Background
„ Hospitals are being compared based on
Comparative Rankings of Hospital Quality –
Does the Data Source Matter?
Anne Elixhauser, Ph.D.
Bernard Friedman, Ph.D.
readily available data
„ Data on Medicare patients are available
from virtually all U.S. hospitals
„ Convenient – but do we know how the
Medicare experience reflects hospital
quality overall?
June 26, 2005
AcademyHealth Research Meeting
Purpose of Study
Methods – Data Source
„ Examine the extent to which information
„ 2001 Healthcare Cost and Utilization Project
on Medicare patients can be
extrapolated to the general population
when comparing hospital quality
(HCUP) Nationwide Inpatient Sample (NIS)
„ Sample of 986 hospitals from 33 states
– All discharges from each hospital are included
„ No weighting for this study – Used NIS as a
convenience sample of hospitals
„ Study population: hospital inpatients from
shortshort-term, nonnon-Federal, acute care
hospitals
– Limited to hospitals with Medicare patients
Methods – Quality Measures
„ AHRQ Quality Indicators
– Based on hospital administrative data
– 15 Patient Safety Indicators (PSIs)
„ Risk adjusted using gender, age,
comorbidities, and collapsed DRGs
– 12 inin-hospital mortality measures from the
Inpatient Quality Indicators (IQIs)
„ Risk adjusted using APRAPR-DRGs
Methods – Rankings
For each measure:
– Dropped the 10% of hospitals with the
fewest Medicare cases
– Using Medicare discharges only
„ Ranked hospitals and ordered into deciles
– Using all patients (including Medicare)
„ Ranked hospitals and ordered into deciles
1
Comparison of Rankings
Percent of hospitals in lowest decile
that increased rank by at least 2 deciles
Patient Safety Indicators
„ How many hospitals changed from the
highest or lowest rank by at least two
deciles?
50
45
40
35
30
25
20
15
10
5
0
„ Compared rank using MedicareMedicare-only data to
rank using allall-patient data
„ What % of poorest performing hospitals
increased their ranking?
„ What % of bestbest-performing hospitals fell in
their ranking?
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Percent of hospitals in highest decile
that fell in rank by at least 2 deciles
Percent of hospitals in lowest decile
that increased rank by at least 2 deciles
Patient Safety Indicators
In-hospital Mortality Indicators
50
45
40
35
30
25
20
15
10
5
0
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th RG lce r cue dy rax re
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Cx mo ubit u e t o reig umo o me osto emo op d top r top sto deh l l ac
P p h ost os Pos Po top nta
ow e c i lur Fo pne e t
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Percent of hospitals in highest decile
that fell in rank by at least 2 deciles
In-hospital Mortality Indicators
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1/4 of hospitals fell to 3rd
decile or lower for:
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Among the top 10% of hospitals (best, or lowest PSI rates):
1/3 of hospitals fell to 3rd
decile or lower for:
I
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Summary of Findings:
Patient Safety Indicators
At least 40% of hospitals fell
to 3rd decile or lower for:
50
45
40
35
30
25
20
15
10
5
0
A
AA
50
45
40
35
30
25
20
15
10
5
0
A
CE
Postop hip fracture
Postop physiologic and metabolic derangement
Postop respiratory failure
Wound dehiscence
Anesthesia complications
Death in low mortality DRGs
Foreign body after procedure
Iatrogenic pneumothorax
Infection due to medical care
Postop hemorrhage
Postop PE and DVT
Postop sepsis
2
Summary of Findings:
InIn-hospital Mortality Indicators
Among top 10% of hospitals (best, or lowest mortality rates):
38% of hospitals fell to 3rd
decile or lower for:
1212-20% of hospitals fell to 3rd
decile or lower for:
Craniotomy
GI hemorrhage
Carotid endarterectomy
Abdominal aortic aneurysm repair
Among bottom 10% of hospitals (worst, or highest mortality rates):
rates):
24% of hospitals rose to 8th
decile or higher
21% of hospitals rose to 8th
decile or higher
14% of hospitals rose to 8th
decile or higher
10% of hospitals rose to 8th
decile or higher
CABG
Craniotomy
PTCA
Abdominal aortic aneurysm repair
Limitations
„ Findings may be unique to these specific
indicators
„ Findings may not hold for cutpoints other
than deciles
„ Convenience sample of hospitals – not
nationally representative
– But hospitals are drawn from a sampling
frame that comprises 80% of U.S.
discharges
Conclusions
„ When comparing Medicare and allall-payer
analyses
– Found loose overlap of the toptop-ranking and
poorestpoorest-ranking hospitals
– Saw largest shifts for PSIs among the toptopranking hospitals
„ Using MedicareMedicare-only data may carry a
greater risk of incorrectly labeling a
hospital as a toptop-ranking performer
„ PrePre-test ranking approaches
3