respiratory failure causing readmission to the icu · 1. respiratory failure is the single biggest...
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Scott D. Halpern, M.D., Ph.D.Associate Professor of Medicine, Epidemiology, and Medical Ethics & Health Policy
Director, Fostering Improvement in End-of-Life Decision Science (FIELDS) program
Deputy Director, Center for Health Incentives and Behavioral Economics (CHIBE)
Respiratory Failure Causing Readmission to the ICU
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Scott D. Halpern, M.D., Ph.D.Associate Professor of Medicine, Epidemiology, and Medical Ethics & Health Policy
Director, Fostering Improvement in End-of-Life Decision Science (FIELDS) program
Deputy Director, Center for Health Incentives and Behavioral Economics (CHIBE)
Respiratory Failure as a Factor Associated withReadmission to the ICU
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Scott D. Halpern, M.D., Ph.D.Associate Professor of Medicine, Epidemiology, and Medical Ethics & Health Policy
Director, Fostering Improvement in End-of-Life Decision Science (FIELDS) program
Deputy Director, Center for Health Incentives and Behavioral Economics (CHIBE)
Readmission to the ICU: not a measure of ICU quality, with or without respiratory failure
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Grant support
NIH (NHLBI, NIA, NCI)
Robert Wood Johnson Foundation
American Heart Association
Greenwall Foundation
Otto Haas Charitable Trust
Gordon and Betty Moore Foundation Paid consultancy
ABIM Foundation’s Choosing Wising
program
In-kind research support
• Cerner
• CVS Health
• Ascension Health
• Kaiser Permanente
Disclosures
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Does scarcity affect ICU patients?Patients readmitted to ICU have much worse outcomes than those who are not
Kramer AA, Higgins TL, Zimmerman JE. Crit Care Med 2012; 40
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Does scarcity affect ICU patients?Readmission rate as an ICU quality marker
• 1995: SCCM Quality Indicators Committee ranks ICU readmission within 48 hours as top indicator of ICU quality
• 1999: Cooper et al. cast skepticism
• No association between ICU readmission rates and case-mix-adjusted in-hospital mortality rates among 28 hospitals
• 2012: ESICM endorses 48-hour readmission as quality measure (1 of 4 outcome measures)
Cooper GS et al. Are readmissions to the intensive care unit a useful measure of hospital performance? Medical Care 1999, 37:399-408.
Rhodes A, et al. Prospectively defined indicators to improve the safety and quality of care for critically ill patients. Intensive Care Med. 2012;38(4):598-605
Society of Critical Care Medicine Quality Indicators Committee. Candidate critical care quality indicators. Anaheim, CA: Society of Critical Care Medicine; 1995.
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Does scarcity affect ICU patients?48-hour readmissions as a quality marker
“A high early re-admission rate suggests poor ICU discharge decision making. It can be caused by discharges occurring before
the patient is ready for ward-based care, incorrect use of ward care and deficient hand-over to staff taking over the care and
responsibility of the patient.”
Rhodes A, et al. Intensive Care Med. 2012;38(4):598-605
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Readmitted patients more commonly have respiratory failure at initial ICU admission
Kramer AA, Higgins TL, Zimmerman JE. Crit Care Med 2012; 40
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Respiratory failure #1 cause of ICU readmission
Brown SES, et al. AJRCCM 2012
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Timing of ICU readmissions
Brown SES, et al. AJRCCM 2012
50% of ICU readmissions within 2 days
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Metrics of severity of illness at ICU admission displayed greater associations with ICU readmission at longer readmission intervals
Inflection point between 2.5 – 3 days
Brown SES, Ratcliffe SJ, Halpern SD. Medical Care 2013
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Readmissions and ICU-based life support
Brown SES, Ratcliffe SJ, Halpern SD. Medical Care 2013
214,697 patients admitted to 157 ICUs in Project IMPACT from 2001-2008
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Importance of ICU discharge practices
Brown SES, Ratcliffe SJ, Halpern SD. Medical Care 2013
214,697 patients admitted to 157 ICUs in Project IMPACT from 2001-2008
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Night-time discharges: a risk for readmission?
Brown SES, Ratcliffe SJ, Halpern SD. Medical Care 2013
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Most readmissions in afternoon regardless of discharge time
Brown SES, Ratcliffe SJ, Halpern SD. Medical Care 2013
Sinusoidal pattern and significance of nighttime discharge risk vanish when defining ICU readmission by calendar days
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Higher deciles of
acuity
Wagner J, et al. Ann Intern Med 2013; 159: 447-455
200,730 patients discharged alive
from 157 U.S. ICUs, 2001-2008
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Strain at ICU discharge influences flow, not ultimate outcomes
*
Wagner J, et al. Ann Intern Med 2013; 159: 447-455
• Extreme increases in all 3 strain measures yielded 6.3 hour reduction in ICU LOS and 1% increase in ICU readmissions among discharged patients (both p < 0.02)
• No differences in subsequent mortality or probability of being discharged home
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Brown SES, Ratcliffe SJ, Halpern SD. Chest 2015
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Correspondence to mortality rates?
Gorodeski EZ, Starling RC, Blackstone EH. NEJM 2010; 363: 297-8.
3857 hospitals in CMS Hospital Compare
Patients with primary diagnosis of congestive heart
failure
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Brown SES, Ratcliffe SJ, Halpern SD. Chest 2015
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Should we evaluate “failure to rescue” patients readmitted to ICU?
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Conclusions1. Respiratory failure is the single biggest reason for ICU readmission
2. If we want to examine ICU readmission as a marker of ICU quality, define it as within 2 calendar days
3. Of the many factors that may cause ICU readmission, there is no available evidence that the quality of ICU care is one of them (some suggestion of protective effect)
4. “Failure to rescue readmitted patients” is a conceptually better ICU quality measure, but need to account for deaths following preference-concordant withholding/withdrawal of life support
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Penn Critical Care Health Services Research Group
Meeta Prasad Kerlin, MD, MSCE Sarah Ratcliffe, PhD
Elizabeth Cooney, MPH Mark Mikkelsen, MD, MSCE
Kate Courtright, MD Michael Detsky, MD, MSHP
Dylan Small, PhD Michael Harhay, PhD (c)
Michael Josephs Nicole Gabler, PhD
Joanna Hart, MD, MSHP Kuldeep Yadav
Anna Buehler Gary Weissman, MD
Sydney Brown, MD, PhD Mark Neumann, MD, MSc
Meghan Lane-Fall, MD, MSHP George Anesi, MD
Rachel Kohn, MD Mary McKenzie, MD, MSHP