Explaining variations in hospital death rates. Randomness, severity of illness, quality of care

R. E. Park, R. H. Brook, J. Kosecoff, J. Keesey, L. Rubenstein, E. Keeler, K. L. Kahn, W. H. Rogers and M. R. Chassin
Health Sciences Program, RAND Corporation, Santa Monica, CA 90406.

We used administrative (Part A Medicare) data to identify a representative sample of 1126 patients with congestive heart failure and 1150 with acute myocardial infarction in hospitals with significant unexpectedly high inpatient, age-sex-race-disease-specific death rates ("targeted") vs all other ("untargeted") hospitals in four states. Although death rates in targeted hospitals were 5.0 to 10.9 higher per 100 admissions than in untargeted hospitals, 56% to 82% of the excess could result from purely random variation. Differences in the quality of the process of care (based on a medical record review) could not explain the remaining statistically significant differences in mortality. Comparing targeted hospitals with subsets of untargeted ones, eg, those with lower than expected death rates, did not affect this conclusion. Severity of illness explained up to 2.8 excess deaths per 100 admissions for patients with myocardial infarction. Identifying hospitals that provide poor-quality care based on administrative data and single-year death rates is unlikely; targeting based on time periods greater than 1 year may be better.

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Risk Stratification and Comorbidity
Ferraris et al.
Card Surg Adult 2008;3:199-246.
FULL TEXT  

Outcomes Research in Specialized Nutrition Support
August and Serrano
Nutr Clin Pract 2007;22:602-608.
ABSTRACT | FULL TEXT  

Patient characteristics and hospital quality for colorectal cancer surgery
Zhang et al.
Int J Qual Health Care 2007;19:11-20.
ABSTRACT | FULL TEXT  

Integrating "Best of Care" Protocols into Clinicians' Workflow via Care Provider Order Entry: Impact on Quality-of-Care Indicators for Acute Myocardial Infarction
Ozdas et al.
J. Am. Med. Inform. Assoc. 2006;13:188-196.
ABSTRACT | FULL TEXT  

Mortality After Acute Myocardial Infarction in Hospitals That Disproportionately Treat Black Patients
Skinner et al.
Circulation 2005;112:2634-2641.
ABSTRACT | FULL TEXT  

Quality of Care Is Associated with Survival in Vulnerable Older Patients
Higashi et al.
ANN INTERN MED 2005;143:274-281.
ABSTRACT | FULL TEXT  

The Hospital Mortality of Patients Admitted to the ICU on Weekends
Ensminger et al.
Chest 2004;126:1292-1298.
ABSTRACT | FULL TEXT  

Thirty-Day Mortality Following Hip Arthroplasty for Acute Fracture
Parvizi et al.
JBJS 2004;86:1983-1988.
ABSTRACT | FULL TEXT  

Society of Surgical Oncology Presidential Address: Volume, Outcome, and Surgical Specialization
Daly
Ann. Surg. Oncol. 2004;11:107-114.
FULL TEXT  

The measurement of active errors: methodological issues
Lilford et al.
Qual Saf Health Care 2003;12:ii8-12.
ABSTRACT | FULL TEXT  

Using routine comparative data to assess the quality of health care: understanding and avoiding common pitfalls
Powell et al.
Qual Saf Health Care 2003;12:122-128.
ABSTRACT | FULL TEXT  

Risk Stratification and Comorbidity
Ferraris and Ferraris
Card Surg Adult 2003;2:187-224.
FULL TEXT  

Intensive Care Management of the Term Neonate: Are There Regional Differences in Outcome?
Touch et al.
CLIN PEDIATR 2002;41:587-592.
ABSTRACT  

Variations in mortality rates among Canadian neonatal intensive care units: interpretation and implications
Tyson and Kennedy
CMAJ 2002;166:191-192.
FULL TEXT  

Why Do Hospital Death Rates Vary?
Halm and Chassin
NEJM 2001;345:692-694.
FULL TEXT  

Use of comorbidity scores for control of confounding in studies using administrative databases
Schneeweiss and Maclure
Int J Epidemiol 2000;29:891-898.
ABSTRACT | FULL TEXT  

Volume-Outcome Relationships in Pediatric Intensive Care Units
Tilford et al.
Pediatrics 2000;106:289-294.
ABSTRACT | FULL TEXT  

Results of Report Cards for Patients with Congestive Heart Failure Depend on the Method Used To Adjust for Severity
Poses et al.
ANN INTERN MED 2000;133:10-20.
ABSTRACT | FULL TEXT  

Health Maintenance Organizations and Hospital Quality for Coronary Artery Bypass Surgery
Escarce et al.
Med Care Res Rev 1999;56:340-362.
ABSTRACT  

Cardiology or Primary Care for Heart Failure in the Community Setting: Process of Care and Clinical Outcomes
Philbin et al.
Chest 1999;116:346-354.
ABSTRACT | FULL TEXT  

Explaining differences in English hospital death rates using routinely collected data
Jarman et al.
BMJ 1999;318:1515-1520.
ABSTRACT | FULL TEXT  

Research Evidence on the Validity of Risk-Adjusted Mortality Rate as a Measure of Hospital Quality of Care
Thomas and Hofer
Med Care Res Rev 1998;55:371-404.
ABSTRACT  

Outreach Education to Improve Quality of Rural ICU Care . Results of a Randomized Trial
HENDRYX et al.
Am. J. Respir. Crit. Care Med. 1998;158:418-423.
ABSTRACT | FULL TEXT  

What Is Outcomes Research and What Can It Tell Us?
Slater
Eval Health Prof 1997;20:243-264.
ABSTRACT  

Hospital and Patient Characteristics Associated With Variation in 28-Day Mortality Rates for Very Low Birth Weight Infants
Horbar et al.
Pediatrics 1997;99:149-156.
ABSTRACT | FULL TEXT  

Where's the Best Medicine?: The Hospital Rating Game
Teasley
Eval Rev 1996;20:568-579.
ABSTRACT  

Rural Hospital Mortality for Myocardial Infarction in Medicare Patients in Illinois
Hand et al.
American Journal of Medical Quality 1996;11:135-141.
ABSTRACT  

Influence of Cardiac-Surgery Performance Reports on Referral Practices and Access to Care -- A Survey of Cardiovascular Specialists
Schneider and Epstein
NEJM 1996;335:251-256.
ABSTRACT | FULL TEXT  

Medical Practice Profiling: Concepts and Caveats
Brand et al.
Med Care Res Rev 1995;52:223-251.
ABSTRACT  

Outcome After Surgery: An Evolving Concept
Kazmers
PERSPECT VASC SURG ENDOVASC THER 1995;8:109-128.
 

Measuring the Quality of Care: Reforming the Health Care System
Longo and Daugird
American Journal of Medical Quality 1994;9:104-115.
ABSTRACT  

Can Administrative Data be Used to Compare the Quality of Health Care?
Romano
Med Care Res Rev 1993;50:451-477.