Validity of the indicator ‘death in low-mortality diagnosis-related groups’ for measuring patient safety and healthcare quality in hospitals

Performance assessment of the inpatient medical services of a clinical subspecialty: A case study with risk adjustment based on diagnosis-related groups in China

Diagnosis-related groups (DRGs) have been receiving increasing attention in health service research in China. In the present study, we used the 2014 Beijing-Diagnosis Related Groups (BJ-DRGs) to evaluate the inpatient service performance of the clinical subspecialty "major operation of the digestive system" of a cancer specialist hospital.The research hospital is one of 16 public municipal hospitals overseen by the Beijing Health Bureau ("16 hospitals"). Discharge data collected between 2008 and 2015 were drawn from the front pages of the medical records of these hospitals. After the data were reported to the Beijing Public Health Information Centre, as well as being grouped using the BJ-DRGs. We evaluated the service performance of this subspecialty in terms of capacity, efficiency, and service quality, based on the BJ-DRGs risk adjustment tool.From 2008 to 2015, the total weight of the subspecialty in the research hospital increased annually. In 2015, the cases in this hospital accounted for 50.27% of the total in 16 hospitals. The time consumption index was 0.91, whereas the charge consumption index was 1.24, which was 24% higher than the average in16 hospitals. The mortality rates of the middle-low risk groups (GB15 and GB25) in the research hospital and the 16 hospitals were zero, while the mortality rates for the middle-high risk groups (GB11 and GB23) in the research hospital were significantly lower than those in 16 hospitals.The service capacity of the subspecialty steadily increased in the research hospital. However, the hospital must offer more attention to complex digestive disease cases (GB11/GB23) and strictly control hospitalization expenses, while maintaining the advantages of service efficiency and quality.

Healthy Life-Years Lost and Excess Bed-Days Due to 6 Patient Safety Incidents: Empirical Evidence From English Hospitals

BACKGROUND

There is little satisfactory evidence on the harm of safety incidents to patients, in terms of lost potential health and life-years.

OBJECTIVE

To estimate the healthy life-years (HLYs) lost due to 6 incidents in English hospitals between the years 2005/2006 and 2009/2010, to compare burden across incidents, and estimate excess bed-days.

RESEARCH DESIGN

The study used cross-sectional analysis of the medical records of all inpatients treated in 273 English hospitals. Patients with 6 types of preventable incidents were identified. Total attributable loss of HLYs was estimated through propensity score matching by considering the hypothetical remaining length and quality of life had the incident not occurred.

RESULTS

The 6 incidents resulted in an annual loss of 68 HLYs and 934 excess bed-days per 100,000 population. Preventable pressure ulcers caused the loss of 26 HLYs and 555 excess bed-days annually. Deaths in low-mortality procedures resulted in 25 lost life-years and 42 bed-days. Deep-vein thrombosis/pulmonary embolisms cost 12 HLYs, and 240 bed-days. Postoperative sepsis, hip fractures, and central-line infections cost <6 HLYs and 100 bed-days each.

DISCUSSION

The burden caused by the 6 incidents is roughly comparable with the UK burden of Multiple Sclerosis (80 DALYs per 100,000), HIV/AIDS and Tuberculosis (63 DALYs), and Cervical Cancer (58 DALYs). There were marked differences in the harm caused by the incidents, despite the public attention all of them receive. Decision makers can use the results to prioritize resources into further research and effective interventions.

What is the value of hospital mortality indicators, and are there ways to do better?

Monitoring hospital performance using patient safety indicators is one of the key components of healthcare reform in Australia. Mortality indicators, including the hospital standardised mortality ratio and deaths in low mortality diagnosis reference groups have been included in the core national hospital-based outcome indicator set recommended for local generation and review and public reporting. Although the face validity of mortality indicators such as these is high, an increasing number of studies have demonstrated that there are concerns regarding their internal, construct and criterion validity. Use of indicators with poor validity has the consequence of potentially incorrectly classifying hospitals as performance outliers and expenditure of limited hospital staff time on activities which may provide no gain to hospital quality and safety and may in fact cause damage to morale. This paper reviews the limitations of current approaches to monitoring hospital quality and safety performance using mortality indicators. It is argued that there are better approaches to improving performance than monitoring with mortality indicators generated from hospital administrative data. These approaches include use of epidemiologically sound, clinically relevant data from clinical-quality registries, better systems of audit, evidence-based bundles, checklists, simulators and application of the science of complex systems.

"Death in low-mortality diagnosis-related groups": frequency, and the impact of patient and hospital characteristics

OBJECTIVE

To examine the frequency of deaths in low-mortality diagnosis-related groups (LM-DRGs) and the patient and hospital characteristics associated with them.

DESIGN, SETTING AND PATIENTS

Retrospective cohort study of 2,400,089 discharge episodes for adults (> 18 years) from 122 Victorian public hospitals from 1 July 2006 to 30 June 2008.

MAIN OUTCOME MEASURES

Frequency of episodes of death in LM-DRGs (defined as DRGs with mortality < 0.5% over the previous 3 years or < 0.5% in any of the previous 3 years); associations between characteristics of patients and hospitals with deaths in LM-DRGs.

RESULTS

There were 1,008, 816 LM-DRG episodes with 0-15 LM-DRG deaths per hospital in the 2006-07 financial year and 0-20 deaths per hospital in the 2007-08 financial year. Increased age, level of comorbidity, being male, admission from a residential aged care facility, interhospital transfer, emergency admission and lower hospital volume were associated with an increased risk of death in LM-DRG episodes in both years. Metropolitan location and teaching/major provider status were not associated with LM-DRG deaths (P > 0.10). More than 40% of LM-DRG deaths were among patients aged 83 years or over, who had a length of stay of less than 1 day and had a medical DRG classification. Standardised mortality ratios (SMRs) that adjusted for the patient and hospital characteristics identified nine outlier hospitals with high frequencies of deaths in LM-DRGs in the 2006-07 and six in the 2007-08 financial year compared with 59 hospitals flagged by the death-in-LM-DRG indicator.

CONCLUSIONS

The use of the LM-DRG indicator requires further investigation to test its validity. LM-DRG deaths are infrequent, making it difficult to identify temporal changes and outlier hospitals. Patient characteristics unrelated to quality of care increase the likelihood of death among LM-DRG patients. The SMR analysis showed that failure to adjust for these characteristics may result in unfair and inaccurate identification of outlier hospitals. The increased risk of death associated with interhospital transfer patients and low-volume hospitals requires further investigation.