title: Evaluation of the DAVROS (Development And Validation of Risk-adjusted Outcomes for Systems of emergency care) risk-adjustment model as a quality indicator for healthcare.
abstract: OBJECTIVE
  Risk-adjusted mortality rates can be used as a quality indicator if it is assumed that the discrepancy between predicted and actual mortality can be attributed to the quality of healthcare (ie, the model has attributional validity). The Development And Validation of Risk-adjusted Outcomes for Systems of emergency care (DAVROS) model predicts 7-day mortality in emergency medical admissions. We aimed to test this assumption by evaluating the attributional validity of the DAVROS risk-adjustment model.
  
  
  METHODS
  We selected cases that had the greatest discrepancy between observed mortality and predicted probability of mortality from seven hospitals involved in validation of the DAVROS risk-adjustment model. Reviewers at each hospital assessed hospital records to determine whether the discrepancy between predicted and actual mortality could be explained by the healthcare provided.
  
  
  RESULTS
  We received 232/280 (83%) completed review forms relating to 179 unexpected deaths and 53 unexpected survivors. The healthcare system was judged to have potentially contributed to 10/179 (8%) of the unexpected deaths and 26/53 (49%) of the unexpected survivors. Failure of the model to appropriately predict risk was judged to be responsible for 135/179 (75%) of the unexpected deaths and 2/53 (4%) of the unexpected survivors. Some 10/53 (19%) of the unexpected survivors died within a few months of the 7-day period of model prediction.
  
  
  CONCLUSIONS
  We found little evidence that deaths occurring in patients with a low predicted mortality from risk-adjustment could be attributed to the quality of healthcare provided.
authors.affiliation: Medical Care Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: Richard
authors.initials: R
authors.lastname: Wilson
authors.affiliation: Medical Care Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: Steve W
authors.initials: SW
authors.lastname: Goodacre
authors.affiliation: Medical Care Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: Marcin
authors.initials: M
authors.lastname: Klingbajl
authors.affiliation: Western Health and The University of Melbourne, Victoria, Australia.
authors.forename: Anne-Maree
authors.initials: AM
authors.lastname: Kelly
authors.affiliation: Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.
authors.forename: Tim
authors.initials: T
authors.lastname: Rainer
authors.affiliation: Emergency Department, Leicester Royal Infirmary, Leicester, UK.
authors.forename: Tim
authors.initials: T
authors.lastname: Coats
authors.affiliation: Northampton General Hospital, Northampton, UK.
authors.forename: Vikki
authors.initials: V
authors.lastname: Holloway
authors.affiliation: Department of Emergency Medicine, Hull Royal Infirmary, Hull, UK.
authors.forename: Will
authors.initials: W
authors.lastname: Townend
authors.affiliation: Department of Accident and Emergency, York District General Hospital, York, UK.
authors.forename: Steve
authors.initials: S
authors.lastname: Crane
mesh_terms: D001315:Australia / Q000453:epidemiology; D004636:Emergency Service, Hospital / Q000592:standards*; D004739:England / Q000453:epidemiology; D006723:Hong Kong / Q000453:epidemiology; D017052:Hospital Mortality; D006801:Humans; D015233:Models, Statistical; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care / Q000592:standards*; D020379:Risk Adjustment; D018570:Risk Assessment
keywords: emergency care systems; management, quality assurance; quality assurance; research, methods