Factoring socioeconomic status into cardiac performance profiling for hospitals: does it matter?
BACKGROUND
Critics of "scorecard medicine" often highlight the incompleteness of risk-adjustment methods used when accounting for baseline patient differences. Although socioeconomic status is a highly important determinant of adverse outcome for patients admitted to the hospital with acute myocardial infarction, it has not been used in most risk-adjustment models for cardiovascular report cards.


OBJECTIVE
To determine the incremental impact of socioeconomic status adjustments on age, sex, and illness severity for hospital-specific 30-day mortality rates after acute myocardial infarction.


METHODS
The authors compared the absolute and relative hospital-specific 30-day acute myocardial infarction mortality rates in 169 hospitals throughout Ontario between April 1, 1994 and March 31, 1997. Patient socioeconomic status was characterized by median neighborhood income using postal codes and 1996 Canadian census data. They examined two risk-adjustment models: the first adjusted for age, sex, and illness severity (standard), whereas the second adjusted for age, sex, illness severity, and median neighborhood income level (socioeconomic status).


RESULTS
There was an extremely strong correlation between 'standard' and 'socioeconomic status' risk-adjusted mortality rates (r = 0.99). Absolute differences in 30-day risk-adjusted mortality rates between the socioeconomic status and standard risk-adjustment models were small (median, 0.1%; 25th-75th percentile, 0.1-0.2). The agreement in the quintile rankings of hospitals between the socioeconomic status and standard risk-adjustment models was high (weighted kappa = 0.93).


CONCLUSIONS
Despite its importance as a determinant of patient outcomes, the effect of socioeconomic status on hospital-specific mortality rates over and above standard risk-adjustment methods for acute myocardial infarction hospital profiling in Ontario was negligible.
Alter
David A
DA
Division of Cardiology, Schulich Heart Centre, University of Toronto, Ontario. david.alter@ices.on.ca
Austin
Peter C
PC
Naylor
C David
CD
Tu
Jack V
JV
D000367:Age Factors; D000368:Aged; D019985:Benchmarking; D016009:Chi-Square Distribution; D015331:Cohort Studies; D005260:Female; D006302:Health Services Research; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality*; D009864:Ontario / Q000453:epidemiology; D010043:Outcome and Process Assessment, Health Care; D020379:Risk Adjustment; D012720:Severity of Illness Index; D012737:Sex Factors; D012923:Social Class; D013503:Surgery Department, Hospital / Q000592:standards*