How many patients die in the hospital during treatment for which quality may affect outcomes? How are death rates changing over time?

Hospital death rates declined for five selected conditions or procedures from 1994 to 2003, and from 1995 to 2004 among Medicare beneficiaries, suggesting that quality of care improved during this time. Among Medicare beneficiaries, death rates measured 30 days after hospitalization increased for four of these conditions from 2000 to 2002, but have since declined.

Why is this important?

• Hospitals often provide complex care to individuals with life-threatening conditions and are thus an important focus for quality improvement. There were 37.8 million discharges from U.S. hospitals in 2002 (AHRQ 2005), accounting for 30 percent of total health care expenditures (Cowan et al. 2004).
• The federal Agency for Healthcare Research and Quality's inpatient quality indicators measure hospital death rates for medical conditions and surgical procedures for which there is some evidence that the quality of hospital care can affect patient survival (AHRQ 2002).

Findings

In-hospital death rates (risk-adjusted to control for differences in the patient population) declined from 1994 to 2003 among adult patients hospitalized for five conditions or procedures (AHRQ 2006). Similar trends were observed among Medicare beneficiaries from 1995 to 2004. However, these improvements were attenuated when death rates were measured 30 days after hospital admission (MedPAC 2004, 2005, 2006).

Of concern, 30-day death rates increased for four conditions from 2000 to 2002 among Medicare beneficiaries—wiping out some of the gains made from 1995 to 2000. These rates have since declined to a level lower than in 1995 (MedPAC 2005, 2006).

Implications

• Although some deaths in the hospital are unavoidable, reductions in death rates suggest that patients are receiving higher quality treatment. Improvements in diagnostic and treatment modalities also may play an important role.
• The up-tick in 30-day mortality rates among Medicare patients in 2002 gives rise to concern that patients might not have received adequate follow-up care and support once they left the hospital, or that hospitals were not adequately preparing them for discharge. This experience highlights the importance of ongoing monitoring to identify and address such factors.

Improvement Ideas and Resources

• A study of 1,784 U.S. hospitals found that institutions in which a larger proportion of managers and staff participated in quality improvement teams achieved better performance on these indicators (Weiner et al. 2006).
• Some hospital collaborations are using mortality indicators to benchmark performance and identify practices associated with better outcomes. For example, the mortality rate for heart bypass surgery declined by 24 percent, compared with expected performance, among hospitals participating in the Northern New England Cardiovascular Disease Study Group (O'Connor et al. 1996).
• Some states and purchaser coalitions are using hospital mortality in public report cards and pay-for-performance programs to stimulate improvement. Following release of the New York State Cardiac Surgery Reports, for example, heart bypass surgery mortality declined significantly more than the national average and reached the lowest level of any state in the nation (Peterson et al. 1998).

Measure:

The Agency for Healthcare Research and Quality Inpatient Quality Indicators were refined through a process of technical and expert review led by the University of California, San Francisco–Stanford University Evidence-Based Practice Center (AHRQ 2002). The subset of indicators shown in the chart were selected for use in research on hospital quality improvement "based on their favorable performance on four empirical tests of precision and five empirical tests of minimum bias" (Weiner et al. 2006). Adults mean patients ages 18 and older, except heart bypass surgery includes only adults ages 40 and older. Rates exclude obstetric and neonatal admissions and transfers to another hospital and are adjusted by age, gender, age-gender interactions, and APR-DRG risk of mortality score. For definitions and denominators, see the Guide to the Inpatient Quality Indicators (Version 2.1, Revision 3).

Limitations:

The link between quality of hospital care and mortality has been more clearly established for some conditions than for others. Medicare data do not include Medicare Advantage plan members. The 30-day mortality rate was not measured for all hospital patients.

Source:

• Weighted national estimates were calculated by the Agency for Healthcare Research and Quality (AHRQ 2006) using hospital administrative data from the Healthcare Cost and Utilization Project (HCUP) 2002 Nationwide Inpatient Sample (NIS), which is collected from hospitals by statewide data organizations.
• Rates for Medicare beneficiaries were calculated by the Medicare Payment Advisory Commission (MedPAC 2004, 2005, 2006) using Medicare fee-for-service claims data from the Medicare Provider and Review (MedPAR) file.

  References:

  * Indicates source of data used in the chart(s).AHRQ (Agency for Healthcare Research and Quality). 2002. AHRQ Quality Indicators: Guide to Inpatient Quality Indicators. AHRQ Pub. No. 02-RO204. Rockville, Md.: U.S. Department of Health and Human Services. * AHRQ (Agency for Healthcare Research and Quality). 2006. Healthcare Cost and Utilization Project. Rockville, Md.: U.S. Department of Health and Human Services. Cowan, C., A. Catlin, C. Smith et al. 2004. National Health Expenditures, 2002. Health Care Financing Review 25 (4): 143–66. * MedPAC (Medicare Payment Advisory Commission). 2004. A Data Book: Healthcare Spending and the Medicare Program. Washington, D.C.: Medicare Payment Advisory Commission. * MedPAC (Medicare Payment Advisory Commission). 2005. A Data Book: Healthcare Spending and the Medicare Program. Washington, D.C.: Medicare Payment Advisory Commission. * MedPAC (Medicare Payment Advisory Commission). 2006. A Data Book: Healthcare Spending and the Medicare Program. Washington, D.C.: Medicare Payment Advisory Commission. O'Connor, G. T., S. K. Plume, E. M. Olmstead et al. 1996. A Regional Intervention to Improve the Hospital Mortality Associated with Coronary Artery Bypass Graft Surgery. The Northern New England Cardiovascular Disease Study Group. Journal of the American Medical Association 275 (11): 841–6. Peterson, E. D., E. R. DeLong, J. G. Jollis et al. 1998. The Effects of New York's Bypass Surgery Provider Profiling on Access to Care and Patient Outcomes in the Elderly. Journal of the American College of Cardiology 32 (4): 993–9. Weiner, B. J., J. A. Alexander, S. M. Shortell et al. 2006. Quality Improvement Implementation and Hospital Performance on Quality Indicators. Health Services Research 41 (2): 307–34.