Abstract
BackgroundResults of associations between process and mortality indicators, both used for the external assessment of hospital care quality or public reporting, differ strongly across studies. However, most of those studies were conducted in North America or United Kingdom. Providing new evidence based on French data could fuel the international debate on quality of care indicators and help inform French policy-makers. The objective of our study was to explore whether optimal care delivery in French hospitals as assessed by their Hospital Process Indicators (HPIs) is associated with low Hospital Standardized Mortality Ratios (HSMRs).MethodsThe French National Authority for Health (HAS) routinely collects for each hospital located in France, a set of mandatory HPIs. Five HPIs were selected among the process indicators collected by the HAS in 2009. They were measured using random samples of 60 to 80 medical records from inpatients admitted between January 1st, 2009 and December 31, 2009 in respect with some selection criteria. HSMRs were estimated at 30, 60 and 90 days post-admission (dpa) using administrative health data extracted from the national health insurance information system (SNIIR-AM) which covers 77% of the French population. Associations between HPIs and HSMRs were assessed by Poisson regression models corrected for measurement errors with a simulation-extrapolation (SIMEX) method.ResultsMost associations studied were not statistically significant. Only two process indicators were found associated with HSMRs. Completeness and quality of anesthetic records was negatively associated with 30 dpa HSMR (0.72 [0.52–0.99]). Early detection of nutritional disorders was negatively associated with all HSMRs: 30 dpa HSMR (0.71 [0.54–0.95]), 60 dpa HSMR (0.51 [0.39–0.67]) and 90 dpa HSMR (0.52 [0.40–0.68]).ConclusionIn absence of gold standard of quality of care measurement, the limited number of associations suggested to drive in-depth improvements in order to better determine associations between process and mortality indicators. A smart utilization of both process and outcomes indicators is mandatory to capture aspects of the hospital quality of care complexity.
Highlights
Results of associations between process and mortality indicators, both used for the external assessment of hospital care quality or public reporting, differ strongly across studies
Hospital Standardized Mortality Ratios (HSMRs) were calculated for 1284 hospitals located in France based on the 2009 acute care discharge database (PMSI-MCO) which comprised 11,526,545 stays (Table 1)
HSMR medians were close to 1 and the inter-quartile range decreased for longer timeframes which means that observed and expected mortality tends to be similar as the time since admission increases
Summary
Results of associations between process and mortality indicators, both used for the external assessment of hospital care quality or public reporting, differ strongly across studies. PIs have to be strongly associated with related health outcomes to be used for quality assessment Apart from this requirement, PIs present many advantages and are commonly used in quality improvement, public reporting (e.g. Hospital Inpatient Quality Reporting Program in the United States or the Canadian Institute for Health Information’s hospital performance program), or pay-for-performance (e.g. Medicare Hospital Quality Alliance Program [7]) programs [8]. Like other outcome indicators, mortality rates depend on various factors including patient case-mix [12] (i.e. patient characteristics, comorbidity and severity at admission) and data accuracy [13], which could be confounding factors for measuring quality of care They have to be accurately measured and adjusted on case-mix before comparing mortality across providers or being used for hospital profiling. Owing to the above mentioned limitations, they act as signals or flags to identify structures where further investigations have to be conducted [13]
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