Saturday, September 15, 2007

Hospital mortality rates

A wry pathologist once explained to me the reason for post mortem examinations. “Patients die,” he said, “for one of two reasons – patient failure or doctor failure. We ought to know which.”

Today we understand that many factors contribute to hospital outcomes. It is not just what a doctor orders or what a doctor does. Hospital outcomes are affected by the doctor working with the entire caring team, as well as by the effectiveness of hospital processes and support systems. Hospitals are complex places.

Last June the federal government's Hospital Compare website began reporting risk-adjusted 30-day mortality data for hospital heart patients.[1] The government’s report shows that 98.5% and 99.5% of all hospitals treating heart attacks and heart failure, respectively, had mortality rates that were consistent with the national rates.[2] Community General and the other Syracuse hospitals were all within the mortality rate mainstream of the nation’s hospitals.

The government’s website does not show hospital-specific mortality rates, and this lack of detail has been criticized by some. USA Today said that, by not listing hospital-specific death rates, the government’s web page “leaves 98% of the hospitals in the USA statistically indistinguishable from one another.” The newspaper also quoted a source at the Robert Wood Johnson Foundation as saying, “I would want to know if my hospital has higher death rates than the hospital across town.”

But others worry that mortality rates, even after statistical risk-adjustment, do not capture underlying differences that may be affected by patients’ own decision-making, particularly the end-of-life decisions made by the sickest patients. The authors of a recent article in the Journal of the American Medical Association (JAMA) suggest that the public reporting of hospital mortality rates might actually encourage the “overly aggressive treatment” of patients in their final weeks of life at the expense of effective pain control.

Several years ago, an insurance company published misleading mortality data about the pneumonia patients cared for at Community General Hospital. As reported, the pneumonia patients’ mortality was significantly higher at CGH than at other area hospitals. After investigation, we determined that the company did not take into account patients’ advance directives.[3] An examination of the records of the patients found that that 90% of the pneumonia patients who died had a DNR order.[4] In other words, most of the pneumonia deaths occurred among patients who had decided they did not want extraordinary measures used to prolong their lives. Of the non-DNR pneumonia patients cared for at CGH, the death rate was less than one percent. I discussed this situation in 2005.

Interestingly, JAMA reports that the federal government will likely add the mortality rates of pneumonia patients to its website in the future. According to the commentary in JAMA:
“Mortality is a good quality measure for individuals with acute illness who are not supposed to die…However, mortality is a poor quality measure for the majority of patients with multiple chronic diseases who are near the end of their life, and may be engaged in…decisions that result in an earlier (or less delayed) death.”
Hospital report cards are good things, and they will improve over time. As patients and families learn to use these report cards, they will become more informed about differences among hospitals – as well as about limitations of the report cards themselves.

[1] Risk-adjustment is a complex statistical process that takes into account differences in the complexity of patient conditions and differences in hospital service programs so that the mortality rates are, in fact, comparable among hospitals.
[2] The data reflect patients discharged from hospitals from October 2005 through September 2006.
[3] Advance directives are the written instructions patients give to doctors and hospitals that specify the care the patients want to receive (or don’t want to deceive) in the event they cannot make future medical decisions for themselves.
[4] DNR (“do not resuscitate”) is one form of advance directive.

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