Key result
Applying 30-day post-admission or post-discharge mortality timeframes changed the performance categorization of 33% and 22% of hospitals, respectively, compared to in-hospital mortality.
Why the study?
Does applying post-discharge mortality timeframes change the standardised mortality ratios and performance categorization of hospitals compared to in-hospital mortality alone?
Observational (n=1,228,815)
Yes
Does applying post-discharge mortality timeframes change the standardised mortality ratios and performance categorization of hospitals compared to in-hospital mortality alone?
Standardised mortality ratios based solely on in-hospital mortality are subject to discharge bias, suggesting that early post-discharge mortality should be included to accurately assess hospital performance.
May misclassify hospital performance using in-hospital mortality alone; leaves open optimal timeframe for standardized quality metrics.
OBJECTIVES: To assess the consequences of applying different mortality timeframes on standardised mortality ratios of individual hospitals and, secondarily, to evaluate the association between in-hospital standardised mortality ratios and early post-discharge mortality rate, length of hospital stay, and transfer rate. DESIGN: Retrospective analysis of routinely collected hospital data to compare observed deaths in 50 diagnostic categories with deaths predicted by a case mix adjustment method. SETTING: 60 Dutch hospitals. PARTICIPANTS: 1 228 815 patients discharged in the period 2008 to 2010. MAIN OUTCOME MEASURES: In-hospital standardised mortality ratio, 30 days post-admission standardised mortality ratio, and 30 days post-discharge standardised mortality ratio. RESULTS: Compared with the in-hospital standardised mortality ratio, 33% of the hospitals were categorised differently with the 30 days post-admission standardised mortality ratio and 22% were categorised differently with the 30 days post-discharge standardised mortality ratio. A positive association was found between in-hospital standardised mortality ratio and length of hospital stay (Pearson correlation coefficient 0.33; P=0.01), and an inverse association was found between in-hospital standardised mortality ratio and early post-discharge mortality (Pearson correlation coefficient -0.37; P=0.004). CONCLUSIONS: Applying different mortality timeframes resulted in differences in standardised mortality ratios and differences in judgment regarding the performance of individual hospitals. Furthermore, associations between in-hospital standardised mortality rates, length of stay, and early post-discharge mortality rates were found. Combining these findings suggests that standardised mortality ratios based on in-hospital mortality are subject to so-called "discharge bias." Hence, early post-discharge mortality should be included in the calculation of standardised mortality ratios.
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Pouw et al. (2013) conducted an observational in Hospitalized patients in 50 diagnostic categories (n=1,228,815). 30 days post-admission and 30 days post-discharge mortality timeframes vs. In-hospital mortality timeframe was evaluated on Hospital categorization based on standardised mortality ratios. Applying 30-day post-admission or post-discharge mortality timeframes changed the performance categorization of 33% and 22% of hospitals, respectively, compared to in-hospital mortality.
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