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November 19, 1997, Vol 278, No. 19 >
ARTICLE | November 19, 1997

The Risks of Risk Adjustment FREE

Lisa I. lezzoni, MD, MSc
[+] Author Affiliations

Reprints: Lisa I. lezzoni, MD, MSc, Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, East Campus LY-326, Boston, MA 02215.


JAMA. 1997;278(19):1600-1607. doi:10.1001/jama.1997.03550190064046
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Article
References

Context.  —Risk adjustment is essential before comparing patient outcomes across hospitals. Hospital report cards around the country use different risk adjustment methods.

Objectives.  —To examine the history and current practices of risk adjusting hospital death rates and consider the implications for using risk-adjusted mortality comparisons to assess quality.

Data Sources and Study Selection.  —This article examines severity measures used in states and regions to produce comparisons of risk-adjusted hospital death rates. Detailed results are presented from a study comparing current commercial severity measures using a single database. It included adults admitted for acute myocardial infarction (n=11 880), coronary artery bypass graft surgery (n=7765), pneumonia (n=18016), and stroke (n=9407). Logistic regressions within each condition predicted in-hospital death using severity scores. Odds ratios for in-hospital death were compared across pairs of severity measures. For each hospital, z scores compared actual and expected death rates.

Results.  —The severity measure called Disease Staging had the highest c statistic (which measures how well a severity measure discriminates between patients who lived and those who died) for acute myocardial infarction, 0.86; the measure called All Patient Refined Diagnosis Related Groups had the highest for coronary artery bypass graft surgery, 0.83; and the measure, MedisGroups, had the highest for pneumonia, 0.85 and stroke, 0.87. Different severity measures predicted different probabilities of death for many patients. Severity measures frequently disagreed about which hospitals had particularly low or high z scores. Agreement in identifying low- and high-mortality hospitals between severity-adjusted and unadjusted death rates was often better than agreement between severity measures.

Conclusions.  —Severity does not explain differences in death rates across hospitals. Different severity measures frequently produce different impressions about relative hospital performance. Severity-adjusted mortality rates alone are unlikely to isolate quality differences across hospitals.

