title: Comparing hospital performance within and across countries: an illustrative study of coronary artery bypass graft surgery in England and Spain.
abstract: OBJECTIVE
  To assess the feasibility, strengths and weaknesses of using administrative data to compare hospital performance across countries, using mortality after coronary artery bypass graft (CABG) surgery as an illustrative example.
  
  
  METHODS
  Country specific and pooled models using individual-level data and logistic regression methods assess individual hospital performance using funnel plots accounting for multiple testing. Outcomes are adjusted for age, sex, comorbidities and indicators of patient severity. Data includes patients from all publicly funded hospitals delivering CABG surgery in England and Spain. Inpatient hospital-level standardized mortality rates within 30 days of CABG surgery are calculated for 83 999 CABG patients between 2007 and 2009.
  
  
  RESULTS
  Unadjusted national mortality rates are 5% in Spain and 2.3% in England. Country-specific models identified similar patterns of excess mortality 'alerts' and 'alarms' in hospitals in Spain or England. Pooling data from both countries identifies larger numbers of alerts and alarms in Spanish hospitals, and risk-adjustment increased the already large national mortality difference. This was reduced but not eliminated by accounting for lower volume in Spanish hospitals.
  
  
  CONCLUSIONS
  Cross-national comparisons potentially add value by providing international performance benchmarks. Hospital-level analysis across countries can illuminate differences in hospital performance, which might not be identified using country-specific data or incomplete registry data, and can test hypotheses that may explain national differences. Difficulties of making data comparable between countries, however, compound the usual within-country measurement problems.
authors.affiliation: 1 Centre for Health Economics, University of York, England, UK.
authors.forename: Nils
authors.initials: N
authors.lastname: Gutacker
authors.affiliation: 2 Department of Health Sciences, University of York, England, UK karen.bloor@york.ac.uk.
authors.forename: Karen
authors.initials: K
authors.lastname: Bloor
authors.affiliation: 1 Centre for Health Economics, University of York, England, UK.
authors.forename: Richard
authors.initials: R
authors.lastname: Cookson
authors.affiliation: 3 Institute for Health Sciences in Aragon, IIS Aragon, Zaragoza, Spain 4 Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain.
authors.forename: Sandra
authors.initials: S
authors.lastname: Garcia-Armesto
authors.affiliation: 3 Institute for Health Sciences in Aragon, IIS Aragon, Zaragoza, Spain 4 Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain.
authors.forename: Enrique
authors.initials: E
authors.lastname: Bernal-Delgado
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001026:Coronary Artery Bypass / Q000401:mortality*; D003327:Coronary Disease / Q000401:mortality / Q000601:surgery*; D004739:England / Q000453:epidemiology; D005260:Female; D017052:Hospital Mortality; D006761:Hospitals; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care; D012042:Registries; D018570:Risk Assessment / Q000379:methods*; D013030:Spain / Q000453:epidemiology; D017749:Total Quality Management