Penna

(2008). Impact of an inpatient palliative care team: A randomized control trial. Journal of Palliative Medicine, 11, 180-190. doi:10.1089/jpm.2007.0055

22.

Garrido

M. M.

(2014). Propensity scores: A practical method for assessing treatment effects in pain and symptom management research. Journal of Pain and Symptom Management, 48, 711-718. doi:10.1016/j.jpainsymman.2014.05.014

23.

Garrido

M. M.

Kelley

A. S.

Paris

Roza

Meier

D. E.

Morrison

R. S.

Aldridge

M. D.

(2014). Methods for constructing and assessing propensity scores. Health Service Research, 49, 1701-1720. doi:10.1111/1475-6773.12182

24.

Hawley

(2017). Barriers to access to palliative care. Palliative Care: Research and Treatment, 10. doi:10.1177/1178224216688887

25.

Higginson

I. J.

Evans

C. J.

Grande

Preston

Morgan

McCrone

. . . Todd

(2013). Evaluating complex interventions in end of life care: The MORECare statement on good practice generated by a synthesis of transparent expert consultations and systematic reviews. BMC Medicine, 11, 111. doi:10.1186/1741-7015-11-111

26.

Imai

Ratkovic

(2014). Covariate balancing propensity score. Journal of the Royal Statistical Society: Series B, 76, 243-263. doi:10.1111/rssb.12027

27.

Johnston

B. M.

Normand

May

. (2017). Economics of palliative care: Measuring the full value of an intervention. Journal of Palliative Medicine, 20, 222-224. doi:10.1089/jpm.2016.0446

28.

Kavalieratos

Corbelli

Zhang

Dionne-Odom

J. N.

Ernecoff

N. C.

Hanmer

. . . Schenker

(2016). Association between palliative care and patient and caregiver outcomes: A systematic review and meta-analysis. Journal of the American Medical Association, 316, 2104-2114. doi:10.1001/jama.2016.16840

29.

Kelley

A. S.

Covinsky

K. E.

Gorges

R. J.

McKendrick

Bollens-Lund

Morrison

R. S.

Ritchie

C. S.

(2016). Identifying older adults with serious illness: A critical step toward improving the value of health care. Health Service Research, 52, 113-131. doi:10.1111/1475-6773.12479

30.

Kelley

A. S.

Morrison

R. S.

(2015). Palliative care for the seriously ill. New England Journal of Medicine, 373, 747-755. doi:10.1056/NEJMra1404684

31.

Kelley

A. S.

Morrison

R. S.

Wenger

N. S.

Ettner

S. L.

Sarkisian

C. A.

(2010). Determinants of treatment intensity for patients with serious illness: A new conceptual framework. Journal of Palliative Medicine, 13, 807-813. doi:10.1089/jpm.2010.0007

32.

Kilgore

M. L.

Patel

H. K.

Kielhorn

Maya

J. F.

Sharma

(2017). Economic burden of hospitalizations of Medicare beneficiaries with heart failure. Risk Management and Healthcare Policy, 10, 63-70. doi:10.2147/RMHP.S130341

33.

Langton

J. M.

Blanch

Drew

A. K.

Haas

Ingham

J. M.

Pearson

S. A.

(2014). Retrospective studies of end-of-life resource utilization and costs in cancer care using health administrative data: A systematic review. Palliative Medicine, 28, 1167-1196. doi:10.1177/0269216314533813

34.

May

Garrido

M. M.

Cassel

J. B.

Kelley

A. S.

Meier

D. E.

Normand

. . . Morrison

R. S.

(2015). Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: Earlier consultation is associated with larger cost-saving effect. Journal of Clinical Oncology, 33, 2745-2752.

35.

May

Garrido

M. M.

Cassel

J. B.

Morrison

R. S.

Normand

(2016). Using length of stay to control for unobserved heterogeneity when estimating treatment effect on hospital costs with observational data: Issues of reliability, robustness, and usefulness. Health Service Research, 51, 2020-2043. doi:10.1111/1475-6773.12460

36.

May

Garrido

M. M.

Del Fabbro

Noreika

Normand

Skoro

Cassel

J. B.

(2018). Does modality matter? Palliative care units associated with more cost-avoidance than consultations. Journal of Pain and Symptom Management, 55, 766-774. doi:10.1016/j.jpainsymman.2017.08.011

37.

May

Normand

Cassel

J. B.

Del Fabbro

Fine

R. L.

Menz

. . . Morrison

R. S.

(2018). Economics of palliative care for hospitalized adults with serious illness: A meta-analysis. JAMA Internal Medicine, 178, 820-829. doi:10.1001/jamainternmed.2018.0750

38.

May

Normand

Morrison

R. S.

(2014). Economic impact of hospital inpatient palliative care consultation: Review of current evidence and directions for future research. Journal of Palliative Medicine, 17, 1054-1063. doi:10.1089/jpm.2013.0594

39.

McIlvennan

C. K.

Eapen

Z. J.

Allen

L. A.

(2015). Hospital readmissions reduction program. Circulation, 131, 1796-1803. doi:10.1161/CIRCULATIONAHA.114.010270

40.

