Association between prevalent care process measures and facility-specific mortality rates (original) (raw)

2001, Kidney International

It was stronger for the albumin Indicator (R 2 ϭ 11.6, 20.4, Association between prevalent care process measures and facil-21.8). The fractions of patients falling outside of the Indicator ity-specific mortality rates. guidelines tended to be higher in the highest SMR group. The Background. Medical communities often develop practice groups were not well separated, however, particularly for the guidelines recommending certain care processes intended to hematocrit and URR Indicators, and there was substantial promote better clinical outcome among patients. Conformance overlap between them. Finally, although the likelihood that a with those guidelines by facilities is then monitored to evaluate facility would be a member of the high or low SMR group was care quality, presuming that the process is associated with and associated with fractional variance from Core Indicator guidecan be used reliably to predict clinical outcome. Outcome is lines, the strengths of association were weak, and the probabiloften monitored as a facility-specific mortality rate (SMR) stanity that a facility would be a member of the high or low group dardized to the mix of patients treated, also presuming that could not be easily distinguished from the probability that it inferior outcome implies a suboptimal process. The U.S. Health would be a member of the middle group. Care Financing Administration monitors three practice guide-Conclusions. While there were statistical associations belines, called Core Indicators, in dialysis facilities to assist mantween SMR and the fraction of patients in facilities who were agement of its end-stage renal disease program: (1) patients' at variance with these guidelines, they were weak and variances hematocrit values should exceed 30 vol%, (2) the urea reducfrom the guidelines could not be used reliably to predict high or tion ratio (URR) during dialysis should equal or exceed 65%, low SMR. Such findings do not imply that measures reflecting and (3) patients' serum albumin concentrations should equal anemia, dialysis dose, or medical processes that influence serum or exceed 3.5 g/dL. albumin concentration are irrelevant to the quality of care. They Methods. The associations of a facility-specific SMR were evaldo suggest, however, that more attention needs be paid to these uated with the fractions of hemodialysis patients not conformand other associates and causes of mortality among dialysis ing to (that is, at variance with) the Core Indicators during three patients when developing care process indicator guidelines. successive years (1993 to 1995) in large numbers of facilities (394, 450, and 498) using one-variable and multivariable statistical models. Three related strategies were used. First, the association of the SMR with the fraction of patients not meeting Process measures of care, such as the Health Care Fithe guideline was evaluated. Second, each facility was classified nancing Administration's (HCFA) Core Indicators, are by whether its SMR exceeded the 80% confidence interval selected measures thought to affect the outcome of care above 1.0 (worse than 1.0, Group 3), was less than the inter-[1-3]. They are sometimes monitored within preselected val below 1.0 (better than 1.0, Group 1), or was within the interval (Group 2). The fraction of those patients who did not limits hoping to influence the quality and outcome of care meet the Indicator guidelines was then evaluated in each group. [4]. The Core Indicators were used for that purpose. Thus, Third, the ability of variance from Indicator guidelines to prethey should be strongly associated with and predict clinidict into which of the three SMR groups a facility would be cal outcome. That is particularly true if they are the main categorized was evaluated. or exclusive measures used to judge the care quality among Results. SMR was directly correlated with variance from the Indicator guidelines, but the strengths of the associations were facilities. It is necessary, therefore, to understand and demweak particularly for the hematocrit (R 2 ϭ 2.2%, 5.6, and 2.2 onstrate the nature and strength of association between for each of the 3 years) and URR Indicators (R 2 ϭ 2.6, 0.6, 3.3). outcome and those measures selected for monitoring in order to ensure that actions taken pursuant to monitoring will likely be effective and efficient in achieving the