Quality of Care in Hospital Medicine

When Medicare reported hospital death rates in the early 90’s, it lost the effort due to poor planning after severe criticism that the reporting did not reflect true death rates, as different hospitals deal with same diagnosis but with different severities and co-morbidities. This time around, CMS has come prepared. As I wrote in a previous blog, CMS has created “hospitalcompare.hhs.gov” where it is posting different indicators of quality of care as rendered by hospitals. I came across a one-and-a-half page article in USA Today in August, in which CMS made its intentions clear- to launch a publicity campaign and increase public awareness about the availability of the site and encourage its use. To give CMS credit, the site is both easy to use and easy to interpret.

The statistical efforts behind the numbers are far more real and defensible. Mortality is adjusted for case mix. Since mortality is measured for 30 days, I believe it includes post-discharge deaths as well. I could not find any separation in house mortality versus deaths after being discharged from hospital. Numbers, statistics and reporting seem to be contagious though, as the Leap Frog group is planning to develop its own reporting tool by end of this year. Based on responses from more than 1100 hospitals, it has already modified its website to report quality indicators, medical errors, etc; basically comparing hospitals on overall patient safety and procedure based comparison. Leap Frog, for those of us who do not know it, is a voluntary not-for-profit organization. In 1998, a group of large employers came together to start monitoring and establishing standards in health care. Considering that they employ millions of insured lives, their volume purchasing gives them a strong voice. Some examples of elite members of this group are large companies such as Boeing, Chrysler, FedEx, IBM, Intel and Marriott.

There is a significant impact on hospitalist practice, as more and more in-patients are being treated by hospitalists- not only internal medicine in-patients, but also patients belonging to medical sub-specialties including cardiology and nephrology. An increasing number of orthopedic patients (particularly in small community hospitals) are using hospitalists as physicians on record. We need to make ourselves well versed with the site, visit the site frequently, and react to the statistics as needed, it is only going to get worse before it improves.