An Evaluation of Generic Screens for Poor Quality of Hospital Care on a General Medicine Service

In this study, 675 general medicine admissions at a university teaching hospital were reviewed to evaluate six potential generic quality screens: 1) in-hospital death; 2) 28-day early readmission; 3) low patient satisfaction; 4) worsening severity of illness (as determined by an increase in Laboratory Acute Physiology and Chronic Health Evaluation APACHE-L); and 5) deviations from expected hospital length of stay; and 6) expected ancillary resource use. The quality of care for a stratified random sample of admissions were evaluated using structured implicit review (inter-rater reliability, Kappa=0.5). Patients who died in-hospital were substantially more likely than those who were discharged alive to be rated as having had substandard care (30% vs. 10%; P<0.001). In contrast, cases who had subsequent early readmissions did not have poorer quality ratings. Similarly, lower patient satisfaction was not associated with poorer ratings of technical process of care. Cases with lower-than-expected ancillary resource use (case-mix adjusted for diagnosis-related group) were more likely to be rated as having received substandard care than those with higher-than-expected resource use (16% vs. 6%; P<0.05), and there was a similar trend for cases with shorter than expected length of stays. Associations between worsening severity of illness, as determined by APACHE-L scores, and quality were confounded because such patients were more likely to have died in-hospital. When deaths were excluded from the analysis, we found no association between increases in APACHE-L scores during the hospital course and quality of care. It was found that in-hospital death and lower-than-expected ancillary resource use were associated with poorer implicit quality ratings, but that early readmission, lower patient satisfaction, and increases in APACHE-L scores were not. Quality screens, such as early readmissions, should be critically evaluated before being used administratively.