Using mortality rates as a screening tool: the experience of the Department of Veterans Affairs

What is the empirical evidence that hospitals with higher-risk adjusted mortality rates provide poorer quality care? A systematic review of the literature

Background

Despite increasing interest and publication of risk-adjusted hospital mortality rates, the relationship with underlying quality of care remains unclear. We undertook a systematic review to ascertain the extent to which variations in risk-adjusted mortality rates were associated with differences in quality of care.

Methods

We identified studies in which risk-adjusted mortality and quality of care had been reported in more than one hospital. We adopted an iterative search strategy using three databases – Medline, HealthSTAR and CINAHL from 1966, 1975 and 1982 respectively. We identified potentially relevant studies on the basis of the title or abstract. We obtained these papers and included those which met our inclusion criteria.

Results

From an initial yield of 6,456 papers, 36 studies met the inclusion criteria. Several of these studies considered more than one process-versus-risk-adjusted mortality relationship. In total we found 51 such relationships in a widen range of clinical conditions using a variety of methods. A positive correlation between better quality of care and risk-adjusted mortality was found in under half the relationships (26/51 51%) but the remainder showed no correlation (16/51 31%) or a paradoxical correlation (9/51 18%).

Conclusion

The general notion that hospitals with higher risk-adjusted mortality have poorer quality of care is neither consistent nor reliable.

Enhancing performance in health care: a theoretical perspective on agency and the role of information

This paper examines the role of information in securing control of health care systems. The discussion focuses on the impact of the proposed 'Performance Framework', which entails a significant increase in the importance attached to formal performance indicators in the management of the UK National Health Service. The paper starts with a discussion of the role of performance data in securing organizational control within health care systems and summarizes recent research into the behavioural consequences of seeking to control health care agents using such information. A theoretical principal/agent model is then used to illustrate the incentives that exist for dysfunctional behaviour within health care when only imperfect information systems are available. The theoretical results are then examined in the context of a qualitative empirical study, which elicited the perceptions of managers and health care professionals connected with eight NHS hospitals. The study confirmed the existence and importance of serious dysfunctional consequences arising from the use of information as a means of control, and concludes that the Performance Framework will be successful only if it is used in careful conjunction with other means of control.

The "new VA": a national laboratory for health care quality management

In 1995, the Veterans Health Administration (VHA) initiated the most radical redesign of the veterans health care system since the system was formally created in 1946. One of the goals of this reengineering effort has been to ensure the consistent and predictable provision of high-quality care everywhere in the system. To accomplish this goal, the VHA has organized more than 100 different quality improvement activities according to a structure-, process-, and outcomes-focused quality management accountability framework (QMAF) that targets 10 interrelated dimensions of quality management (QM). Each of these dimensions utilizes a defined strategy and employs a menu of quality assessment and assurance tactics. Organizing these many different quality improvement activities into an accountability framework should facilitate the development of policies and procedures that will systematize the VHA's QM. The VHA's new operational structure and its approach to quality improvement provide a unique national laboratory for health care QM.

League tables for performance improvement in health care

OBJECTIVES

Increasingly health care performance data are being disseminated in the form of 'league tables' of health care providers, with the implication that such publication helps purchasers select the better providers, and spurs providers into improvements. This paper examines progress to date.

METHODS

Three stages of the league table process are considered: measurement, analysis and action.

RESULTS

A wide range of measurement schemes are now in place, although the emphasis has been on process variables and mortality as a measure of outcome. Several analytical techniques have been deployed to help users make sense of league tables, and to help determine the causes of variations in reported performance. The weakest aspect of current methods relates to the use to which such analysis is put.

CONCLUSIONS

A haphazard approach to using league table data exists, with few reports on the impact of publication. A variety of directions for future research into the use of performance data are needed.