Hospitals’ risk-standardized stroke-care rankings can be unfairly impacted if the severity of strokes are not considered, says a new study from UCLA.
Under the ACA, hospitals and medical centers must report their quality-of-care and risk-standardized outcomes for stroke and other common medical conditions. But reporting models for mortality that don’t consider stroke severity may unfairly skew these results, researchers say.
Using a model that considers stroke severity completely alters performance outcomes and rankings for many hospitals, particularly when reporting on 30-day mortality rates for Medicare beneficiaries hospitalized with acute stroke.
Researchers have found that 26.3 percent of hospitals that ranked in the top or bottom 20 percent for risk-standardized mortality would be ranked differently if models were adjusted for initial stroke acuity. Of those hospitals with “worse than expected” mortality, more than half were reclassified as having “as expected” mortality after adjusting for stroke severity.
These findings are particularly relevant now, because if the CMS and other healthcare payors include a 30-day mortality outcomes measure for acute stroke, facilities that don’t measure up may receive lower payments, may not be eligible for incentives and could be fined, the report continues. If rankings aren’t reclassified according to stroke severity, hospitals may consider turning away patients with more severe strokes or transferring them to other hospitals after they’ve been assessed by the ED to avoid being misclassified as having a higher mortality risk, researchers note.
For the study, researchers used data from 782 hospitals participating in the American Heart Association/American Stroke Association’s Get With the Guidelines–Stroke (GWTG–Stroke) quality-improvement program between April 2003 and September 2009. They looked at 127,950 FFS Medicare beneficiaries who were hospitalized for stroke and whose initial acuity level had been assessed with the National Institutes of Health Stroke Scale (NIH Stroke Scale), a bedside tool used by doctors and nurses to evaluate the effects of strokes on various areas, including consciousness, language, motor strength and sensory loss. The team also utilized corresponding administrative claims that were obtained from the CMS.
The team compared hospitals’ 30-day mortality risk models with and without the NIH Stroke Scale information and assessed whether the hospitals performed “better than expected,” “as expected” or “worse than expected.” The researchers found that of the hospitals initially classified as having “worse than expected” mortality, 57.7 percent were reclassified to “as expected” mortality by the model with the NIH Stroke Scale.
The researchers also ranked hospitals using both risk models to reflect a top 20 percent, a middle 60 percent and bottom 20 percent — all categories that are commonly used in pay-for-performance programs in which the top performers are eligible for bonus payments and the bottom performers may receive a lower penalty payment.
More than 40 percent of hospitals identified in the top or bottom 5 percent for risk-adjusted mortality would have been reclassified into the middle mortality range using a NIH Stroke Scale model, the researchers said.
A critical question confronting clinicians, hospitals, payors and policymakers is whether current and emerging measures that assess 30-day mortality are adequate for public reporting and for use in rewarding and penalizing hospitals, researchers say.
Source: UCLA, July 17, 2012
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