title: A quality indicator can be biased by intra-hospital heterogeneity: the case for quality of patient record keeping in France.
abstract: BACKGROUND
  Since 2008, French health institutions providing medical, surgical and obstetrical care are assessed on the basis of a set of quality indicators. The French National Authority for Health developed a survey design in which 80 records are randomly selected from each institution. The main aim was to assess the effects of internal heterogeneity of a hospital that comprises several units. The survey method is based on the hypothesis of intra-institution homogeneity, which overlooks the fact that in wide hospitals homogeneity is related to departments and thus leads to overall intra-hospital heterogeneity.
  
  
  METHODS
  Simulated databases were created to modelise the heterogeneity of our hospital and computed to assess the reliance of indicator measurement. We used real data from a large teaching hospital having internal heterogeneity related to each department.
  
  
  RESULTS
  Variance under heterogeneity was greater than under homogeneity (3- to 18-fold) leading to an increased size of the confidence interval (CI) (at 95%) from 9 (given Haute Autorité de Santé sources) to 22 (for greatest internal heterogeneity).
  
  
  CONCLUSIONS
  The variations in a quality indicator can be explained by intra-institution heterogeneity and are not related to changes in the quality policy of the hospitals and may lead to errors in terms of pay for performance.
authors.affiliation: 1 Department of Public Health, Clermont-Ferrand University Hospital Center, Clermont-Ferrand, France 2 EA 4681, PEPRADE, University of Auvergne, Clermont-Ferrand, France a_lelong@chu-clermontferrand.fr.
authors.forename: Audrey
authors.initials: A
authors.lastname: Lelong
authors.affiliation: 1 Department of Public Health, Clermont-Ferrand University Hospital Center, Clermont-Ferrand, France 3 Laboratoire de Mathématiques, Université Clermont Auvergne, Université Blaise Pascal, BP 10448 F-63000 Clermont-Ferrand, France 4 CNRS, UMR 6620, Laboratoire de Mathématiques, F-63171 Aubière, France.
authors.forename: Stéphanie
authors.initials: S
authors.lastname: Léger
authors.affiliation: 1 Department of Public Health, Clermont-Ferrand University Hospital Center, Clermont-Ferrand, France 2 EA 4681, PEPRADE, University of Auvergne, Clermont-Ferrand, France 5 Department of Obstetrics & Gynecology, Clermont-Ferrand University Hospital Center, Clermont-Ferrand, France.
authors.forename: Françoise
authors.initials: F
authors.lastname: Vendittelli
authors.affiliation: 1 Department of Public Health, Clermont-Ferrand University Hospital Center, Clermont-Ferrand, France.
authors.forename: Marie
authors.initials: M
authors.lastname: Blanquet
authors.affiliation: 1 Department of Public Health, Clermont-Ferrand University Hospital Center, Clermont-Ferrand, France.
authors.forename: Cong-Tri
authors.initials: CT
authors.lastname: Thuong
authors.affiliation: 1 Department of Public Health, Clermont-Ferrand University Hospital Center, Clermont-Ferrand, France 2 EA 4681, PEPRADE, University of Auvergne, Clermont-Ferrand, France.
authors.forename: Bénédicte
authors.initials: B
authors.lastname: Belgacem
authors.affiliation: 1 Department of Public Health, Clermont-Ferrand University Hospital Center, Clermont-Ferrand, France 2 EA 4681, PEPRADE, University of Auvergne, Clermont-Ferrand, France.
authors.forename: Laurent
authors.initials: L
authors.lastname: Gerbaud
mesh_terms: D015982:Bias; D005602:France; D006748:Hospital Departments / Q000592:standards*; D006761:Hospitals / Q000592:standards*; D006784:Hospitals, Teaching / Q000592:standards; D006801:Humans; D008499:Medical Records / Q000592:standards*; D019984:Quality Indicators, Health Care / Q000592:standards*; D011787:Quality of Health Care / Q000592:standards