Study Shows Hospital Performance Predicts Only 

Small Differences in Hospital Risk-Adjusted 

Mortality Rates 

Overview 

It is widely recognized that the quality of health care in the United States is uneven 

and often inadequate. Adding to this is the variation in hospital quality of care, 

particularly compliance with hospital performance measures. In response to these 

concerns, the Hospital Quality Alliance began measuring hospital performance, and 

the Centers for Medicare and Medicaid Services reports these results on their website, 

Hospital Compare. Hospital performance measurement and reporting can provide an 

incentive to improve quality of the care delivered and to influence consumer choice of 

hospitals. In a recent study conducted, in part, by an HSR&D investigator and 

published in the December 13, 2006 issue of JAMA, investigators sought to test 

whether quality measured with the process measures used in Hospital Compare are 

correlated with, and predictive of, hospitals' risk-adjusted mortality rates for three 

conditions: 

z acute myocardial infarction (AMI), 

z pneumonia, 

z and heart failure. 

In other words, from a consumer's perspective can a hospital's performance on 

process measures be used to choose a hospital where patients can expect to have 

better outcomes? 

Study Methods 

Using observational analysis, investigators analyzed data on ten performance 

measures for 3,657 acute care hospitals in the United States that were included in 

Hospital Compare between 1/1/04 and 12/31/04. Five of the performance measures 

assessed quality of care for AMI (aspirin within 24 hours of arrival, beta-blocker within

24 hours of arrival, angiotensin-converting enzyme inhibitor for left ventricular 

dysfunction, aspirin prescribed at discharge, and beta-blocker prescribed at 

discharge); three measures were for pneumonia (timing of initial antibiotics, 

pneumococcal vaccination, and assessment of oxygenation within 24 hours of 

admission); and two measures were for heart failure (assessment of left ventricular 

function, and use of ACE-inhibitor for left ventricular dysfunction). 

Results and Interpretations 

Results of the study show that hospitals with high and low performance on Medicare 

quality measures had little difference in the rate of death for the three conditions, 

indicating that the performance measures may not accurately reflect patient 

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outcomes. For example, across all AMI performance measures the absolute reduction 

in risk-adjusted mortality rates between hospitals performing in the 25th percentile 

versus those performing in the 75th percentile was 0.005 for inpatient mortality, 0.006 

for 30-day mortality, and 0.012 for 1-year mortality. For the heart failure 

performance measures, the absolute death reduction was smaller, ranging from 0.001 

for inpatient death to 0.002 for 1-year death. For the pneumonia performance 

measures, the absolute reduction in death ranged from 0.001 for 30-day death to 

0.005 for inpatient death. 

In interpreting these results, authors note that if one-third of the patients receiving 

care at the lowest performing hospitals received care at high-performance hospitals, 

approximately 3000 lives might have been saved. However, if this is put in the 

context of the number of patients who have access to high-performing hospitals, the 

number of lives at risk becomes smaller. It also is important to note that the riskadjusted models used in this study were based on administrative data, in which 

patient comorbidities may have been under-reported. 

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Werner R and Bradlow E. Evaluating the role of performance measures in choosing low mortality hospitals: Evidence 

from Medicare's Hospital Compare. The Journal of the American Medical Association December 13, 2006;296

(22):2964-2702.