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Emmett B. Keeler, PhD; Lisa V. Rubenstein, MD, MSPH; Katherine L. Kahn, MD; David Draper, PhD; Ellen R. Harrison, MS; Michael J. McGinty, PhD; William H. Rogers, PhD; Robert H. Brook, MD, ScD

JAMA. 1992;268(13):1709-1714.

Abstract
Objective.
—To compare quality of care measured by explicit criteria, implicit review, and sickness-adjusted outcomes at different types of hospitals.

Design.
—Further analysis of data retrospectively abstracted from medical records to evaluate the effects of prospective payment on quality of care for hospitalized Medicare patients.

Setting.
—Hospitals in five states were sampled to represent the national Medicare admissions along many dimensions.

Patients.
—A total of 14008 elderly patients with one of the following five diseases: congestive heart failure, acute myocardial infarction, pneumonia, stroke, or hip fracture. These patients were randomly sampled from those with these diseases in 297 hospitals in two time periods, 1981 to 1982 and 1985 to 1986.

Outcome Measures.
—Explicit criteria, implicit review, and mortality within 30 days of admission adjusted for sickness at admission.

Results.
—Quality of care ratings for hospital types are similar using explicit criteria, implicit review, and outcomes adjusted for sickness at admission. Quality differences between types of hospitals were large, with the lowest group estimated to have four percentage points higher mortality than major teaching hospitals in a cohort of patients with average mortality of 16%. Quality varies from state to state, but teaching, larger, and more urban hospitals have better quality in general than nonteaching, small, and rural hospitals. Hospital quality persists overtime, but small nonteaching hospitals narrowed the gap with better quality hospitals between 1981 and 1986.

Conclusions.
—The different measures led to consistent and plausible relationships between quality and hospital characteristics. Thus, valid information about hospital quality can be obtained. We need to develop ways to use such information to improve care.

(JAMA. 1992;268:1709-1714)

Author Affiliations
From the Health Program of RAND, Santa Monica, Calif (Drs Keeler, Rubenstein, Kahn, Rogers, and Brook and Ms Harrison); the Departments of Medicine (Drs Kahn and Brook), Health Services (Dr Brook), and Mathematics (Dr Draper), University of California at Los Angeles; the Sepulveda (Calif) Veterans Affairs Hospital (Dr Rubenstein); and the California Association of Public Hospitals, Berkeley (Dr McGinty).

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