Are mortality indicators good indicators of health care quality?

Citation
P. Ravaud et al., Are mortality indicators good indicators of health care quality?, PRESSE MED, 28(29), 1999, pp. 1604-1609
Citations number
48
Categorie Soggetti
General & Internal Medicine","Medical Research General Topics
Journal title
PRESSE MEDICALE
ISSN journal
07554982 → ACNP
Volume
28
Issue
29
Year of publication
1999
Pages
1604 - 1609
Database
ISI
SICI code
0755-4982(19991002)28:29<1604:AMIGIO>2.0.ZU;2-N
Abstract
Importance of publishing mortality rates: Mortality rates for certain inter ventions or disease states have been used over the last decade as indicator s of the quality of care provided by a given hospital, unit or, medical tea m. If published, these rates would be a useful tool for decision makers in the process of fund allocations, for public information, and for promoting improved care in hospitals or units with a low classification. Methodological limitations: It is difficult to adjust an indicator of morta lity to disease-related risk factors and any modification of this adjustmen t can have major consequences on the validity of subsequent comparisons. Th e differences in mortality observed between hospitals and physicians can re flect not only differences in quality of care but also differences in appro aches to disease-related risk factors, therapeutic choices, or coding pract ices. The lack of statistical power is a major limiting factor in interpret ing differences in mortality rates. To evidence a statistically significant difference in mortality between two hospitals whose rates are respectively 0.5% and 1% (for example in total hip replacement patients), it would be n ecessary to include 4673 patients, a number which would correspond to 20 ye ars data for a hospital performing 230 interventions per year. Consequently , the number of interventions performed in the most active hospitals would not be sufficient to make such comparisons. Limitations and counter effects: Some studies have demonstrated that the pu blication of mortality rates does not have a major influence on patients' d ecisions nor on physicians' choice of a referral hospital. It would have no effect on improving health care quality of the institutions cited. One the contrary, certain counter effects have been observed: modification in pati ent recruitment, higher-risk patients being referred to hospitals with unpu blished mortality rates. For many authors, procedure indicators are more pe rtinent than outcome indicators for detecting differences in health care qu ality between different care structures.