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Risk-Standardized Mortality Rates From 1995-2006

Harlan M. Krumholz, MD, SM; Yun Wang, PhD; Jersey Chen, MD, MPH; Elizabeth E. Drye, MD, SM; John A. Spertus, MD, MPH; Joseph S. Ross, MD, MHS; Jeptha P. Curtis, MD; Brahmajee K. Nallamothu, MD, MPH; Judith H. Lichtman, PhD, MPH; Edward P. Havranek, MD; Frederick A. Masoudi, MD, MSPH; Martha J. Radford, MD; Lein F. Han, PhD; Michael T. Rapp, MD, JD; Barry M. Straube, MD; Sharon-Lise T. Normand, PhD

JAMA. 2009;302(7):767-773.

Context  During the last 2 decades, health care professional, consumer, and payer organizations have sought to improve outcomes for patients hospitalized with acute myocardial infarction (AMI). However, little has been reported about improvements in hospital short-term mortality rates or reductions in between-hospital variation in short-term mortality rates.

Objective  To estimate hospital-level 30-day risk-standardized mortality rates (RSMRs) for patients discharged with AMI.

Design, Setting, and Patients  Observational study using administrative data and a validated risk model to evaluate 3 195 672 discharges in 2 755 370 patients discharged from nonfederal acute care hospitals in the United States between January 1, 1995, and December 31, 2006. Patients were 65 years or older (mean, 78 years) and had at least a 12-month history of fee-for-service enrollment prior to the index hospitalization. Patients discharged alive within 1 day of an admission not against medical advice were excluded, because it is unlikely that these patients had sustained an AMI.

Main Outcome Measure  Hospital-specific 30-day all-cause RSMR.

Results  At the patient level, the odds of dying within 30 days of admission if treated at a hospital 1 SD above the national average relative to that if treated at a hospital 1 SD below the national average were 1.63 (95% CI, 1.60-1.65) in 1995 and 1.56 (95% CI, 1.53-1.60) in 2006. In terms of hospital-specific RSMRs, a decrease from 18.8% in 1995 to 15.8% in 2006 was observed (odds ratio, 0.76; 95% CI, 0.75-0.77). A reduction in between-hospital heterogeneity in the RSMRs was also observed: the coefficient of variation decreased from 11.2% in 1995 to 10.8%, the interquartile range from 2.8% to 2.1%, and the between-hospital variance from 4.4% to 2.9%.

Conclusion  Between 1995 and 2006, the risk-standardized hospital mortality rate for Medicare patients discharged with AMI showed a significant decrease, as did between-hospital variation.

Author Affiliations: Section of Cardiovascular Medicine (Drs Krumholz, Wang, Chen, Drye, and Curtis), Robert Wood Johnson Clinical Scholars Program (Dr Krumholz), Section of Health Policy and Administration, School of Public Health (Dr Krumholz), and Section of Chronic Disease Epidemiology, School of Public Health (Dr Lichtman), Yale University School of Medicine, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven (Drs Krumholz and Wang); University of Missouri at Kansas City School of Medicine and Mid America Heart Institute, Kansas City (Dr Spertus); Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, New York (Dr Ross); Health Services Research Enhancement Award Program and Geriatrics Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York (Dr Ross); Health Services Research and Development Center of Excellence, Ann Arbor VA Medical Center, and Division of Cardiovascular Disease, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor (Dr Nallamothu); Denver Health Medical Center and the University of Colorado at Denver and Health Sciences Center, Denver (Drs Havranek and Masoudi); New York University School of Medicine, New York, New York (Dr Radford); Centers for Medicare & Medicaid Services, Baltimore, Maryland (Drs Han, Rapp, and Straube); Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (Dr Normand); and Department of Biostatistics, Harvard School of Public Health, Boston (Dr Normand).

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