RT Journal Article SR Electronic T1 Competing risks in quality and safety research: a framework to guide choice of analysis and improve reporting JF BMJ Quality & Safety JO BMJ Qual Saf FD BMJ Publishing Group Ltd SP 1031 OP 1037 DO 10.1136/bmjqs-2021-012988 VO 30 IS 12 A1 Perla J Marang-van de Mheen A1 Hein Putter A1 Esther Bastiaannet A1 Alex Bottle YR 2021 UL http://qualitysafety.bmj.com/content/30/12/1031.abstract AB When comparing hospitals on their readmission rates as currently done in the Hospital Readmission and Reduction Program (HRRP) in the USA, should we include the competing risk of mortality after discharge, which precludes the readmission, in the analysis? Not including competing risks in current HRRP metrics was raised recently as a limitation with possible unintended consequences, as financial penalties for higher readmission rates are more severe than for higher mortality rates. Incorrectly including or ignoring competing risks can both induce bias. In this paper, we present a framework to clarify situations when competing risks should be taken into account and when they should not. We argue that the research question and the perspective from which it is asked determine whether the competing risk is also of interest and should be included in the analysis, or if only the event of interest should be considered. This information is often not explicitly reported but is needed to interpret whether the results are valid. Using the examples of readmissions and cancer, we show how different research questions fit different perspectives from which these are asked (patient, system, regulatory/insurance). Slightly changing the research question or perspective may thus change the analysis. Even though some may argue that any introduced bias is likely to be small, in the context of the HRRP, even small changes may mean that a hospital will face (higher) financial penalties. The impact of getting it wrong matters.There are no data in this work.