Background
Current efforts have focused on examining and reporting indicators in order to increase the quality of care provided to patients in the United States. In January 2004 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) began collecting monthly data from its accredited hospitals on performance measures across three of five select disease conditions. Similarly, since 2004, CMS has provided data from Hospital Quality Alliance members on 10 performance measures in the areas of congestive heart failure, acute myocardial infarction, and pneumonia. This study collected data from these reports to expand on previous work examining the quality of care in the United States on a national level. It also analyzed the characteristics of hospitals that have met these quality measures.
Methods
Overall, 4,856 different hospitals were included in the analysis. Data was obtained for all relevant discharges between January 1 and June 2004 from both CMS and JCAHO, with preference given to the JCAHO data. Discrepancies in reporting data between the two data sets were less than 1%. The 2003 Annual Survey of Hospitals from the American Hospital Association (AHA) was used to define the population of hospitals operating in the United States in terms of:
- Number of beds;
- Ownership (for-profit, not-for-profit, government, or military);
- Region;
- Metropolitan statistical area type (rural, small, medium, or large);
- Teaching status (major—member of the Council of Teaching Hospitals, minor—any other medical school affiliation or residency program, or non-teaching);
- Availability of advanced technology (MRI and PET scanning);
- Nurse staffing patterns; and
- Number of Medicaid and Medicare discharges.
These data sets were linked. Composite scales were created for each disease. Bivariate associations using two-tailed T-tests for continuous variables and chi-squared tests for categorical variables were made. For each individual and composite measure, the mean performance and the 25th and 75th percentiles were calculated. The top performing quintiles for each of the three diseases were taken and cross-tabulated across the three specific disease composites. A random-effects logistic regression model was estimated for each composite using a binary logistic model with SAS statistical software and the grouped hospital data that modeled the number of opportunities met in each hospital out of the total number of opportunities at the hospital.
Results
Hospitalized patients with congestive heart failure, acute myocardial infarction, and pneumonia received 75.9% of the recommended processes of care as a whole. Performance varied considerably, from a mean of 0.36 (0.00-0.67) for thrombolytic therapy administered within 30 minutes of arrival for an MI to a mean of 0.98 (0.98-1.00) for assessment of oxygen for patients with pneumonia. Mean composite scores were 0.85 (0.81-0.95) for acute myocardial infarction, 0.64 (0.52-0.78) for congestive heart failure, and 0.88 (0.80-0.97) for pneumonia.
When comparing hospitals in quintiles of performance, 10.5% were in the top quintile for two out of three diseases, but only 3.8% were in the top quintile for all three diseases. “Treatment and diagnosis” as well as “counseling and prevention” were correlated among all three conditions after factor analysis.
Multivariate analysis demonstrated for-profit hospitals as consistently performing worse than not-for-profit hospitals in meeting performance measures. Federal and military hospitals had the highest success in meeting the measures for the three diseases analyzed. Major teaching hospitals met more quality indicators for patients with acute MI and “treatment and diagnosis” but not for CHF, pneumonia, or “counseling and prevention” when compared with non-teaching hospitals. Performance decreased as the share of Medicaid patients increased. More technology and a registered nursing staff with more education were factors associated with higher success in meeting quality indicators.