Meier

D. E.

(2011). Increased access to palliative care and hospice services: Opportunities to improve value in health care. Milbank Quarterly, 89, 343-380. doi:10.1111/j.1468-0009.2011.00632.x

41.

Morrison

R. S.

(2013). Models of palliative care delivery in the United States. Current Opinion in Supportive and Palliative Care, 7, 201-206. doi:10.1097/SPC.0b013e32836103e5

42.

Morrison

R. S.

Penrod

J. D.

Cassel

J. B.

Caust-Ellenbogen

Litke

Spragens

Meier

D. E.

(2008). Cost savings associated with US hospital palliative care consultation programs. JAMA Internal Medicine, 168, 1783-1790. doi:10.1001/archinte.168.16.1783

43.

National Coalition for Hospice & Palliative Care. (2013). Clinical practice guidelines for quality palliative care. Retrieved from https://www.nationalcoalitionhpc.org/ncp-guidelines-2013/

44.

National Technical Information Service. (2018). Social security death master file. Retrieved from https://dmf.ntis.gov/

45.

Ness

Kramer

(2013, August 16). Reducing hospital readmissions: It’s about improving patient care. Health Affairs. Retrieved from http://healthaffairs.org/blog/2013/08/16/reducing-hospital-readmissions-its-about-improving-patient-care/

46.

Neumann

P. J.

Sanders

G. D.

Russell

L. B.

Siegel

J. E.

Ganiats

T. G.

(2017). Cost effectiveness in health and medicine (2nd ed.). New York, NY: Oxford University Press.

47.

O’Connor

N. R.

Moyer

M. E.

Behta

Casarett

D. J.

(2015). The impact of inpatient palliative care consultations on 30-day hospital readmissions. Journal of Palliative Medicine, 18, 956-961. doi:10.1089/jpm.2015.0138

48.

Penrod

J. D.

Garrido

M. M.

McKendrick

May

Aldridge

M. D.

Meier

D. E.

. . . Morrison

R. S.

(2017). Characteristics of hospitalized cancer patients referred for inpatient palliative care consultation. Journal of Palliative Medicine, 20, 1321-1326. doi:10.1089/jpm.2017.0111

49.

R Core Team. (2016). R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing.

50.

Rubin

D. B.

(2007). The design versus the analysis of observational studies for causal effects: Parallels with the design of randomized trials. Statistics in Medicine, 26, 20-36. doi:10.1002/sim.2739

51.

Spetz

Dudley

Trupin

Rogers

Meier

D. E.

Dumanovsky

(2016). Few hospital palliative care programs meet national staffing recommendations. Health Affairs, 35, 1690-1697. doi:10.1377/hlthaff.2016.0113

52.

StataCorp. (2011). Stata statistical software (Version 12) [Computer software]. College Station, TX: Author.

53.

Szychowski

J. M.

Roth

D. L.

Clay

O. J.

Mittelman

M. S.

(2010). Patient death as a censoring event or competing risk event in models of nursing home placement. Statistics in Medicine, 29, 371-381. doi:10.1002/sim.3797

54.

Tangeman

J. C.

Rudra

C. B.

Kerr

C. W.

Grant

P. C.

(2014). A hospice-hospital partnership: Reducing hospitalization costs and 30-day readmissions among seriously ill adults. Journal of Palliative Medicine, 17, 1005-1010. doi:10.1089/jpm.2013.0612

55.

Temel

J. S.

Greer

J. A.

Muzikansky

Gallagher

E. R.

Admane

Jackson

V. A.

. . . Lynch

T. J.

(2010). Early palliative care for patients with metastatic non-small-cell lung cancer. New England Journal of Medicine, 363, 733-742. doi:10.1056/NEJMoa1000678

56.

The Joint Commission. (2014). Advanced certification for palliative care programs. Retrieved from http://www.jointcommission.org/certification/palliative_care.aspx

57.

Varadhan

Weiss

C. O.

Segal

J. B.

A. W.

Scharfstein

Boyd

(2010). Evaluating health outcomes in the presence of competing risks: A review of statistical methods and clinical applications. Medical Care, 48(Suppl. 6), S96-S105. doi:10.1097/MLR.0b013e3181d99107

58.

Weissman

D. E.

Meier

D. E.

(2008). Operational features for hospital palliative care programs: Consensus recommendations. Journal of Palliative Medicine, 11, 1189-1194. doi:10.1089/jpm.2008.0149

59.

Weissman

D. E.

Meier

D. E.

(2009). Center to advance palliative care inpatient unit operational metrics: Consensus recommendations. Journal of Palliative Medicine, 12, 21-25. doi:10.1089/jpm.2008.0210

60.

Wolbers

Koller

M. T.

Stel

V. S.

Schaer

Jager

K. J.

Leffondré

Heinze

(2014). Competing risks analyses: Objectives and approaches. European Heart Journal, 35, 2936-2941. doi:10.1093/eurheartj/ehu131

61.

Zimmermann

Swami

Krzyzanowska

Hannon

Leighl

Oza

. . . Lo

(2014). Early palliative care for patients with advanced cancer: A cluster-randomised controlled trial. Lancet, 383, 1721-1730. doi:10.1016/S0140-6736(13)62416-2