REFERENCES

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2 +
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3 +
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4 +
Keeler EB, Kahn KL, Draper D, et al.  Changes in sickness at admission following the introduction of the prospective payment system . JAMA . 1990;;264:1962-1968.
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Iezzoni LI, Shwartz M, Moskowitz MA, Ash AS, Sawitz E, Burnside S.  Illness severity and costs of admissions at teaching and nonteaching hospitals . JAMA . 1990;;264:1426-1431.
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Sullivan LW, Wilensky GR. Medicare Hospital Mortality Information. 1987, 1988, 1989. Washington, DC: US Dept of Health and Human Services, Health Care Financing Administration; 1991.
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Iezzoni LI, Shwartz M, Restuccia J.  The role of severity information in health policy debates . Inquiry . 1991;;28:117-128.
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Iezzoni LI, Greenberg LG.  Widespread assessment of risk-adjusted outcomes: lessons from local initiatives . Jt Comm J Qual Improv . 1994;;20:305-316.
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Romano PS, Zach A, Luft HS, Rainwater J, Remy LL, Campa D.  The California hospital outcomes project . Jt Comm J Qual Improv . 1995;;21:668-682.
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Rosenthal GE, Harper DL.  Cleveland health quality choice: a model for collaborative communitybased outcomes assessment . Jt Comm J Qual Improv . 1994;;20:425-442.
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Iezzoni LI.  Dimensions of risk . In: Iezzoni LI, ed. Risk Adjustment for Measuring Healthcare Outcomes . 2nd ed. Chicago, Ill: Health Administration Press; 1997;.
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Iezzoni LI, Daley J.  A description and clinical assessment of the computerized severity index . Qual Rev Bull . 1992;;18:44-52.
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Steen PM.  Approaches to predictive modeling . Ann Thorac Surg . 1994;;58:1836-1840.
30 +
Iezzoni LI, Moskowitz MA.  A clinical assessment of MedisGroups . JAMA . 1988;;260:3159-3163.
31 +
Hannan EL, Kilburn H, O'Donnell JF, Lukacik G, Shields EP.  Adult open heart surgery in New York State: an analysis of risk factors and hospital mortality rates . JAMA . 1990;;264:2768-2774.
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Hannan EL, Kilburn H, Racz M, Shields E, Chassin MR.  Improving the outcomes of coronary artery bypass surgery in New York State . JAMA . 1994;;271:761-766.
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Hannan EL, Siu AL, Kumar D, Kilburn H Jr, Chassin MR.  The decline in coronary artery bypass graft surgery mortality in New York State . JAMA . 1995;;273:209-213.
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Chassin MR, Hannan EL, DeBuono BA.  Benefits and hazards of reporting medical outcomes publicly . N Engl J Med . 1996;;334:394-398.
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O'Connor GT, Plume SK, Olmstead EM, et al, for the Northern New England Cardiovascular Disease Study Group.  Multivariate prediction of inhospital mortality associated with coronary artery bypass graft surgery from the Northern New England Cardiovascular Disease Study Group . Circulation . 1992;;85:2110-2118.
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Edwards N, Honemann D, Burley D, Navarro M.  Refinement of the Medicare diagnosis-related groups to incorporate a measure of severity . Health Care Financing Rev . 1994;;16:45-64.
38 +
Goldfield N, Boland P, eds. Physician Profiling and Risk Adjustment . Gaithersburg, Md: Aspen Publishers Inc; 1996;.
39 +
Gonnella JS, Hornbrook MC, Louis DZ.  Staging of disease: a case-mix measurement . JAMA . 1984;;251:637-644.
40 +
Markson LE, Nash DB, Louis DZ, Gonnella JS.  Clinical outcomes management and Disease Staging . Eval Health Prof . 1991;;14:201-227.
41 +
Young WW, Kohler S, Kowalski J.  PMC patient severity scale: derivation and validation . Health Serv Res . 1994;;29:367-390.
42 +
Iezzoni LI.  Severity of illness measures and assessing the quality of hospital care . In: Goldfield N, Nash DB, eds. Providing Quality Care: Future Challenges . 2nd ed. Ann Arbor, Mich: Health Administration Press; 1995;:59-82.
43 +
Horn SD.  Validity, reliability and implications of an index of inpatient severity of illness . Med Care . 1981;;19:354-362.
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Brewster AC, Karlin BG, Hyde LA, et al.  MEDISGRPS: a clinically based approach to classifying hospital patients at admission . Inquiry . 1985;;12:377-387.
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Gonnella JS, Louis DZ, McCord JJ.  The staging concept—approach to the assessment of outcome of ambulatory care . Med Care . 1976;;14:13-21.
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Vladeck BC.  Medicare hospital payment by diagnosis-related groups . Ann Intern Med . 1984;;100:576-591.
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Fetter RB, Shin Y, Freeman JH, Averill R, Thompson J.  Case mix definition by diagnosis related groups . Med Care . 1980;;18( (suppl) ):1-53.
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Simborg DW.  DRG creep: a new hospital-acquired disease . N Engl J Med . 1981;;304:1602-1604.
