An Administrative Claims Model for Profiling Hospital 30- Day Mortality Rates for Pneumonia Patients Dale W. Bratzler1, Sharon-Lise T. Normand 2 , Yun Wang 3 , Walter J. O’Donnell4, Mark Metersky5, Lein F. Han 6 , Michael T. Rapp6,7, Harlan M. Krumholz3,8* 1 Oklahoma Foundation for Medical Quality, Oklahoma City, Oklahoma, United States of America, 2 Department of Health Care Policy, Harvard Medical School and Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, United States of America, 3 Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, and Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America, 4 Pulmonary and Critical Care Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America, 5 Division of Pulmonary and Critical Care Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, United States of America, 6 Centers for Medicare and Medicaid Services, Baltimore, Maryland, United States of America, 7 Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, D.C., United States of America, 8 Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, and Section of Health Policy and Administration, School of Public Health, Yale University School of Medicine, New Haven, Connecticut, United States of America Abstract Background: Outcome measures for patients hospitalized with pneumonia may complement process measures in characterizing quality of care. We sought to develop and validate a hierarchical regression model using Medicare claims data that produces hospital-level, risk-standardized 30-day mortality rates useful for public reporting for patients hospitalized with pneumonia. Methodology/Principal Findings: Retrospective study of fee-for-service Medicare beneficiaries age 66 years and older with a principal discharge diagnosis of pneumonia. Candidate risk-adjustment variables included patient demographics, administrative diagnosis codes from the index hospitalization, and all inpatient and outpatient encounters from the year before admission. The model derivation cohort included 224,608 pneumonia cases admitted to 4,664 hospitals in 2000, and validation cohorts included cases from each of years 1998–2003. We compared model-derived state-level standardized mortality estimates with medical record-derived state-level standardized mortality estimates using data from the Medicare National Pneumonia Project on 50,858 patients hospitalized from 1998–2001. The final model included 31 variables and had an area under the Receiver Operating Characteristic curve of 0.72. In each administrative claims validation cohort, model fit was similar to the derivation cohort. The distribution of standardized mortality rates among hospitals ranged from 13.0% to 23.7%, with 25th, 50th, and 75th percentiles of 16.5%, 17.4%, and 18.3%, respectively. Comparing model-derived risk- standardized state mortality rates with medical record-derived estimates, the correlation coefficient was 0.86 (Standard Error = 0.032). Conclusions/Significance: An administrative claims-based model for profiling hospitals for pneumonia mortality performs consistently over several years and produces hospital estimates close to those using a medical record model. Citation: Bratzler DW, Normand S-LT, Wang Y, O’Donnell WJ, Metersky M, et al. (2011) An Administrative Claims Model for Profiling Hospital 30-Day Mortality Rates for Pneumonia Patients. PLoS ONE 6(4): e17401. doi:10.1371/journal.pone.0017401 Editor: Rory Edward Morty, University of Giessen Lung Center, Germany Received July 23, 2010; Accepted February 3, 2011; Published April 12, 2011 This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication. Funding: The analyses upon which this publication is based were performed in part under Contract Numbers 500-02-OK-03 and Subcontract #500-05-CO01, funded by the Centers for Medicare and Medicaid Services, an agency of the U.S. Department of Health and Human Services. The content of this publication does not necessarily reflect the views of policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. (025_HQMSS_OK0402_0407) CMS reviewed and approved the use of its data for this work and approved submission of the manuscript. The funder had no role in study design, data collection and analysis, or manuscript preparation. Dr. Krumholz reports that he is a consultant to UnitedHealthcare, and that he is supported by grant U01 HL105270-01 from the National Heart, Lung, and Blood Institute. Dr. Normand reports that she is funded by the Massachusetts Department of Public Health to monitor the quality of care following cardiac surgery or percutaneous coronary intervention. The other authors report no conflicts. Competing Interests: Dr. Metersky discloses that he is a consultant to the Centers for Medicare and Medicaid Services, and is a volunteer on the Executive Committee of the Physician Consortium for Performance Improvement. * E-mail: harlan.krumholz@yale.edu Introduction Pneumonia, the second most common cause of hospitalization of the elderly, accounts for approximately 770,000 admissions annually among patients 65 years of age or older in the United States [1,2]. Hospitalization rates for pneumonia have increased by 20% from 1988–1990 to 2000–2002 for patients aged 65 to 84 years [2]. The combined reporting category of pneumonia and influenza remains the fifth leading cause of death in this age group [3]. Care of patients with pneumonia has been the target of quality measurement and reporting initiatives [4,5]. Two of the largest initiatives focused on the quality of pneumonia care are the Centers for Medicare & Medicaid Service’s (CMS) National Pneumonia Project and The Joint Commission ORYXH initiatives PLoS ONE | www.plosone.org 1 April 2011 | Volume 6 | Issue 4 | e17401