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The Consequences of Diversity in Patient Mix

Jesse Green, PhD; Leigh J. Passman, MD, PhD; Neil Wintfeld, PhD

JAMA. 1991;265(14):1849-1853.

Abstract
Consumers and payers increasingly demand data with which to evaluate health care providers. While publication of risk-adjusted hospital-specific death rates is one response, debate continues over whether higher than predicted mortality is a warning about quality of care or rather a reflection of a hospital's atypical patient population. To help inform this debate, we compared the characteristics of Medicare patients discharged from 187 hospitals that the Health Care Financing Administration (HCFA) had labeled "high-mortality outliers" with those of Medicare patients from 5373 hospitals not so designated. Hospitals were most likely to be flagged as high-mortality outliers by HCFA when they had large shares of very elderly patients (age 85 years), patients with high-risk diagnoses, or patients requiring nursing home care. After adjustments were made to compensate for these biases, nearly half the hospitals flagged as outliers by HCFA were no longer so designated. Statistics purporting to measure effectiveness of care from hospital death rates should be modified to account for diversity in patient mix.

(JAMA. 1991;265:1849-1853)

Author Affiliations
From the Department of Health Policy Research (Drs Green and Wintfeld), New York (NY) University Medical Center; New York (NY) University School of Medicine (Dr Green); and Department of Medicine, UCLA Medical Center, Los Angeles, Calif (Dr Passman).

Footnotes
Reprint requests to Director of Health Policy Research, New York University Medical Center, 550 First Ave, (IRM), New York, NY 10016 (Dr Green).

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