title: Comparing and ranking hospitals based on outcome: results from The Netherlands Stroke Survey.
abstract: BACKGROUND
  Measuring quality of care and ranking hospitals with outcome measures poses two major methodological challenges: case-mix adjustment and variation that exists by chance.
  
  
  OBJECTIVE
  To compare methods for comparing and ranking hospitals that considers these.
  
  
  METHODS
  The Netherlands Stroke Survey was conducted in 10 hospitals in the Netherlands, between October 2002 and May 2003, with prospective and consecutive enrollment of patients with acute brain ischaemia. Poor outcome was defined as death or disability after 1 year (modified Rankin scale of > or =3). We calculated fixed and random hospital effects on poor outcome, unadjusted and adjusted for patient characteristics. We compared the hospitals using the expected rank, a novel statistical measure incorporating the magnitude and the uncertainty of differences in outcome.
  
  
  RESULTS
  At 1 year after stroke, 268 of the total 505 patients (53%) had a poor outcome. There were substantial differences in outcome between hospitals in unadjusted analysis (chi(2) = 48, 9 df, P < 0.0001). Adjustment for 12 confounders led to halving of the chi(2) (chi(2) = 24). The same pattern was observed in random effects analysis. Estimated performance of individual hospitals changed considerably between unadjusted and adjusted analysis. Further changes were seen with random effect estimation, especially for smaller hospitals. Ordering by expected rank led to shrinkage of the original ranks of 1-10 towards the median rank of 5.5 and to a different order of the hospitals, compared to ranking based on fixed effects.
  
  
  CONCLUSIONS
  In comparing and ranking hospitals, case-mix-adjusted random effect estimates and the expected ranks are more robust alternatives to traditional fixed effect estimates and simple rankings.
authors.affiliation: Department of Public Health, Erasmus MC, CA Rotterdam, The Netherlands. h.lingsma@erasmusmc.nl
authors.forename: H F
authors.initials: HF
authors.lastname: Lingsma
authors.forename: E W
authors.initials: EW
authors.lastname: Steyerberg
authors.forename: M J C
authors.initials: MJ
authors.lastname: Eijkemans
authors.forename: D W J
authors.initials: DW
authors.lastname: Dippel
authors.forename: W J M
authors.initials: WJ
authors.lastname: Scholte Op Reimer
authors.forename: H C
authors.initials: HC
authors.lastname: Van Houwelingen
mesh_terms: D000368:Aged; D005260:Female; D006761:Hospitals / Q000145:classification / Q000592:standards*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D017063:Outcome Assessment, Health Care / Q000379:methods*; D011787:Quality of Health Care / Q000592:standards*; D020521:Stroke / Q000628:therapy*