Does the inclusion of stroke severity in a 30-day mortality model change standardized mortality rates at veterans affairs hospitals?

Salomeh Keyhani, Eric Cheng, Gregory Arling, Xinli Li, Laura Myers, Susan Ofner, Linda Williams, Michael Phipps, Diana Ordin, Dawn Bravata

Research output: Contribution to journalArticle

11 Citations (Scopus)

Abstract

Background-The Centers for Medicare and Medicaid Services is considering developing a 30-day ischemic stroke hospitallevel mortality model using administrative data. We examined whether inclusion of the National Institutes of Health Stroke Scale (NIHSS), a measure of stroke severity not included in administrative data, would alter 30-day mortality rates in the Veterans Health Administration. Methods and Results-A total of 2562 veterans admitted with ischemic stroke to 64 Veterans Health Administration Hospitals in the fiscal year 2007 were included. First, we examined the distribution of unadjusted mortality rates across the Veterans Health Administration. Second, we estimated 30-day all-cause, risk standardized mortality rates (RSMRs) for each hospital by adjusting for age, sex, and comorbid conditions using hierarchical models with and without the inclusion of the NIHSS. Finally, we examined whether adjustment for the NIHSS significantly changed RSMRs for each hospital compared with other hospitals. The median unadjusted mortality rate was 3.6%. The RSMR interquartile range without the NIHSS ranged from 5.1% to 5.6%. Adjustment with the NIHSS did not change the RSMR interquartile range (5.1%-5.6%). Among veterans =65 years, the RSMR interquartile range without the NIHSS ranged from 9.2% to 10.3%. With adjustment for the NIHSS, the RSMR interquartile range changed from 9.4% to 10.0%. The plot of 30-day RSMRs estimated with and without the inclusion of the NIHSS in the model demonstrated overlapping 95% confidence intervals across all hospitals, with no hospital significantly below or above the mean-unadjusted 30-day mortality rate. The 30-day mortality measure did not discriminate well among hospitals. Conclusion-The impact of the NIHSS on RSMRs was limited. The small number of stroke admissions and the narrow range of 30-day stroke mortality rates at the facility level in the Veterans Health Administration cast doubt on the value of using 30-day RSMRs as a means of identifying outlier hospitals based on their stroke care quality.

Original languageEnglish
Pages (from-to)508-513
Number of pages6
JournalCirculation: Cardiovascular Quality and Outcomes
Volume5
Issue number4
DOIs
StatePublished - Jul 2012

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Veterans Hospitals
Stroke
National Institutes of Health (U.S.)
Mortality
Veterans Health
United States Department of Veterans Affairs
Veterans
Centers for Medicare and Medicaid Services (U.S.)
Quality of Health Care

Keywords

  • Hospital mortality
  • Outcome assessment (health care)
  • Stroke

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Does the inclusion of stroke severity in a 30-day mortality model change standardized mortality rates at veterans affairs hospitals? / Keyhani, Salomeh; Cheng, Eric; Arling, Gregory; Li, Xinli; Myers, Laura; Ofner, Susan; Williams, Linda; Phipps, Michael; Ordin, Diana; Bravata, Dawn.

In: Circulation: Cardiovascular Quality and Outcomes, Vol. 5, No. 4, 07.2012, p. 508-513.

Research output: Contribution to journalArticle

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title = "Does the inclusion of stroke severity in a 30-day mortality model change standardized mortality rates at veterans affairs hospitals?",
abstract = "Background-The Centers for Medicare and Medicaid Services is considering developing a 30-day ischemic stroke hospitallevel mortality model using administrative data. We examined whether inclusion of the National Institutes of Health Stroke Scale (NIHSS), a measure of stroke severity not included in administrative data, would alter 30-day mortality rates in the Veterans Health Administration. Methods and Results-A total of 2562 veterans admitted with ischemic stroke to 64 Veterans Health Administration Hospitals in the fiscal year 2007 were included. First, we examined the distribution of unadjusted mortality rates across the Veterans Health Administration. Second, we estimated 30-day all-cause, risk standardized mortality rates (RSMRs) for each hospital by adjusting for age, sex, and comorbid conditions using hierarchical models with and without the inclusion of the NIHSS. Finally, we examined whether adjustment for the NIHSS significantly changed RSMRs for each hospital compared with other hospitals. The median unadjusted mortality rate was 3.6{\%}. The RSMR interquartile range without the NIHSS ranged from 5.1{\%} to 5.6{\%}. Adjustment with the NIHSS did not change the RSMR interquartile range (5.1{\%}-5.6{\%}). Among veterans =65 years, the RSMR interquartile range without the NIHSS ranged from 9.2{\%} to 10.3{\%}. With adjustment for the NIHSS, the RSMR interquartile range changed from 9.4{\%} to 10.0{\%}. The plot of 30-day RSMRs estimated with and without the inclusion of the NIHSS in the model demonstrated overlapping 95{\%} confidence intervals across all hospitals, with no hospital significantly below or above the mean-unadjusted 30-day mortality rate. The 30-day mortality measure did not discriminate well among hospitals. Conclusion-The impact of the NIHSS on RSMRs was limited. The small number of stroke admissions and the narrow range of 30-day stroke mortality rates at the facility level in the Veterans Health Administration cast doubt on the value of using 30-day RSMRs as a means of identifying outlier hospitals based on their stroke care quality.",
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T1 - Does the inclusion of stroke severity in a 30-day mortality model change standardized mortality rates at veterans affairs hospitals?

