Abstract 2542: The Limited Value of All Cause Risk-adjusted Mortality Hospital Report Cards in Measuring and Improving Quality of Care
Introduction: Report cards for coronary artery bypass graft (CABG) surgery have primarily consisted of hospital and/or surgeon specific in-hospital mortality rates.
Objective: This study attempted to understand the utility of report cards in identifying hospitals with a larger proportion of deaths that could potentially have been avoided and were related to quality of care problems.
Methods: This was a retrospective analysis of 40 randomly selected, in-hospital deaths following isolated CABG surgery at each of the nine cardiac surgery institutions between April 2000-March 2002 in Ontario. Additional cases were reviewed from fiscal years 1998, 1999, 2002, and 2003 for hospitals with small volumes or with new cardiac surgery programs. Nurse abstracted chart summaries were blindly reviewed (ie blinded to patient, physician, and hospital) by two trained cardiac surgeons (an experienced staff surgeon/chief was chosen from each participating hospital) independent to the hospital from which the patient originated using a standardized implicit tool to identify preventable death.
Results: 347 deaths (40 per hospital for 8 hospitals, 27 deaths at a new cardiac surgery program) were each reviewed by 2 of 9 physician reviewers to give a total of 694 single reviews. The total number of preventable deaths determined through physician double review with a third review for disagreements was 32% (111 deaths/347 deaths reviewed). The majority of deaths were related to problems that occurred in the operating room (86%) and intensive care unit (61%), with a minority occurring on the ward (15%). There was no significant correlation between all-cause, risk-adjusted mortality rates, and the proportion of preventable deaths across the nine hospitals (Spearman coefficient p=0.77).
Conclusions: In summary all-cause, risk-adjusted mortality rates currently employed on CABG report cards are useful as a screening aid in identifying gross abnormalities in quality of care, however regardless of the results of these reports all providers need further independent audits to help drive improvements in quality that are meaningful.