‘Big 3’ performance measures predict overall quality

Hospitals with low 30-day mortality rates for three publicly reported conditions are more likely to be top performers for overall mortality. Rates for acute MI, heart failure and pneumonia also proved to be better predictors than traditional markers of performance, according to results published online June 24 in JAMA Internal Medicine.

The Centers for Medicare & Medicaid Services (CMS) requires hospitals to publicly report 30-day mortality and readmissions rates for acute MI, heart failure and pneumonia. Beginning in 2014, CMS will integrate hospital mortality rates into its hospital inpatient value-based purchasing program.

That raises the question: Do the three conditions used to track hospital performance truly reflect broader hospital quality? Marta L. McCrum, MD, of Harvard School of Public Health in Boston, and colleagues used Medicare administrative data to examine the issue.

Through Medicare Provider Analysis and Review files, they obtained data on beneficiaries admitted to nonfederal acute care hospitals in 2008 and 2009. The final sample of 2,322 hospitals included 90.3 percent of Medicare fee-for-service patients in the U.S. In addition, they culled American Hospital Association survey data from 2009 for hospital characteristics.

Aggregate 30-day mortality rates for acute MI, heart failure and pneumonia served as the primary predictor, and the outcome of interest was the composite medical and surgical 30-day mortality rate. For medical outcomes, that included stroke, arrhythmia, chronic obstructive pulmonary disease, respiratory tract infection, sepsis, urinary tract infection, gastrointestinal bleed, renal failure and esophagitis or gastroenteritis. The surgical procedures were CABG, aortic valve repair, above-knee amputation, colon resection, small bowel resection, exploratory laparotomy, pulmonary lobe resection, abdominal aortic aneurysm repair, esophagectomy and pancreatectomy.

They then calculated and compared risk-adjusted mortality rates overall and by medical and surgical composite set within quartiles for mortality rates for the publicly reported three conditions. They also looked at two common markers of quality—hospital size and status as a major teaching hospital—to assess the likelihood of those hospitals being top performers for overall outcomes as well as medical and surgical outcomes.

Hospitals ranked as top performers based on the three conditions had lower overall mortality rates compared with bottom performers, at 9.4 percent vs. 13 percent. The comparative medical mortality rates were 10.5 percent vs. 14.1 percent and surgical mortality rates were 7.8 percent vs. 11.1 percent, respectively.  

The odds of a hospital that was a top performer for the publicly reported conditions being a top performer overall were five-fold higher than for other hospitals. The odds remained high for medical mortality (odds ratio of 8.4) and for surgical mortality (odds ratio of 2.7). Hospital size and teaching status proved to be weaker predictors of top performance than the three aggregate conditions.

McCrum et al speculated that uniform procedures in top performing hospitals may explain the link between performance on the publicly reported measures and overall mortality. Uniformity may apply more to medical services than surgical services, given the results. They also proposed that leadership within a hospital may influence its culture and instill a drive for excellence.

“[T]he broader findings from our work support the notion that there may actually be ‘good’ and ‘bad’ hospitals and that performance on a manageable set of key indicators can help identify such institutions,” they wrote. The added that understanding the system and leadership characteristics of top performers might provide useful tools that poorer performers could deploy to improve quality.

Based on their results, performance measures reported publicly offer value to consumers, who should be encouraged to use them as a resource, they concluded.