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In the USA, hospitals are increasingly evaluated and paid, based on a burgeoning list of publicly reported quality and safety metrics. Performance measurement is undoubtedly essential for improving healthcare quality, but developing the ‘right’ metrics has remained a formidable challenge1 and has resulted in significant discourse over the validity, authenticity and utility of several publicly reported measures.2–4 Yet, despite the debate, the amount of financial incentives tied to quality metrics continues to grow.
As stakes for physicians and hospitals in the USA continue to rise, several of the measures used in performance programmes have come under greater scrutiny. For instance, the use of the Patient Safety Indicator-90 (PSI-90) measure—a metric comprised of eight distinct PSI measures weighted to varying degrees—in two major pay-for-performance initiatives has been questioned for its validity.2 Another measure increasingly tied to financial incentives in the USA is hospital mortality. We believe its use, while well intentioned and with some value, is too problematic to merit inclusion in pay-for-performance programmes.
In 2008, the Center for Medicare and Medicaid Services (CMS, a US federal agency responsible for the administration of Medicare and Medicaid insurance products that provide health coverage for the elderly and the poor, respectively) began publicly reporting 30-day risk-adjusted hospital mortality rates (death within 30 days of admission adjusted for selected comorbidities) for Medicare patients admitted with one of three conditions: acute myocardial infarction, heart failure and pneumonia. The decision to use risk-adjusted hospital mortality rates in quality measurement and public reporting to drive improvement in care is understandable. Mortality is perhaps the ultimate outcome in healthcare, one that both providers and patients care deeply about.
Indeed, the use of risk-adjusted mortality as a publicly reported measure appears now to be a fairly well-established practice. For example, public reporting of risk-adjusted mortality rates for …
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