"Report Card" Grades for Hospitals Depend on the Methods Used for Reporting

Summaries for Patients are a service provided by Annals to help patients better understand the complicated and often mystifying language of modern medicine.

Summaries for Patients are presented for informational purposes only. These summaries are not a substitute for advice from your own medical provider. If you have questions about this material, or need medical advice about your own health or situation, please contact your physician. The summaries may be reproduced for not-for-profit educational purposes only. Any other uses must be approved by the American College of Physicians-American Society of Internal Medicine.

The summary below is from the full report titled "Results of Report Cards for Patients with Congestive Heart Failure Depend on the Method Used To Adjust for Severity." It is in the 4 July 2000 issue of Annals of Internal Medicine (volume 133, pages 10-20). The authors are R.M. Poses, D.K. McClish, W.R. Smith, E.C. Huber, F.L.W. Clemo, B.P. Schmitt, D. Alexander, E.M. Racht, and C.C. Colenda III.

What is the problem and what is known about it so far?

A growing number of "report cards " try to grade the quality of care provided by hospitals by assessing patients' outcomes (for example, death rates). It is hard to develop report card grades that reflect the true quality of care delivered at a particular hospital, however, partly because patients at some hospitals are sicker to begin with, and thus are more likely to have bad outcomes, than those at other hospitals. To deal with this problem, report cards can take patients' level of sickness into account by using a statistical process known as "risk adjustment " or "severity adjustment. " Some risk adjustment methods assess the general sickness of patients with various illnesses, and others assess the severity of specific medical conditions.

Why did the researchers do this particular study?

To see if the quality rankings of hospitals changed depending on which risk adjustment method was used.

Who was studied?

The researchers studied patients with congestive heart failure who came to emergency departments in a community hospital, a university hospital, and a Veterans Affairs hospital. Congestive heart failure is a condition in which the heart muscle becomes weak, leading to buildup of fluid in the body.

How was the study done?

The researchers measured how many patients with congestive heart failure were still living 30 days and 1 year after first coming to the study hospitals. They then adjusted the death rates using four general measures of sickness and four specific measures that rated the severity of congestive heat failure when these patients first presented. The researchers then studied the hospitals' quality rankings using each of the adjustment methods.

What did the researchers find?

Before researchers accounted for differences in patients' initial levels of sickness at each hospital, it looked like the patients at the university hospital were more likely to be alive 30 days and 1 year after leaving the hospital than the patients at the community and Veterans Affairs hospitals. However, after accounting for the initial levels of sickness at the different hospitals using different methods, it was unclear which hospital's patients did better. The rankings of the hospitals depended on the risk adjustment method used.

What were the limitations of the study?

This study examined only three hospitals and patients with a single medical condition; the results might be different for different hospitals and diseases. In addition, the study measured only survival rates but did not find out how often patients at each hospital actually received recommended treatments.

What are the implications of the study?

Hospitals' "grades" on outcome report cards depend on the methods used to account for the level of sickness of the patients seen at those hospitals. Outcome report cards may not truly reflect the quality of care at a specific hospital.