| Hospital Quality, Death Rates, Don’t Go Hand-in-Hand
Inpatient mortality rates used, by organizations to
issue report cards on the quality of individual U.S. hospitals, are a
poor gauge of how well hospitals actually perform and should be
abandoned in favor of measures that more accurately assess patient
harms and care provided, argued patient safety experts in a new study.
The study, co-authored by Dr. Peter Pronovost, professor
of anesthesiology and critical care medicine at the Johns Hopkins
University School of Medicine, and Richard Lilford, professor of
clinical epidemiology at the University of Birmingham in England,
appeared in the British Medical Journal.
The study said that hospital mortality rates take into
account all inpatient deaths, not just the ones that could have been
prevented with quality care. Since many patients are often too sick to
be saved by the time they are admitted to the hospital, the researchers
argue, hospital mortality rates shouldn’t be the factor that
determines whether hospitals are "good" or "bad."
Only one of every 20 hospital deaths in the United States is believed to be preventable.
Pronovost and Lilford looked specifically at hospital standardized mortality ratios.
Hospital mortality seems like the most obvious way to
judge a hospital’s care. It is easily measured, of undisputed
importance to everyone, and common to all hospital settings. But it
does not tell the whole story, Pronovost said.
"It’s laudable to want to look at preventing
deaths. But if you want to look at preventing deaths, why on earth
would you look at all deaths, when it’s only a small percentage
that fall into that category?" he added.
Pronovost wants to use selected measures that are
accurate, that are used to examine events that can be prevented and
that have been scientifically studied. He isn’t against
collecting data on mortality; he just thinks they shouldn’t be
the sole basis for sanction or reward.
"The goal is to say, ‘Yes, we need to be more
accountable for quality of care,’ but we need to be scientific in
how we separate hospitals of better quality from hospitals of worse
quality," he said.
Using mortality rates can mislead the public into
thinking a hospital offers poor care when it does not, he said, or to
comfort those who score well, who may just have a false sense of
confidence since the rates are not meaningful. In the United Kingdom,
mortality ratios vary by 60 percent among hospitals, making it an
"absurd" measure of quality, Pronovost said, when only one in 20 deaths
can be prevented.
One yardstick by which hospitals could be better judged,
he said, is the rate of bloodstream infections in hospital intensive
care units, which cause 31,000 deaths in U.S. hospitals each year.
Pronovost’s previous research has found that these infections are
largely preventable by hospitals that use a five-step checklist with
simple steps proven to reduce the infections. Research on the checklist
showed that bloodstream infections at Johns Hopkins Hospital, and
hospitals throughout the state of Michigan, have been virtually
eliminated when the checklist is followed.
Looking at some mortality rates may make sense, he said.
For example, looking at death rates following a heart attack or
elective surgery could be a quality measure since there is an
expectation that those patients should survive.
He said more research needs to be done into which
measures most accurately assess how hospitals prevent needless deaths.
These, he said, should be how hospital quality is judged.
Address: Johns Hopkins University, 733 North Broadway, Baltimore, MD 21205-2196; (410) 955-5000, www.hopkinsmedicine.org.
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