Measuring Quality of Care With Explicit Process Criteria Before and After Implementation of the DRG-Based Prospective Payment System

Katherine L. Kahn, MD; William H. Rogers, PhD; Lisa V. Rubenstein, MD, MSPH; Marjorie J. Sherwood, MD; Ellen J. Reinisch, MS; Emmett B. Keeler, PhD; David Draper, PhD; Jacqueline Kosecoff, PhD; Robert H. Brook, MD, ScD
JAMA. 1990;264(15):1969-1973. doi:10.1001/jama.1990.03450150069033.
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We developed explicit process criteria and scales for Medicare patients hospitalized with congestive heart failure, myocardial infarction, pneumonia, cerebrovascular accident, and hip fracture. We applied the process scales to a nationally representative sample of 14 012 patients hospitalized before and after the implementation of the diagnosis related group—based prospective payment system. For the four medical diseases, a better process of care resulted in lower mortality rates 30 days after admission. Patients in the upper quartile of process scores had a 30-day mortality rate 5% lower than that of patients in the lower quartile. The process of care improved after the introduction of the prospective payment system; eg, better nursing care after the introduction of the prospective payment system was associated with an expected decrease in 30-day mortality rates in pneumonia patients of 0.8 percentage points, and better physician cognitive performance was associated with an expected decrease in 30-day mortality rates of 0.4 percentage points. Overall, process improvements across all four medical conditions were associated with a 1 percentage point reduction in 30-day mortality rates after the introduction of the prospective payment system.

(JAMA. 1990;264:1969-1973)


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