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Jencks SF, Williams DK, Kay TL.  Assessing hospital-associated deaths from discharge data . JAMA . 1988;;260:2240-2246.
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Iezzoni LI, Foley SM, Daley J, Hughes J, Fisher ES, Heeren T.  Comorbidities, complications, and coding bias: does the number of diagnosis codes matter in predicting in-hospital mortality? JAMA . 1992;;267:2197-2203.
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Green J, Wintfeld N.  How accurate are hospital discharge data for evaluating effectiveness of care? Med Care . 1993;;31:719-731.
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Young WW, Swinkola RB, Zorn DM.  The measurement of hospital case mix . Med Care . 1982;;20:501-512.
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Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Iezzoni LI.  100 Apples divided by 15 red herrings: a cautionary tale from the mid-19th century on comparing hospital mortality rates . Ann Intern Med . 1996;;124:1079-1085.
2 +
Response to letter by William Farr. Med Times Gazette . (February 13) ,1864;:187. Letter.
3 +
Epstein A.  Performance reports on quality . N Engl J Med . 1995;;333:57-61.
4 +
Keeler EB, Kahn KL, Draper D, et al.  Changes in sickness at admission following the introduction of the prospective payment system . JAMA . 1990;;264:1962-1968.
5 +
Iezzoni LI, Shwartz M, Moskowitz MA, Ash AS, Sawitz E, Burnside S.  Illness severity and costs of admissions at teaching and nonteaching hospitals . JAMA . 1990;;264:1426-1431.
6 +
Sullivan LW, Wilensky GR. Medicare Hospital Mortality Information. 1987, 1988, 1989. Washington, DC: US Dept of Health and Human Services, Health Care Financing Administration; 1991.
7 +
US General Accounting Office, Health, Education, and Human Services Division. Employers and Individual Consumers Want Additional Information on Quality . Washington, DC: US General Accounting Office; 1995;. GAO/HEHS-95-201.
8 +
US General Accounting Office, Health, Education, and Human Services Division. Health Care Reform: 'Report Cards' Are Useful but Significant Issues Need to Be Addressed . Washington, DC: US General Accounting Office; 1994;. GAO/HEHS-94-219.
9 +
US General Accounting Office, Health, Education, and Human Services Division. Employers Urge Hospitals to Battle Costs Using Performance Data Systems . Washington, DC: US General Accounting Office; 1994;. GAO/HEHS-95-1.
10 +
Pennsylvania Health Care Cost Containment Council. A Consumer Guide to Coronary Artery Bypass Graft Surgery, Volume IV: 1993 Data . Harrisburg: Pennsylvania Health Care Cost Containment Council; 1995;.
11 +
Pennsylvania Health Care Cost Containment Council. Focus on Heart Attack in Western Pennsylvania: A1993 Summary Report for Health Benefits Purchasers, Health Care Providers, Policymakers, and Consumers . Harrisburg: Pennsylvania Health Care Cost Containment Council; 1996;.
12 +
Wilson P, Smoley SR, Werdegar D. Annual Report of the California Hospital Outcomes Project . Sacramento, Calif: Office of Statewide Health Planning and Development; 1993;.
13 +
Wilson P, Smoley SR, Werdegar D. Second Report of the California Hospital Outcomes Project: Acute Myocardial Infarction, Volume One: Study Overview and Results Summary . Sacramento, Calif: Office of Statewide Health Planning and Development; 1996;.
14 +
Iezzoni LI, Shwartz M, Restuccia J.  The role of severity information in health policy debates . Inquiry . 1991;;28:117-128.
15 +
Iezzoni LI, Greenberg LG.  Widespread assessment of risk-adjusted outcomes: lessons from local initiatives . Jt Comm J Qual Improv . 1994;;20:305-316.
16 +
Romano PS, Zach A, Luft HS, Rainwater J, Remy LL, Campa D.  The California hospital outcomes project . Jt Comm J Qual Improv . 1995;;21:668-682.
17 +
Rosenthal GE, Harper DL.  Cleveland health quality choice: a model for collaborative communitybased outcomes assessment . Jt Comm J Qual Improv . 1994;;20:425-442.
18 +
Freeman JL, Fetter RB, Park H, et al.  Diagnosis-related group refinement with diagnosis- and procedure-specific comorbidities and complications . Med Care . 1995;;33:806-827.
19 +
Iezzoni LI.  Dimensions of risk . In: Iezzoni LI, ed. Risk Adjustment for Measuring Healthcare Outcomes . 2nd ed. Chicago, Ill: Health Administration Press; 1997;.
20 +
Calkins DR, Rubenstein LV, Cleary PD, et al.  Failure of physicians to recognize functional disability in ambulatory patients . Ann Intern Med . 1991;;114:451-454.
21 +
Kahn KL, Pearson ML, Harrison ER, et al.  Health care for black and poor hospitalized Medicare patients . JAMA . 1994;;15:1169-1174.
22 +
Burstin HR, Lipsitz SR, Brennan TA.  Socioeconomic status and risk for substandard medical care . JAMA . 1992;;268:2383-2387.
23 +
Knaus WA, Wagner DP, Draper EA, et al.  The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults . Chest . 1991;;100:1619-1636.
24 +
Knaus WA, Wagner DP, Zimmerman JE, Draper EA.  Variations in mortality and length of stay in intensive care units . Ann Intern Med . 1993;;118:753-761.
25 +
Horn SD, Sharkey PD, Buckle JM, Backofen JE, Averill RF, Horn RA.  The relationship between severity of illness and hospital length of stay and mortality . Med Care . 1991;;29:305-317.
26 +
