  Readmission following discharge from an initial hospitalization is a key
marker of quality of health care in the United States. For the most part,
readmission has been used to study quality of care for patients with acute
health conditions, such as pneumonia and heart failure, with analyses typically
based on a logistic-Normal generalized linear mixed model. Applying this model
to the study readmission among patients with increasingly prevalent advanced
health conditions such as pancreatic cancer is problematic, however, because it
ignores death as a competing risk. A more appropriate analysis is to imbed such
studies within the semi-competing risks framework. To our knowledge, however,
no comprehensive statistical methods have been developed for cluster-correlated
semi-competing risks data. In this paper we propose a novel hierarchical
modeling framework for the analysis of cluster-correlated semi-competing risks
data. The framework permits parametric or non-parametric specifications for a
range of model components, including baseline hazard functions and
distributions for key random effects, giving analysts substantial flexibility
as they consider their own analyses. Estimation and inference is performed
within the Bayesian paradigm since it facilitates the straightforward
characterization of (posterior) uncertainty for all model parameters including
hospital-specific random effects. The proposed framework is used to study the
risk of readmission among 5,298 Medicare beneficiaries diagnosed with
pancreatic cancer at 112 hospitals in the six New England states between
2000-2009, specifically to investigate the role of patient-level risk factors
and to characterize variation in risk across hospitals that is not explained by
differences in patient case-mix.
