title: Survival curves to support quality improvement in hospitals with excess 30-day mortality after acute myocardial infarction, cerebral stroke and hip fracture: a before-after study.
abstract: OBJECTIVE
  To evaluate survival curves (Kaplan-Meier) as a means of identifying areas in the clinical pathway amenable to quality improvement.
  
  
  METHODS
  Observational before-after study.
  
  
  METHODS
  In Norway, annual public reporting of nationwide 30-day in-and-out-of-hospital mortality (30D) for three medical conditions started in 2011: first time acute myocardial infarction (AMI), stroke and hip fracture; reported for 2009. 12 of 61 hospitals had statistically significant lower/higher mortality compared with the hospital mean.
  
  
  METHODS
  Three hospitals with significantly higher mortality requested detailed analyses for quality improvement purposes: Telemark Hospital Trust Skien (AMI and stroke), Østfold Hospital Trust Fredrikstad (stroke), Innlandet Hospital Trust Gjøvik (hip fracture).
  
  
  METHODS
  Survival curves, crude and risk-adjusted 30D before (2008-2009) and after (2012-2013).
  
  
  METHODS
  Unadjusted survival curves for the outlier hospitals were compared to curves based on pooled data from the other hospitals for the 30-day period 2008-2009. For patients admitted with AMI (Skien), stroke (Fredrikstad) and hip fracture (Gjøvik), the curves suggested increased mortality from the initial part of the clinical pathway. For stroke (Skien), increased mortality appeared after about 8 days. The curve profiles were thought to reflect suboptimal care in various phases in the clinical pathway. This informed improvement efforts.
  
  
  RESULTS
  For 2008-2009, hospital-specific curves differed from other hospitals: borderline significant for AMI (p=0.064), highly significant (p≤0.005) for the remainder. After intervention, no difference was found (p>0.188). Before-after comparison of the curves within each hospital revealed a significant change for Fredrikstad (p=0.006). For the three hospitals, crude 30D declined and they were non-outliers for risk-adjusted 30D for 2013.
  
  
  CONCLUSIONS
  Survival curves as a supplement to 30D may be useful for identifying suboptimal care in the clinical pathway, and thus informing design of quality improvement projects.
authors: Quality Measurement Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway.
authors: Doris Tove
authors: DT
authors: Kristoffersen
authors: Quality Measurement Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway.
authors: Jon
authors: J
authors: Helgeland
authors: Telemark Hospital Trust Skien, Skien, Norway.
authors: Halfrid Persdatter
authors: HP
authors: Waage
authors: Telemark Hospital Trust Skien, Skien, Norway.
authors: Jacob
authors: J
authors: Thalamus
authors: Innlandet Hospital Trust Gjøvik, Brumunddal, Norway.
authors: Dirk
authors: D
authors: Clemens
authors: Quality Measurement Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway.
authors: Anja Schou
authors: AS
authors: Lindman
authors: Quality Measurement Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway.
authors: Liv Helen
authors: LH
authors: Rygh
authors: Quality Measurement Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway South-Eastern Norway Regional Health Authority, Hamar, Norway.
authors: Ole
authors: O
authors: Tjomsland
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D056988:Anterior Wall Myocardial Infarction / Q000401:mortality / Q000628:therapy; D065187:Controlled Before-After Studies; D005260:Female; D006620:Hip Fractures / Q000401:mortality* / Q000628:therapy; D017052:Hospital Mortality; D006760:Hospitalization; D006761:Hospitals / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality* / Q000628:therapy; D009664:Norway / Q000453:epidemiology; D017063:Outcome Assessment, Health Care; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D020521:Stroke / Q000401:mortality* / Q000628:therapy; D017741:Survivors / Q000706:statistics & numerical data*; D055815:Young Adult
keywords: STATISTICS & RESEARCH METHODS; STROKE MEDICINE