Mortality for Publicly Reported Conditions and Overall Hospital Mortality Rates

E John Orav,Ashish K Jha,Marta L Mccrum,Atul A Gawande,Karen E Joynt

doi:10.1001/jamainternmed.2013.7049

E John Orav, Ashish K Jha + Show 3 more

Open Access

https://doi.org/10.1001/jamainternmed.2013.7049

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Abstract

Federal efforts about public reporting and quality improvement programs for hospitals have focused primarily on a small number of medical conditions. Whether performance on these conditions accurately predicts the quality of broader hospital care is unknown. To determine whether mortality rates for publicly reported medical conditions are correlated with hospitals' overall performance. Using national Medicare data, we compared hospital performance at 2322 US acute care hospitals on 30-day risk-adjusted mortality, aggregated across the 3 publicly reported conditions (acute myocardial infarction, congestive heart failure, and pneumonia), with performance on a composite risk-adjusted mortality rate across 9 other common medical conditions, a composite mortality rate across 10 surgical conditions, and both composites combined. We also examined the relationship between alternative surrogates of quality (hospital size and teaching status) and performance on these composite outcomes. Our sample included 6,670,859 hospitalizations for Medicare fee-for-service beneficiaries from 2008 through 2009. Hospitals in the top quartile of performance on publicly reported conditions had a 3.6% lower absolute risk-adjusted mortality rate on the combined medical-surgical composite than those in the bottom quartile (9.4% vs 13.0%; P < .001). These top performers on publicly reported conditions had 5 times greater odds of being in the top quartile on the overall combined composite risk-adjusted mortality rate (odds ratio [OR], 5.3; 95% CI, 4.3-6.5). Mortality rates for the index condition were predictive of medical (OR, 8.4; 95% CI, 6.8-10.3) and surgical (2.7; 2.2-3.3) performance when these groups were considered separately. In comparison, large size (OR, 1.9; 95% CI, 1.5-2.4) and teaching status (2.4; 1.8-3.2) showed weaker relationships with overall hospital mortality rates. Hospital performance on publicly reported conditions can potentially be used as a signal of overall hospital mortality rates.

Highlights

Large size (OR, 1.9; 95% CI, 1.5-2.4) and teaching status (2.4; 1.8-3.2) showed weaker relationships with overall hospital mortality rates
Hospital performance on publicly reported conditions can potentially be used as a signal of overall hospital mortality rates
We identified all hospitalizations with primary discharge diagnoses of acute myocardial infarction, congestive heart failure, or pneumonia

Summary

Methods

Using national Medicare data, we compared hospital performance at 2322 US acute care hospitals on 30-day risk-adjusted mortality, aggregated across the 3 publicly reported conditions (acute myocardial infarction, congestive heart failure, and pneumonia), with performance on a composite risk-adjusted mortality rate across 9 other common medical conditions, a composite mortality rate across 10 surgical conditions, and both composites combined. Data We used the Medicare Provider Analysis and Review files to identify all elderly fee-for-service enrollees admitted to a nonfederal acute care hospital during 2008 or 2009. We began with 4580 acute care hospitals that treated Medicare patients in the 50 states or the District of Columbia and excluded all 1270 Critical Access Hospitals because they are not required to participate in federal public reporting and their sample sizes are generally small. Our final sample of 2322 hospitals provided 90.3% of all acute care for Medicare fee-for-service patients in the United States. We used the American Hospital Association survey[8] from 2009 to obtain data on hospital characteristics, including size, teaching status (membership in the Council of Teaching Hospitals), ownership, geographic region, proportions of Medicare and Medicaid patients, and nursing ratios. We obtained data on the communities in which the hospitals were located using the 2009 Area Resource File.[9]

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Discussion

Conclusion