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The measurement of mortality. A risk-adjusted variable time window approach
S T Fleming1, L F McMahon, S I Desharnais
1Department of Health Services Management, University of Missouri-Columbia 65211.
Abstract:
This paper describes the development of risk-adjusted mortality indices (RAMI) using 1985 MEDPAR data from 657 hospitals. The RAMI methodology is adopted from the Commission on Professional and Hospital Activities, however, both inhospital and post-discharge deaths are counted within time windows that vary by clinical condition. Five different RAMI measures (expected deaths/observed deaths) are developed, compared, and aggregated into various hospital characteristic strata. These measures vary by which discharge is held responsible for deaths within a time window, and whether or not inhospital deaths that occur beyond the time window are included. The RAMIs using varying time windows are compared with the RAMIs based upon inhospital deaths only. The inhospital RAMI was higher for the nonteaching hospitals (.95) as compared with the major and minor teaching institutions (.91 and .89). The RAMIs using the varying time windows, on the other hand, tend to be higher for the teaching institutions (e.g., 1.07 for major teaching hospitals; 0.99 for nonteaching hospitals).
Insights
This study developed risk-adjusted mortality indices (RAMI) to compare hospital performance. RAMI measures varied, showing teaching hospitals had higher mortality rates when including post-discharge deaths.
Area of Science:
- Healthcare Management
- Medical Statistics
- Hospital Quality Assessment
Background:
- Assessing hospital quality and patient outcomes is crucial for healthcare improvement.
- Traditional mortality measures often focus solely on in-hospital deaths, potentially underestimating true patient mortality.
- Developing robust risk-adjusted mortality indices is essential for accurate hospital performance evaluation.
Purpose of the Study:
- To develop and compare various risk-adjusted mortality indices (RAMI) using comprehensive death data.
- To analyze how different RAMI methodologies, including post-discharge deaths, affect hospital performance comparisons.
- To investigate variations in RAMI across different hospital types, such as teaching versus non-teaching institutions.
Main Methods:
- Utilized 1985 Medicare Provider Analysis and Review (MEDPAR) data from 657 hospitals.
- Adapted the RAMI methodology from the Commission on Professional and Hospital Activities.
- Developed five distinct RAMI measures, incorporating both in-hospital and post-discharge deaths within condition-specific time windows.
Main Results:
- In-hospital only RAMI was higher for non-teaching hospitals (0.95) compared to major (0.91) and minor (0.89) teaching hospitals.
- RAMI measures incorporating varying time windows for post-discharge deaths were generally higher for teaching institutions (e.g., 1.07 for major teaching hospitals).
- The inclusion of post-discharge deaths significantly altered the comparative performance of teaching versus non-teaching hospitals.
Conclusions:
- The definition of the time window and inclusion of post-discharge deaths critically influence risk-adjusted mortality index calculations.
- RAMI incorporating broader mortality definitions may provide a more comprehensive assessment of hospital quality.
- Findings suggest that teaching hospitals may have a higher observed mortality when accounting for a wider range of patient deaths post-discharge.