Does the Inclusion of Stroke Severity in a 30-Day Mortality Model Change Standardized Mortality Rates at Veterans Affairs Hospitals?
- 1 July 2012
- journal article
- research article
- Published by Ovid Technologies (Wolters Kluwer Health) in Circulation: Cardiovascular Quality and Outcomes
- Vol. 5 (4), 508-513
- https://doi.org/10.1161/circoutcomes.111.962936
Abstract
Background—: The Centers for Medicare and Medicaid Services is considering developing a 30-day ischemic stroke hospital-level 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. Conclusions—: 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.Keywords
This publication has 12 references indexed in Scilit:
- Estimating and Reporting on the Quality of Inpatient Stroke Care by Veterans Health Administration Medical CentersCirculation: Cardiovascular Quality and Outcomes, 2012
- Hospital-Level Variation in Mortality and Rehospitalization for Medicare Beneficiaries With Acute Ischemic StrokeStroke, 2011
- Risk Score for In-Hospital Ischemic Stroke Mortality Derived and Validated Within the Get With The Guidelines–Stroke ProgramCirculation, 2010
- Association between Stroke Severity and Fall Risk among Stroke PatientsNeuroepidemiology, 2010
- Prevalence, predictors, and outcomes of poststroke falls in acute hospital settingJournal of Rehabilitation Research and Development, 2010
- Accuracy and completeness of mortality data in the Department of Veterans AffairsPopulation Health Metrics, 2006
- An Administrative Claims Model Suitable for Profiling Hospital Performance Based on 30-Day Mortality Rates Among Patients With an Acute Myocardial InfarctionCirculation, 2006
- An Administrative Claims Model Suitable for Profiling Hospital Performance Based on 30-Day Mortality Rates Among Patients With Heart FailureCirculation, 2006
- Development of an integrated stroke outcomes database within Veterans Health AdministrationJournal of Rehabilitation Research and Development, 2005
- Retrospective Assessment of Initial Stroke Severity With the NIH Stroke ScaleStroke, 2000