Does the inclusion of stroke severity in a 30-day mortality model change standardized mortality rates at Veterans Affairs hospitals?
BACKGROUND
The Centers for Medicare and Medicaid Services is considering developing a 30-day ischemic stroke hospital-level mortality model using administrative data. We examined whether inclusion of the National Institutes of Health Stroke Scale (NIHSS), a measure of stroke severity not included in administrative data, would alter 30-day mortality rates in the Veterans Health Administration.


RESULTS
A total of 2562 veterans admitted with ischemic stroke to 64 Veterans Health Administration Hospitals in the fiscal year 2007 were included. First, we examined the distribution of unadjusted mortality rates across the Veterans Health Administration. Second, we estimated 30-day all-cause, risk standardized mortality rates (RSMRs) for each hospital by adjusting for age, sex, and comorbid conditions using hierarchical models with and without the inclusion of the NIHSS. Finally, we examined whether adjustment for the NIHSS significantly changed RSMRs for each hospital compared with other hospitals. The median unadjusted mortality rate was 3.6%. The RSMR interquartile range without the NIHSS ranged from 5.1% to 5.6%. Adjustment with the NIHSS did not change the RSMR interquartile range (5.1%-5.6%). Among veterans ≥65 years, the RSMR interquartile range without the NIHSS ranged from 9.2% to 10.3%. With adjustment for the NIHSS, the RSMR interquartile range changed from 9.4% to 10.0%. The plot of 30-day RSMRs estimated with and without the inclusion of the NIHSS in the model demonstrated overlapping 95% confidence intervals across all hospitals, with no hospital significantly below or above the mean-unadjusted 30-day mortality rate. The 30-day mortality measure did not discriminate well among hospitals.


CONCLUSIONS
The impact of the NIHSS on RSMRs was limited. The small number of stroke admissions and the narrow range of 30-day stroke mortality rates at the facility level in the Veterans Health Administration cast doubt on the value of using 30-day RSMRs as a means of identifying outlier hospitals based on their stroke care quality.
San Francisco VA Medical Center HSR&D REAP, San Francisco, CA, USA. salomeh.keyhani@va.gov
Salomeh
S
Keyhani
Eric
E
Cheng
Greg
G
Arling
Xinli
X
Li
Laura
L
Myers
Susan
S
Ofner
Linda S
LS
Williams
Michael
M
Phipps
Diana
D
Ordin
Dawn M
DM
Bravata
D000368:Aged; D000369:Aged, 80 and over; D004185:Disability Evaluation; D005260:Female; D006787:Hospitals, Veterans / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000592:standards*; D011237:Predictive Value of Tests; D019984:Quality Indicators, Health Care / Q000592:standards*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis* / Q000401:mortality*; D013997:Time Factors; D014481:United States / Q000453:epidemiology; D014728:Veterans / Q000706:statistics & numerical data*