A Profile of Patient Care and
Safety in Hospitals with Differing
Case-Mix and Financial Condition
Sema K. Aydede, PhD
Institute for Child Health Policy, University of Florida
(for the Research Project Team)
Funded by
Agency for Healthcare Research and Quality
Grant # R01 HS13094
Background
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Some hospitals treat disproportionately
larger share of severely ill patients
Mid to late 1990’s, all hospitals faced
increased pressures to contain costs
Medical errors account for 44,000 to
98,000 deaths of hospitalized Americans
a year (IOM, 1999)
Research Questions
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What differences exist in the quality of
inpatient care and safety across hospital
groups?
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financially distressed/serving low severity
financially distressed/serving high severity
non-distressed/serving low severity
non-distressed/serving high severity
What differences exist in the structural and
organizational characteristics across these
hospital groups?
Methods and Key Variables
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Data Sources – AHA, MCR, HCUP(SID)
Sample – Nonfederal, acute care general
hospitals in 11 SID states (AZ, CA, CO, FL, IA,
MD, MA, NJ, NY, WA and WI)
Treating Severely Ill Patients – Above
average APR-DRG major and extreme cases in
1995
Financial Distress – Average negative
operating margin, 1993-1995
Methods and Key Variables
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Inpatient Quality Indicators (IQI)
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Patient Safety Indicators (PSI)
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AMI, CHF, Acute Stroke, GI Hemorrhage, Pneumonia
Complication of Anesthesia, Death in Low Mortality
DRG, Decubitus Ulcer, Infections Due to Medical Error,
Post-OP Hemorrhage, Post-OP PE or DVT, Accidental
Puncture or Laceration
Adjusted Least Square Means – for each IQI &
PSI, 1996-2000
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Hospital patient age distribution, gender and race
Results – Hospital Structure and
Organizational Characteristics,1995
Distressed
Non-Distressed
Low
Severity
High
Severity
Low
Severity
High
Severity
Bed Size (mean)
187.32
227.15
164.82
213.36
Publicly Owned (%)
31.43
21.59
10.53
9.02
Major Teaching (%)
8.78
14.02
3.22
3.38
System Member (%)
33.05
39.39
51.80
56.39
Medicaid Payer (%)
23.35
19.59
18.47
12.65
RN FTEs/1000 Case-Mix APDs
2.27
2.18
2.48
2.37
Results–CHF Mortality Rate
IQI 16
0.07
0.06
0.05
Rates
0.04
0.03
0.02
0.01
0
1996
1997
1998
1999
2000
Years
Distressed/Low-Severity
Distressed/High-Severity
Non-Distressed/Low-Severity
Non-Distressed/High-Severity
Results–Stroke Mortality Rate
IQI 17
0.16
0.14
0.12
Rates
0.1
0.08
0.06
0.04
0.02
0
1996
1997
1998
1999
2000
Years
Distressed/Low-Severity
Distressed/High-Severity
Non-Distressed/Low-Severity
Non-Distressed/High-Severity
Results–GI Hemorrhage Mortality Rate
IQI 18
0.045
0.04
0.035
0.03
Rate
0.025
0.02
0.015
0.01
0.005
0
1996
1997
1998
1999
2000
Years
Distressed/Low-Severity
Distressed/High-Severity
Non-Distressed/Low-Severity
Non-Distressed/High-Severity
Results–Pneumonia Mortality Rate
IQI 20
0.12
0.1
Rate
0.08
0.06
0.04
0.02
0
1996
1997
1998
1999
2000
Years
Distressed/Low-Severity
Distressed/High-Severity
Non-Distressed/Low-Severity
Non-Distressed/High-Severity
Results – Decubitus Ulcer
PSI 03
0.025
0.02
Rates
0.015
0.01
0.005
0
1996
1997
1998
1999
2000
Years
Distressed/Low-Severity
Distressed/High-Severity
Non-Distressed/Low-Severity
Non-Distressed/High-Severity
Results – Infection Due to Medical Error
PSI 07
0.025
0.02
Rates
0.015
0.01
0.005
0
1996
1997
1998
1999
2000
Years
Distressed/Low -Severity
Distressed/High-Severity
Non-Distressed/Low -Severity
Non-Distressed/High-Severity
Results–Post-Operative PE or DVT
PSI 12
0.01
0.009
0.008
0.007
Rates
0.006
0.005
0.004
0.003
0.002
0.001
0
1996
1997
1998
1999
2000
Ye ars
Dist r essed/ Low- Sev er it y
Dist r essed/ High- Sev er it y
Non- Dist r essed/ Low- Sev er it y
Non- Dist r essed/ High- Sev er it y
Results
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No significant differences across hospital
groups
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IQI – AMI
PSI – Sentinel event indicators (Complications of
Anesthesia and Death in Low Mortality DRG)
No clear pattern across hospital groups
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PSI – Technical complication indicators (Post-OP
Hemorrhage or Hematoma and Accidental Puncture
or Laceration)
Summary
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IQI mortality rates – CHF, Stroke, GI
Hemorrhage & Pneumonia
 Non-distressed/high severity hospitals perform
better
PSI adverse event rates – Decubitus Ulcer,
Infections Due to Medical Error & Post-OP PE or
DVT
 High severity hospitals (non-distressed &
distressed) perform worse
Significance to Policy and
Future Research
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Learning by doing may overcome adverse effects
of financial distress for IQI
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Significant findings for post-operative medical
and nursing related adverse event PSIs
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Future research – examine hospital volume
Future research – examine the effects of hospital
facility and organizational characteristics; explore ways
to better adjust for acuity
Examine rates of change in IQI & PSI over time