Analysis of hospital readmissions with competing risks

The 30-day hospital readmission rate has been used in provider profiling for evaluating inter-provider care coordination, medical cost effectiveness, and patient quality of life. Current profiling analyzes use logistic regression to model 30-day readmission as a binary outcome, but one disadvantage of this approach is that this outcome is strongly affected by competing risks (e.g., death). Thus, one, perhaps unintended, consequence is that if two facilities have the same rates of readmission, the one with the higher rate of competing risks will have the lower 30-day readmission rate. We propose a discrete time competing risk model wherein the cause-specific readmission hazard is used to assess provider-level effects. This approach takes account of the timing of events and focuses on the readmission rates which are of primary interest. The quality measure, then is a standardized readmission ratio, akin to a standardized mortality ratio. This measure is not systematically affected by the rate of competing risks. To facilitate the estimation and inference of a large number of provider effects, we develop an efficient Blockwise Inversion Newton algorithm, and a stabilized robust score test that overcomes the conservative nature of the classical robust score test. An application to dialysis patients demonstrates improved profiling, model fitting, and outlier detection over existing methods.