Assessing Hospital-Associated Deaths

To the Editor.—  The comparison by Jencks et al¹ of hospital discharge death rates with 30-day postadmission death rates demonstrates the probable superiority of the longer period for hospital mortality analysis and reporting. The analysis, however, and the hospital death rate release by the Health Care Financing Administration assume throughout that the proper starting time for the 30-day period is the time of admission to the hospital.² I question the wisdom of that assumption.One problem is that many patients who experience surgical misadventures or other iatrogenic mistakes die only after long attempts to recover from the mistakes. Thus, the deaths excluded from the 30-day postadmission criteria are likely to be the in-hospital deaths most attributable to poor quality of care.The second problem is that in New York State, for diseases such as stroke, where average length of stay is quite long, the bad outcomes include some