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Comparative Rankings of Hospital Quality – Comparative Rankings of Hospital Quality – Does the Data Source Matter?Does the Data Source Matter?
Anne Elixhauser, Ph.D.Anne Elixhauser, Ph.D.Bernard Friedman, Ph.D. Bernard Friedman, Ph.D.
June 26, 2005June 26, 2005AcademyHealth Research MeetingAcademyHealth Research Meeting
BackgroundBackground
Hospitals are being compared based on readily Hospitals are being compared based on readily available dataavailable data
Data on Medicare patients are available from Data on Medicare patients are available from virtually all U.S. hospitalsvirtually all U.S. hospitals
Convenient – but do we know how the Convenient – but do we know how the Medicare experience reflects hospital quality Medicare experience reflects hospital quality overall?overall?
Purpose of StudyPurpose of Study
Examine the extent to which information Examine the extent to which information on Medicare patients can be on Medicare patients can be extrapolated to the general population extrapolated to the general population when comparing hospital qualitywhen comparing hospital quality
Methods – Data SourceMethods – Data Source
2001 Healthcare Cost and Utilization Project (HCUP) Nationwide 2001 Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS)Inpatient Sample (NIS)
Sample of 986 hospitals from 33 statesSample of 986 hospitals from 33 states– All discharges from each hospital are includedAll discharges from each hospital are included
No weighting for this study – Used NIS as a convenience sample of No weighting for this study – Used NIS as a convenience sample of hospitals hospitals
Study population: hospital inpatients from short-term, non-Federal, Study population: hospital inpatients from short-term, non-Federal, acute care hospitalsacute care hospitals– Limited to hospitals with Medicare patientsLimited to hospitals with Medicare patients
Methods – Quality MeasuresMethods – Quality Measures
AHRQ Quality IndicatorsAHRQ Quality Indicators– Based on hospital administrative data Based on hospital administrative data – 15 Patient Safety Indicators (PSIs) 15 Patient Safety Indicators (PSIs)
Risk adjusted using gender, age, comorbidities, and Risk adjusted using gender, age, comorbidities, and collapsed DRGscollapsed DRGs
– 12 in-hospital mortality measures from the Inpatient 12 in-hospital mortality measures from the Inpatient Quality Indicators (IQIs)Quality Indicators (IQIs) Risk adjusted using APR-DRGsRisk adjusted using APR-DRGs
Methods – RankingsMethods – Rankings
For each measure:For each measure:– Dropped the 10% of hospitals with the fewest Dropped the 10% of hospitals with the fewest
Medicare casesMedicare cases– Using Medicare discharges onlyUsing Medicare discharges only
Ranked hospitals and ordered into decilesRanked hospitals and ordered into deciles
– Using all patients (including Medicare)Using all patients (including Medicare) Ranked hospitals and ordered into decilesRanked hospitals and ordered into deciles
Comparison of RankingsComparison of Rankings
How many hospitals changed from the highest How many hospitals changed from the highest or lowest rank by at least two deciles?or lowest rank by at least two deciles?
Compared rank using Medicare-only data to rank using Compared rank using Medicare-only data to rank using all-patient dataall-patient data
What % of poorest performing hospitals increased their What % of poorest performing hospitals increased their ranking?ranking?
What % of best-performing hospitals fell in their What % of best-performing hospitals fell in their ranking? ranking?
