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Hospital Performance Measures May Not Make Much Difference When It Comes to Mortality

Researchers at the University of Pennsylvania’s School of Medicine have found that hospitals with high and low performance on Medicare quality measures// had little difference in the rate of death for three common conditions at the hospitals, indicating that the performance measures may not accurately reflect patient outcomes. Senior author Rachel M. Werner, MD, PhD, Assistant Professor of Medicine at the University of Pennsylvania, Core Investigator with the Center for Health Equity Research and Promotion at the Philadelphia Veterans Affairs Medical Center, and colleague Eric Bradlow, PhD, Professor of Marketing and Statistics at the University of Pennsylvania’s Wharton School report their findings in the December 13th issue of JAMA.

In the United States, quality of care delivered in hospitals is often variable. Because it is assumed that measuring quality of care is a key component in improving care, quality measures have an increasingly prominent role in quality improvement, according to background information in the article. These measures can provide an incentive to improve quality of the care delivered and to influence consumer choice of hospitals and health care plans. While some research has documented an association between higher adherence to care guidelines and better outcomes of patients who receive that care, to date there has been limited evidence demonstrating that hospitals that perform better on process measures also have better overall quality.

“What we would like is a kind of ‘Consumer Reports’ for hospitals so that patients can find out which hospitals are better and then go to these hospitals,” said Werner. “Medicare has taken an important step toward that goal by publishing hospital performance in all acute care hospitals in the United States on their website, ‘Hospital Compare.’”

This study was conducted to determine whether these quality measures are correlated with and predictive of hospitals’ risk-adjusted death rates. The researchers analyzed data from Hospital Compare between January 1 and December 31, 2004, and compared hospital performance for heart attack, heart failure, and pneumonia with hospital risk-adjusted death rates, which were measured using Medicare Part A claims data. A total of 3,657 acute care hospitals were included in the study based on their performance reported in Hospital Compare.

Across all heart attack performance measures, the absolute reduction in risk-adjusted death rates between hospitals performing in the 25th percentile versus those in the 75th percentile was 0.005 for inpatient death, 0.006 for 30-day death, and 0.012 for death at 1-year. For the heart failure performance measures, the absolute death reduction was smaller, ranging from 0.001 for inpatient death to 0.002 for 1-year death. For the pneumonia performance measures, the absolute reduction in death ranged from 0.001 for 30-day death to 0.005 for inpatient death.

“Because the differences in hospitals are so small, it is unlikely that this information will be very useful to patients,” said Werner. “This is particularly true because patients might not live close to the better hospitals. It is not helpful to know that another hospital is better if it is only a tiny bit better. And it is even less helpful if the better hospital is 50 miles farther and you are having a heart attack. But evaluating hospitals is clearly a good idea and Hospital Compare is an important start. With time, the system will get better. In the meantime, though, effort should be focused on developing new measures that are more tightly linked to the clinical outcomes patients care about.”

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