title: Quality of care in the US territories.
abstract: BACKGROUND
  Health care quality in the US territories is poorly characterized. We used process measures to compare the performance of hospitals in the US territories and in the US states.
  
  
  METHODS
  Our sample included nonfederal hospitals located in the United States and its territories discharging Medicare fee-for-service (FFS) patients with a principal discharge diagnosis of acute myocardial infarction (AMI), heart failure (HF), or pneumonia (PNE) (July 2005-June 2008). We compared risk-standardized 30-day mortality and readmission rates between territorial and stateside hospitals, adjusting for performance on core process measures and hospital characteristics.
  
  
  RESULTS
  In 57 territorial hospitals and 4799 stateside hospitals, hospital mean 30-day risk-standardized mortality rates were significantly higher in the US territories (P<.001) for AMI (18.8% vs 16.0%), HF (12.3% vs 10.8%), and PNE (14.9% vs 11.4%). Hospital mean 30-day risk-standardized readmission rates (RSRRs) were also significantly higher in the US territories for AMI (20.6% vs 19.8%; P=.04), and PNE (19.4% vs 18.4%; P=.01) but was not significant for HF (25.5% vs 24.5%; P=.07). The higher risk-standardized mortality rates in the US territories remained statistically significant after adjusting for hospital characteristics and core process measure performance. Hospitals in the US territories had lower performance on all core process measures (P<.05).
  
  
  CONCLUSIONS
  Compared with hospitals in the US states, hospitals in the US territories have significantly higher 30-day mortality rates and lower performance on every core process measure for patients discharged after AMI, HF, and PNE. Eliminating the substantial quality gap in the US territories should be a national priority.
authors.affiliation: Department of Medicine, Yale UniversitySchool of Medicine, PO Box 208088, IE-61 SHM, New Haven, CT 06520, USA. marcella.nunez-smith@yale.edu
authors.forename: Marcella
authors.initials: M
authors.lastname: Nunez-Smith
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Bradley
authors.forename: Jeph
authors.initials: J
authors.lastname: Herrin
authors.forename: Calie
authors.initials: C
authors.lastname: Santana
authors.forename: Leslie A
authors.initials: LA
authors.lastname: Curry
authors.forename: Sharon-Lise T
authors.initials: SL
authors.lastname: Normand
authors.forename: Harlan M
authors.initials: HM
authors.lastname: Krumholz
mesh_terms: D000368:Aged; D018588:Fee-for-Service Plans / Q000191:economics; D005260:Female; D006141:Guam; D006333:Heart Failure / Q000191:economics / Q000401:mortality*; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D006278:Medicare / Q000191:economics; D008849:Micronesia; D008875:Middle Aged; D009203:Myocardial Infarction / Q000191:economics / Q000401:mortality*; D011014:Pneumonia / Q000191:economics / Q000401:mortality*; D011647:Puerto Rico; D011787:Quality of Health Care / Q000191:economics*; D014481:United States; D014767:United States Virgin Islands