title: Derivation and validation of a risk standardization model for benchmarking hospital performance for health-related quality of life outcomes after acute myocardial infarction.
abstract: BACKGROUND
  Before outcomes-based measures of quality can be used to compare and improve care, they must be risk-standardized to account for variations in patient characteristics. Despite the importance of health-related quality of life (HRQL) outcomes among patients with acute myocardial infarction (AMI), no risk-standardized models have been developed.
  
  
  RESULTS
  We assessed disease-specific HRQL using the Seattle Angina Questionnaire at baseline and 1 year later in 2693 unselected AMI patients from 24 hospitals enrolled in the Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients' Health status (TRIUMPH) registry. Using 57 candidate sociodemographic, economic, and clinical variables present on admission, we developed a parsimonious, hierarchical linear regression model to predict HRQL. Eleven variables were independently associated with poor HRQL after AMI, including younger age, previous coronary artery bypass graft surgery, depressive symptoms, and financial difficulties (R(2)=20%). The model demonstrated excellent internal calibration and reasonable calibration in an independent sample of 1890 AMI patients in a separate registry, although the model slightly overpredicted HRQL scores in the higher deciles. Among the 24 TRIUMPH hospitals, 1-year unadjusted HRQL scores ranged from 67-89. After risk-standardization, HRQL score variability narrowed substantially (range=79-83), and the group of hospital performance (bottom 20%/middle 60%/top 20%) changed in 14 of the 24 hospitals (58% reclassification with risk-standardization).
  
  
  CONCLUSIONS
  In this predictive model for HRQL after AMI, we identified risk factors, including economic and psychological characteristics, associated with HRQL outcomes. Adjusting for these factors substantially altered the rankings of hospitals as compared with unadjusted comparisons. Using this model to compare risk-standardized HRQL outcomes across hospitals may identify processes of care that maximize this important patient-centered outcome.
authors.affiliation: From Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., Y.L., P.G.J., J.A.S.); University of Missouri-Kansas City, Kansas City, MO (S.V.A., J.A.S.); and the Division of Cardiology, University of Colorado, Denver, CO (F.A.M., J.S.R.).
authors.forename: Suzanne V
authors.initials: SV
authors.lastname: Arnold
authors.forename: Frederick A
authors.initials: FA
authors.lastname: Masoudi
authors.forename: John S
authors.initials: JS
authors.lastname: Rumsfeld
authors.forename: Yan
authors.initials: Y
authors.lastname: Li
authors.forename: Philip G
authors.initials: PG
authors.lastname: Jones
authors.forename: John A
authors.initials: JA
authors.lastname: Spertus
mesh_terms: D000368:Aged; D019985:Benchmarking / Q000379:methods / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D009203:Myocardial Infarction / Q000453:epidemiology / Q000523:psychology / Q000628:therapy; D010043:Outcome and Process Assessment, Health Care / Q000379:methods / Q000592:standards*; D011237:Predictive Value of Tests; D011788:Quality of Life; D012042:Registries / Q000706:statistics & numerical data; D018570:Risk Assessment / Q000379:methods / Q000592:standards; D012307:Risk Factors
keywords: myocardial infarction; quality of life; risk factors