Percent of hospitals in Percent of hospitals in lowestlowest decile that decile that increasedincreased rank by at least 2 deciles rank by at least 2 deciles
05
101520253035404550
Cx anesth
Death-low m
ort DRG
Decubitus ulcer
Failure to
rescue
Foreign body
Iatro pneumothorax
Infx due to m
ed care
Postop hip fx
Postop hemorrhage
Postop derange
Postop resp fa
il
Postop PE DVT
Postop sepsis
Postop dehiscence
Accidental laceratio
n
Patient Safety Indicators
Percent of hospitals in Percent of hospitals in highesthighest decile decile that that fellfell in rank by at least 2 deciles in rank by at least 2 deciles
05
101520253035404550
Cx anesth
Death-low m
ort DRG
Decubitus ulcer
Failure to
rescue
Foreign body
Iatro pneumothorax
Infx due to m
ed care
Postop hip fx
Postop hemorrhage
Postop derange
Postop resp fa
il
Postop PE DVT
Postop sepsis
Postop dehiscence
Accidental laceratio
n
Patient Safety Indicators
Percent of hospitals in Percent of hospitals in lowestlowest decile that decile that increasedincreased rank by at least 2 deciles rank by at least 2 deciles
05
101520253035404550
AAA repair
CABG
Craniotomy
Hip replacement
AMICHF
Stroke
GI hemorrh
age
Hip fracture
PneumoniaPTCA
CEA
In-hospital Mortality Indicators
Percent of hospitals in Percent of hospitals in highest highest decile decile that that fellfell in rank by at least 2 deciles in rank by at least 2 deciles
05
101520253035404550
AAA repair
CABG
Craniotomy
Hip replacement
AMICHF
Stroke
GI hemorrh
age
Hip fracture
PneumoniaPTCA
CEA
In-hospital Mortality Indicators
Summary of Findings:Summary of Findings:Patient Safety IndicatorsPatient Safety Indicators
Among the top 10% of hospitals (best, or lowest PSI rates):Among the top 10% of hospitals (best, or lowest PSI rates):At least 40% of hospitals fell to At least 40% of hospitals fell to 33rdrd decile or lower for: decile or lower for:
Postop hip fracturePostop hip fracture
Postop physiologic and metabolic derangementPostop physiologic and metabolic derangement
Postop respiratory failurePostop respiratory failure
Wound dehiscenceWound dehiscence
1/3 of hospitals fell to 31/3 of hospitals fell to 3rdrd decile or lower for:decile or lower for:
Anesthesia complicationsAnesthesia complications
Death in low mortality DRGsDeath in low mortality DRGs
Foreign body after procedureForeign body after procedure
1/4 of hospitals fell to 31/4 of hospitals fell to 3rdrd decile or lower for:decile or lower for:
Iatrogenic pneumothoraxIatrogenic pneumothorax
Infection due to medical careInfection due to medical care
Postop hemorrhagePostop hemorrhage
Postop PE and DVTPostop PE and DVT
Postop sepsisPostop sepsis
Summary of Findings:Summary of Findings:In-hospital Mortality IndicatorsIn-hospital Mortality Indicators
Among top 10% of hospitals (best, or lowest mortality rates):Among top 10% of hospitals (best, or lowest mortality rates):38% of hospitals fell to 338% of hospitals fell to 3rdrd decile or lower for:decile or lower for:
CraniotomyCraniotomy
12-20% of hospitals fell to 312-20% of hospitals fell to 3rdrd decile or lower for:decile or lower for:
GI hemorrhageGI hemorrhage
Carotid endarterectomyCarotid endarterectomy
Abdominal aortic aneurysm repairAbdominal aortic aneurysm repair
Among bottom 10% of hospitals (worst, or highest mortality rates):Among bottom 10% of hospitals (worst, or highest mortality rates):24% of hospitals rose to 824% of hospitals rose to 8thth decile or higherdecile or higher
CABGCABG
21% of hospitals rose to 821% of hospitals rose to 8thth decile or higherdecile or higher
CraniotomyCraniotomy
14% of hospitals rose to 814% of hospitals rose to 8thth decile or higherdecile or higher
PTCAPTCA
10% of hospitals rose to 810% of hospitals rose to 8thth decile or higherdecile or higher
Abdominal aortic aneurysm repairAbdominal aortic aneurysm repair
LimitationsLimitations
Findings may be unique to these specific indicatorsFindings may be unique to these specific indicators Findings may not hold for cutpoints other than Findings may not hold for cutpoints other than
decilesdeciles Convenience sample of hospitals – not nationally Convenience sample of hospitals – not nationally
representativerepresentative– But hospitals are drawn from a sampling frame that But hospitals are drawn from a sampling frame that
comprises 80% of U.S. dischargescomprises 80% of U.S. discharges
ConclusionsConclusions
When comparing Medicare and all-payer analysesWhen comparing Medicare and all-payer analyses– Found loose overlap of the top-ranking and poorest-ranking Found loose overlap of the top-ranking and poorest-ranking
hospitals hospitals – Saw largest shifts for PSIs among the top-ranking hospitalsSaw largest shifts for PSIs among the top-ranking hospitals
Using Medicare-only data may carry a greater risk of Using Medicare-only data may carry a greater risk of incorrectly labeling a hospital as a top-ranking incorrectly labeling a hospital as a top-ranking performerperformer
Pre-test ranking approaches Pre-test ranking approaches