Results of report cards for patients with congestive heart failure depend on the method used to adjust for severity

Background: The validity of outcome report cards may depend on the ways in which they are adjusted for risk. Objectives: To compare the predictive ability of generic and disease-specif ic survival prediction models appropriate for use in patients with heart fa ilure, to simulate outcome report cards by comparing survival across hospit als and adjusting for severity of illness using these models, and to assess the ways in which the results of these comparisons depend on the adjustmen t method. Design: Analysis of data from a prospective cohort, study. Setting: A university hospital, a Veterans Affairs (VA) medical center, and a community hospital. Patients: Sequential patients presenting in the emergency department with a cute congestive heart failure. Measurements: Unadjusted 30-day and 1-year mortality across hospitals and 3 0-day and 1-year mortality adjusted by using disease-specific survival pred iction models (two sickness-at-admission models, the Cleveland Health Quali ty Choice model, the Congestive Heart Failure Mortality Time-independent Pr edictive Instrument) and generic models (Acute Physiology and Chronic Healt h Evaluation [APACHE] II, APACHE III, the mortality prediction model, and t he Charlson comorbidity index). Results: The community hospital's unadjusted 30-day survival rate (85.0%) a nd the VA medical center's unadjusted 1-year survival rate (60.9%) were sig nificantly lower than corresponding rates at the university hospital (92.7% and 67.5%, respectively). No severity model had excellent ability to discr iminate patients by survival rates tall areas under the receiver-operating characteristic curve < 0.73). Whether the VA medical center, the community hospital, both, or neither had worse survival rates on simulated report car ds than the university hospital depended on the prediction model used for a djustment. Conclusions: Results of simulated outcome report cards for survival in pati ents with congestive heart failure depend on the method used to adjust for severity.