BMJ Qual Saf 21:325-336 doi:10.1136/bmjqs-2011-000615
  • Original research

Association of National Hospital Quality Measure adherence with long-term mortality and readmissions

Editor's Choice
  1. Hui Zheng6
  1. 1Center for Quality and Safety and Department of Surgery, Massachusetts General Hospital, Boston, USA
  2. 2Harvard Medical School, Boston, USA
  3. 3Department of Medicine, Massachusetts General Hospital, Boston, USA
  4. 4Center for Quality and Safety, Massachusetts General Hospital, Boston, USA
  5. 5Northeast Health Care Quality Foundation, Dover, USA
  6. 6Biostatistics Center, Massachusetts General Hospital, Boston, USA
  1. Correspondence to Dr David M Shahian, Center for Quality and Safety and Department of Surgery, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA; dshahian{at}
  1. Contributors All authors satisfy the following requirements: substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; and final approval of the version to be published.

  • Accepted 20 December 2011
  • Published Online First 2 March 2012


Background In existing studies, the association between adherence with recommended hospital care processes and subsequent outcomes has been inconsistent. This has substantial implications because process measure scores are used for accountability, quality improvement and reimbursement. Our investigation addresses methodological concerns with previous studies to better clarify the process–outcomes association for three common conditions.

Methods The study included all patients discharged from Massachusetts General Hospital between 1 July 2004 and 31 December 2007 with a principle diagnosis of acute myocardial infarction (AMI), heart failure (HF) or pneumonia (PN) who were eligible for at least one National Hospital Quality Measure. The number of patients analysed varied by measure (374 to 3020) depending on Centers for Medicare and Medicaid Services eligibility criteria. Hospital data were linked with state administrative data to determine mortality and readmissions. For patients with multiple admissions, the time-weighted impact of measure failures on mortality was estimated using exponential decay functions. All patients had follow-up for at least 1 year or until death or readmission. Cox models were used to estimate HRs adjusted for transfer status, age, gender, race, census block-group socioeconomic status, number of Elixhauser comorbidities, and do not resuscitate orders.

Results Adjusted survival and freedom from readmission for AMI and PN showed superior results for 100% and 50–99% adherence compared with 0–49% adherence. For HF, the results were inconsistent and sometimes paradoxical, although several individual measures (eg, ACE inhibitor/angiotensin receptor blockade) were associated with improved outcomes.

Conclusion Adherence with recommended AMI and PN care processes is associated with improved long-term outcomes, whereas the results for HF measures are inconsistent. The evidence base for all process measures must be critically evaluated, including the strength of association between these care processes and outcomes in real-world populations. Some currently recommended processes may not be suitable as accountability measures.


  • Funding Internal.

  • Competing interests Dr Ramunno is Chief Quality Officer for Northeast Health Care Foundation, a Medicare QIO. He has been involved with the development, revision, and implementation of National Hospital Quality Measures as a contractor with the federal government.

  • Patient consent Retrospective review of previously collected administrative claims data and state all-payer administrative records. Not feasible to obtain permission, and risk considered minimal.

  • Ethics approval Partners IRB (2008P000003).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Online supplemental material includes detailed information on numbers of eligible patients for each measure; descriptive characteristics and bivariate associations; and examples of the exponential decay approach used in this study.

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