Evaluation of hospital outcomes: the relation between length-of-stay, readmission, and mortality in a large international administrative database

Abstract

BackgroundHospital mortality, readmission and length of stay (LOS) are commonly used measures for quality of care. We aimed to disentangle the correlations between these interrelated measures and propose a new way of combining them to evaluate the quality of hospital care.MethodsWe analyzed administrative data from the Global Comparators Project from 26 hospitals on patients discharged between 2007 and 2012. We correlated standardized and risk-adjusted hospital outcomes on mortality, readmission and long LOS. We constructed a composite measure with 5 levels, based on literature review and expert advice, from survival without readmission and normal LOS (best) to mortality (worst outcome). This composite measure was analyzed using ordinal regression, to obtain a standardized outcome measure to compare hospitals.ResultsOverall, we observed a 3.1% mortality rate, 7.8% readmission rate (in survivors) and 20.8% long LOS rate among 4,327,105 admissions. Mortality and LOS were correlated at the patient and the hospital level. A patient in the upper quartile LOS had higher odds of mortality (odds ratio = 1.45, 95% confidence interval 1.43–1.47) than those in the lowest quartile. Hospitals with a high standardized mortality had higher proportions of long LOS (r = 0.79, p < 0.01). Readmission rates did not correlate with either mortality or long LOS rates. The interquartile range of the standardized ordinal composite outcome was 74–117. The composite outcome had similar or better reliability in ranking hospitals than individual outcomes.ConclusionsCorrelations between different outcome measures are complex and differ between hospital- and patient-level. The proposed composite measure combines three outcomes in an ordinal fashion for a more comprehensive and reliable view of hospital performance than its component indicators.

Ranking hospitals: do we gain reliability by using composite rather than individual indicators?

“…The ordering of this ordinal measure was described in a previous study17 based on patients views from the existing literature where patients considered complications after discharge (often resulting in readmissions) as worse quality of care than complications during admission (resulting in longer LOS) 18. The measure was presented at a meeting to about 100 quality of care experts (including physicians and CEOs) from different countries involved in the Global Comparators Project and considered adequate.…”

Patient care effectiveness and financial outcomes of hospital physician contracting emphasis

“…Readmissions and mortality: Additionally, care quality may also reflect in patient readmissions and mortality (Lingsma et al, 2018). CMS provides information on hospital-level three-year rolling averages of for 30-day readmissions and mortality for three conditions HF, AMI, PN.…”

Textbook Outcome: an Ordered Composite Measure for Quality of Bariatric Surgery

“…[19,20] Parameters An ordinal composite outcome measure has been developed in previous research taking into account mutual relationships between mortality, readmission and prolonged length of stay. [7,8] For the present study, members of the DATO scientific committee selected internationally described and relevant outcome parameters for desirable patient outcome after bariatric surgery. [17,[21][22][23][24] The measured outcome parameters were mortality, severe and mild postoperative complications, readmission and prolonged LOS, defined as hospital admission > 2 days after primary surgery.…”

“…[6] However, these outcome indicators provide insight into single outcome parameters, but do not necessarily provide insight into the entire care process in which different outcome parameters could be related to each other. [7,8] In the field of gastrointestinal cancer surgery and elective aneurysm surgery, a composite measure has been illustrated to give insight in the entire care process and make hospital Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11695-018-03642-1) contains supplementary material, which is available to authorized users. comparison possible.…”