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Roger A. Rosenblatt, MD, MPH; L. Gary Hart, PhD
University of Washington School of Medicine Seattle

JAMA. 1993;269(7):865-866.

	Since this article does not have an abstract, we have provided the first 150 words of the full text PDF and any section headings.

To the Editor.

—The study by Keeler et al¹ further develops the use of risk-adjusted mortality rates to compare the performance of groups of hospitals, at least with regard to the care of a subset of quite ill Medicare patients from 6 to 11 years ago. The finding that larger urban hospitals have lower mortality for selected conditions than their smaller rural counterparts corroborates the earlier work of Luft et al,² and demonstrates that for selected conditions, a greater volume of experience correlates with lower mortality.

Despite the utility of risk-adjusted mortality as one measure of quality, it is important to place these results in context in order to use them appropriately to shape public policy. The lower quality scores given to physician performance in rural hospitals may not reflect their lack of skill—as the authors suggest—but other factors such as their workload. The relative scarcity of rural . . . [Full Text PDF of this Article]

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