AU - Keyhani, Salomeh

AU - Cheng, Eric

AU - Arling, Gregory

AU - Li, Xinli

AU - Myers, Laura

AU - Ofner, Susan

AU - Williams, Linda

AU - Phipps, Michael

AU - Ordin, Diana

AU - Bravata, Dawn

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N2 - Background-The Centers for Medicare and Medicaid Services is considering developing a 30-day ischemic stroke hospitallevel mortality model using administrative data. We examined whether inclusion of the National Institutes of Health Stroke Scale (NIHSS), a measure of stroke severity not included in administrative data, would alter 30-day mortality rates in the Veterans Health Administration. Methods and Results-A total of 2562 veterans admitted with ischemic stroke to 64 Veterans Health Administration Hospitals in the fiscal year 2007 were included. First, we examined the distribution of unadjusted mortality rates across the Veterans Health Administration. Second, we estimated 30-day all-cause, risk standardized mortality rates (RSMRs) for each hospital by adjusting for age, sex, and comorbid conditions using hierarchical models with and without the inclusion of the NIHSS. Finally, we examined whether adjustment for the NIHSS significantly changed RSMRs for each hospital compared with other hospitals. The median unadjusted mortality rate was 3.6%. The RSMR interquartile range without the NIHSS ranged from 5.1% to 5.6%. Adjustment with the NIHSS did not change the RSMR interquartile range (5.1%-5.6%). Among veterans =65 years, the RSMR interquartile range without the NIHSS ranged from 9.2% to 10.3%. With adjustment for the NIHSS, the RSMR interquartile range changed from 9.4% to 10.0%. The plot of 30-day RSMRs estimated with and without the inclusion of the NIHSS in the model demonstrated overlapping 95% confidence intervals across all hospitals, with no hospital significantly below or above the mean-unadjusted 30-day mortality rate. The 30-day mortality measure did not discriminate well among hospitals. Conclusion-The impact of the NIHSS on RSMRs was limited. The small number of stroke admissions and the narrow range of 30-day stroke mortality rates at the facility level in the Veterans Health Administration cast doubt on the value of using 30-day RSMRs as a means of identifying outlier hospitals based on their stroke care quality.

AB - Background-The Centers for Medicare and Medicaid Services is considering developing a 30-day ischemic stroke hospitallevel mortality model using administrative data. We examined whether inclusion of the National Institutes of Health Stroke Scale (NIHSS), a measure of stroke severity not included in administrative data, would alter 30-day mortality rates in the Veterans Health Administration. Methods and Results-A total of 2562 veterans admitted with ischemic stroke to 64 Veterans Health Administration Hospitals in the fiscal year 2007 were included. First, we examined the distribution of unadjusted mortality rates across the Veterans Health Administration. Second, we estimated 30-day all-cause, risk standardized mortality rates (RSMRs) for each hospital by adjusting for age, sex, and comorbid conditions using hierarchical models with and without the inclusion of the NIHSS. Finally, we examined whether adjustment for the NIHSS significantly changed RSMRs for each hospital compared with other hospitals. The median unadjusted mortality rate was 3.6%. The RSMR interquartile range without the NIHSS ranged from 5.1% to 5.6%. Adjustment with the NIHSS did not change the RSMR interquartile range (5.1%-5.6%). Among veterans =65 years, the RSMR interquartile range without the NIHSS ranged from 9.2% to 10.3%. With adjustment for the NIHSS, the RSMR interquartile range changed from 9.4% to 10.0%. The plot of 30-day RSMRs estimated with and without the inclusion of the NIHSS in the model demonstrated overlapping 95% confidence intervals across all hospitals, with no hospital significantly below or above the mean-unadjusted 30-day mortality rate. The 30-day mortality measure did not discriminate well among hospitals. Conclusion-The impact of the NIHSS on RSMRs was limited. The small number of stroke admissions and the narrow range of 30-day stroke mortality rates at the facility level in the Veterans Health Administration cast doubt on the value of using 30-day RSMRs as a means of identifying outlier hospitals based on their stroke care quality.

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KW - Outcome assessment (health care)

KW - Stroke

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