Hospitals Doing Care Right Reduce Death Rates

BOSTON, July 18 -- If hospitals consistently meet quality targets, mortality rates for three common conditions are 7% to 15% lower than in less rigorous institutions, health analysts here reported.

Significantly more patients with acute myocardial infarction, congestive heart failure, or pneumonia were discharged alive from hospitals that most frequently met all quality benchmarks for each condition, reported Ashish K. Jha, M.D., M.P.H., of the Harvard School of Public Health, and colleagues.

The investigators used pneumonia data from 3,272 hospitals, congestive heart failure data from 2,396 hospitals, and MI data from 1,965 hospitals.

The authors divided each group into quartiles, from best-performing to worst. If the poorest-performing hospitals used all of the recommended interventions for the three conditions, there would be about 2,200 fewer deaths, the authors wrote in the July/August issue of Health Affairs.

The benchmarks were derived from the Hospital Quality Alliance, a national program using hospital-reported data to judge how well health care institutions manage the three conditions, which together account for more than 15% of Medicare hospital admissions for medical and surgical services.

The findings appeared to validate the use of process-based measures for judging the quality of healthcare in U.S. hospitals. The measures were prompted in part by passage in 2005 of the Deficit Reduction Act, which provides financial incentives for hospitals to report quality data, the investigators said.

"It is clear that the United States has embarked on a continuing and expanding initiative to monitor the quality of hospital care," they wrote. "Our findings underscore the potential of this effort for improving quality of care and changing patient outcomes."

In their study, the authors scored hospitals on each of 10 quality indicators -- five for care of patients in AMI, two for patients in heart failure, and three for patients with pneumonia. The indicators for each condition were:

• AMI: aspirin at arrival, aspirin at discharge, beta-blocker at arrival, beta-blocker at discharge, and ACE inhibitor for left ventricular systolic dysfunction.
• CHF: left ventricular function assessment and ACE inhibitor for Left ventricular systolic dysfunction.
• Pneumonia: initial antibiotic timing (antibiotics provided in four hours or less).

For each hospital studied, the authors created summary scores -- the simple weighted average of all measures -- for each of the three conditions, provided that the hospital reported a sample size of at least twenty-five for all of the indicators for that condition.

They were able to obtain information on one or how one or more of the conditions were handled in 3,720 hospitals, which varied by profit status, urban versus rural location, and the presence of ICUs.

They found that hospitals in the bottom quartile of performance on the Hospital Quality Alliance measures had a predicted mortality of 10.8% for AMI, 5.0% for congestive heart failure, and 7.9% for pneumonia.

"Higher performance was consistently associated with lower adjusted mortality rates, as hospitals in the top quartile had nearly 1% lower mortality among patients with AMI, 0.4% among patients with CHF, and 0.8% among patients with pneumonia," they wrote.

In logistic regression models controlling for clustering of patients at the hospital level, they saw that for each of the three conditions higher quality performance was associated with lower mortality.

Patients who were discharged from one of the top quartile hospitals with a diagnosis of AMI had an adjusted odds ratio for death of 0.89 (95% confidence interval, 0.85 to 0.94, P