Iezzoni LI, Daley J.  A description and clinical assessment of the computerized severity index . Qual Rev Bull . 1992;;18:44-52.
27 +
Daley J, Jencks S, Draper D, Lenhart G, Thomas N, Walker J.  Predicting hospital-associated mortality for Medicare patients . JAMA . 1988;;260:3617-3624.
28 +
Steen PM, Brewster AC, Bradbury RC, Estabrook E, Young JA.  Predicted probabilities of hospital death as a measure of admission severity of illness . Inquiry . 1993;;30:128-141.
29 +
Steen PM.  Approaches to predictive modeling . Ann Thorac Surg . 1994;;58:1836-1840.
30 +
Iezzoni LI, Moskowitz MA.  A clinical assessment of MedisGroups . JAMA . 1988;;260:3159-3163.
31 +
Hannan EL, Kilburn H, O'Donnell JF, Lukacik G, Shields EP.  Adult open heart surgery in New York State: an analysis of risk factors and hospital mortality rates . JAMA . 1990;;264:2768-2774.
32 +
Hannan EL, Kilburn H, Racz M, Shields E, Chassin MR.  Improving the outcomes of coronary artery bypass surgery in New York State . JAMA . 1994;;271:761-766.
33 +
Hannan EL, Siu AL, Kumar D, Kilburn H Jr, Chassin MR.  The decline in coronary artery bypass graft surgery mortality in New York State . JAMA . 1995;;273:209-213.
34 +
Chassin MR, Hannan EL, DeBuono BA.  Benefits and hazards of reporting medical outcomes publicly . N Engl J Med . 1996;;334:394-398.
35 +
O'Connor GT, Plume SK, Olmstead EM, et al, for the Northern New England Cardiovascular Disease Study Group.  A regional prospective study of in-hospital mortality associated with coronary artery bypass grafting . JAMA . 1991;;266:803-809.
36 +
O'Connor GT, Plume SK, Olmstead EM, et al, for the Northern New England Cardiovascular Disease Study Group.  Multivariate prediction of inhospital mortality associated with coronary artery bypass graft surgery from the Northern New England Cardiovascular Disease Study Group . Circulation . 1992;;85:2110-2118.
37 +
Edwards N, Honemann D, Burley D, Navarro M.  Refinement of the Medicare diagnosis-related groups to incorporate a measure of severity . Health Care Financing Rev . 1994;;16:45-64.
38 +
Goldfield N, Boland P, eds. Physician Profiling and Risk Adjustment . Gaithersburg, Md: Aspen Publishers Inc; 1996;.
39 +
Gonnella JS, Hornbrook MC, Louis DZ.  Staging of disease: a case-mix measurement . JAMA . 1984;;251:637-644.
40 +
Markson LE, Nash DB, Louis DZ, Gonnella JS.  Clinical outcomes management and Disease Staging . Eval Health Prof . 1991;;14:201-227.
41 +
Young WW, Kohler S, Kowalski J.  PMC patient severity scale: derivation and validation . Health Serv Res . 1994;;29:367-390.
42 +
Iezzoni LI.  Severity of illness measures and assessing the quality of hospital care . In: Goldfield N, Nash DB, eds. Providing Quality Care: Future Challenges . 2nd ed. Ann Arbor, Mich: Health Administration Press; 1995;:59-82.
43 +
Horn SD.  Validity, reliability and implications of an index of inpatient severity of illness . Med Care . 1981;;19:354-362.
44 +
Brewster AC, Karlin BG, Hyde LA, et al.  MEDISGRPS: a clinically based approach to classifying hospital patients at admission . Inquiry . 1985;;12:377-387.
45 +
Gonnella JS, Louis DZ, McCord JJ.  The staging concept—approach to the assessment of outcome of ambulatory care . Med Care . 1976;;14:13-21.
46 +
Vladeck BC.  Medicare hospital payment by diagnosis-related groups . Ann Intern Med . 1984;;100:576-591.
47 +
Fetter RB, Shin Y, Freeman JH, Averill R, Thompson J.  Case mix definition by diagnosis related groups . Med Care . 1980;;18( (suppl) ):1-53.
48 +
Simborg DW.  DRG creep: a new hospital-acquired disease . N Engl J Med . 1981;;304:1602-1604.
49 +
Jencks SF, Williams DK, Kay TL.  Assessing hospital-associated deaths from discharge data . JAMA . 1988;;260:2240-2246.
50 +
Iezzoni LI, Foley SM, Daley J, Hughes J, Fisher ES, Heeren T.  Comorbidities, complications, and coding bias: does the number of diagnosis codes matter in predicting in-hospital mortality? JAMA . 1992;;267:2197-2203.
51 +
Green J, Wintfeld N.  How accurate are hospital discharge data for evaluating effectiveness of care? Med Care . 1993;;31:719-731.
52 +
Young WW, Swinkola RB, Zorn DM.  The measurement of hospital case mix . Med Care . 1982;;20:501-512.
53 +
Brinkley J.  US releasing lists of hospitals with abnormal mortality . New York Times . (March 12) ,1986;:1.
54 +
Dubois RW.  Hospital mortality as an indicator of quality . In: Goldfield N, Nash DB, eds. Providing Quality Care: Future Challenges . 2nd ed. Ann Arbor, Mich: Health Administration Press; 1995;.
55 +
Iglehart JK.  Competition and the pursuit of quality: a conversation with Walter McClure . Health Aff (Millwood) . 1988;;7:79-90.
56 +
Khuri SF, Daley J, Henderson WG, et al.  The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care . J Am Coll Surg . 1995;;180:519-531.
57 +
 Demise of two state-run commissions signals shift to voluntary initiatives in data collection . State Health Watch . 1995;;2:4,10.
58 +
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To understand the clinical management of acute heart failure syndromes.
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Compression-Only CPR: Pushing the Science Forward
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AAM 2010;304:1493-1495.
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BMJ 2010;341:c5893-c1494.
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