Resurrecting immortal‐time bias in the study of readmissions

Abstract

ObjectiveTo compare readmission rates as measured by the Centers for Medicare and Medicaid Services and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) methods.Data Sources20 percent sample of national Medicare data for patients undergoing cystectomy, colectomy, abdominal aortic aneurysm (AAA) repair, and total knee arthroplasty (TKA) between 2010 and 2014.Study DesignRetrospective cohort study comparing 30‐day readmission rates.Data Collection/Extraction MethodsPatients undergoing cystectomy, colectomy, abdominal aortic aneurysm repair, and total knee arthroplasty between 2010 and 2014 were identified.Principal FindingsCystectomy had the highest and total knee arthroplasty had the lowest readmission rate. The NSQIP measure reported significantly lower rates for all procedures compared to the CMS measure, which reflects an immortal‐time bias.ConclusionsWe found significantly different readmission rates across all surgical procedures when comparing CMS and NSQIP measures. Longer length of stay exacerbated these differences. Uniform outcome measures are needed to eliminate ambiguity and synergize research and policy efforts.