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In-hospital mortality rates misleading method for assessing hospital care
Drye EE. Ann Intern Med. 2012;156:19-26.
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Using in-hospital mortality as a measure of hospital performance provides a different assessment than 30-day mortality, researchers reported in a recent study. They found that in-hospital mortality measures may be biased in favor of hospitals with shorter lengths of stay and transfer rates.
The observational study was designed to assess the agreement between performance measures of US hospitals by using risk-standardized in-hospital and 30-day mortality rates. Analysis focused on nonfederal acute care hospitals with at least 30 admissions for acute MI, HF and pneumonia from 2004 to 2006. During that time, more than 700,000 patients with acute MI, 1.3 million patients with HF and 1.4 million patients with pneumonia aged 65 years and older were discharged from nonfederal acute care hospitals.
Mean hospital-level patient length of stay varied across hospitals for each condition, ranging from 2.3 to 13.7 days for acute MI, 3.5 to 11.9 days for HF and 3.8 to 14.8 days for pneumonia.
Risk-standardized mortality rates (RSMR), defined as 30-day RSMR minus in-hospital RSMR, varied widely across hospitals. The mean RSMR differences were 5.3% for acute MI, 6% for HF and 5.7% for pneumonia. In-hospital and 30-day models differed in performance classifications for 8.2% of hospitals for acute MI, 10.8% for HF and 14.7% for pneumonia. For all three conditions, researchers found that hospital mean length of stay was positively correlated with in-hospital RSMRs.
“As the United States increases its use of outcome measures to assess and reimburse for quality and to evaluate system innovations, outcomes measures with standardized follow-up periods, which are unaffected by variation in length of stay or transfer patterns, should be preferred over in-hospital measures,” the researchers concluded. “Building national databases of key outcomes that can be readily linked to patient data, such as mortality, would make measures that use standardized outcome periods more feasible and timely.”
Disclosure: The researchers report several financial disclosures for this study. Dr. Normand received consulting fees or honorarium from Yale-New Haven Hospital System and grants from the Massachusetts Department of Public Health. Dr. Ross received a grant from CMS, the National Institute on Aging/American Federation of Aging Research and Medtronic and is an advisory board member of FAIR Health Inc. Dr. Krumholz received consulting fees or honorarium from United Health.
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