Stop Using In-Hospital Mortality Rates to Judge Quality

Cheryl Clark, January 5, 2012

How should hospitals count patient deaths to measure quality?

Medicare now includes just those that happen within 30 days for three disease categories, and posts those scores on Hospital Compare, a number it soon will use to determine payment of Value Based Purchasing incentives starting in 2014.  

A death on day 29, the hospital might look bad. A death on day 31, and the organization shines. It seems to be a reasonable cutoff, since most deaths for heart attack, congestive heart failure, and pneumonia patients happen within 30 days.

But a paper published Tuesday in the Annals of Internal Medicine, which examined nearly 3.5 million Medicare admissions, highlights a stunning weakness in the method by which many, if not most, other payers measure quality through fatal outcomes.

It turns out they don't look that hard at 30-day mortality. Instead, health plans and some states that measure quality in death look just at the number of patients who expired within the hospital's walls during their stay. That number has dropped rapidly as the mean length of stay has declined significantly across the country, by 25% or more in recent years.

And as you can probably surmise, hospitals that have policies, practices, and procedures resulting in shorter lengths of stay (or that are quicker to transfer or discharge certain candidates with poor prognoses) have lower in-hospital deaths than hospitals that keep patients longer.  And yes, these organizations look better when their death rates are compared with hospitals that keep patients longer.

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