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Results of report cards for patients with congestive heart failure depend on the method used to adjust for severity
R M Poses1, D K McClish, W R Smith
1Brown University Center for Primary Care and Prevention and Memorial Hospital of Rhode Island, Pawtucket 02860, USA. royposes@brownvm.brown.edu
Insights
Outcome report cards for heart failure survival vary based on the risk adjustment method used. Different prediction models significantly alter hospital comparisons, impacting how patient severity is accounted for.
Area of Science:
- Health Services Research
- Outcomes Research
- Cardiology
Background:
- The accuracy of healthcare outcome report cards is influenced by risk adjustment methods.
- Valid comparisons of hospital performance require appropriate adjustments for patient severity.
Purpose of the Study:
- To compare the predictive capabilities of generic and disease-specific survival models in heart failure patients.
- To simulate hospital outcome report cards for heart failure survival, adjusting for illness severity.
- To evaluate the impact of different adjustment methods on simulated report card results.
Main Methods:
- Analysis of data from a prospective cohort study involving patients with acute congestive heart failure.
- Comparison of unadjusted and adjusted 30-day and 1-year mortality rates across three hospitals (university, VA, community).
- Adjustment for illness severity using various disease-specific (e.g., Cleveland Health Quality Choice) and generic (e.g., APACHE II, APACHE III) prediction models.
Main Results:
- Significant differences in unadjusted survival rates were observed between hospitals.
- No severity adjustment model demonstrated excellent discrimination ability (AUC < 0.73).
- The classification of hospitals (better or worse survival) on simulated report cards was dependent on the prediction model employed for adjustment.
Conclusions:
- The validity and interpretation of outcome report cards for heart failure survival are highly sensitive to the chosen risk adjustment methodology.
- Different prediction models yield varying results, highlighting the need for careful selection and validation of adjustment methods in quality assessment.
Background:
The validity of outcome report cards may depend on the ways in which they are adjusted for risk.
Objectives:
To compare the predictive ability of generic and disease-specific survival prediction models appropriate for use in patients with heart failure, to simulate outcome report cards by comparing survival across hospitals and adjusting for severity of illness using these models, and to assess the ways in which the results of these comparisons depend on the adjustment method.
Design:
Analysis of data from a prospective cohort study.
Setting:
A university hospital, a Veterans Affairs (VA) medical center, and a community hospital.
Patients:
Sequential patients presenting in the emergency department with acute congestive heart failure.
Measurements:
Unadjusted 30-day and 1-year mortality across hospitals and 30-day and 1-year mortality adjusted by using disease-specific survival prediction models (two sickness-at-admission models, the Cleveland Health Quality Choice model, the Congestive Heart Failure Mortality Time-Independent Predictive Instrument) and generic models (Acute Physiology and Chronic Health Evaluation [APACHE] II, APACHE III, the mortality prediction model, and the Chadson comorbidity index).
Results:
The community hospital's unadjusted 30-day survival rate (85.0%) and the VA medical center's unadjusted 1-year survival rate (60.9%) were significantly lower than corresponding rates at the university hospital (92.7% and 67.5%, respectively). No severity model had excellent ability to discriminate patients by survival rates (all areas under the receiver-operating characteristic curve < 0.73). Whether the VA medical center, the community hospital, both, or neither had worse survival rates on simulated report cards than the university hospital depended on the prediction model used for adjustment.
Conclusions:
Results of simulated outcome report cards for survival in patients with congestive heart failure depend on the method used to adjust for severity.
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