Age Matters When Ranking Hospitals on Acute MI Care

Megan Brooks

September 27, 2017

NEW HAVEN, CT – Hospital mortality rates for elderly patients with acute MI (AMI) may not accurately reflect mortality rates for younger patients with AMI, a new study suggests[1].

An analysis of data from the largest US registry of AMI found that hospital mortality rankings for older patients with AMI did not consistently reflect those for younger patients, suggesting that data on younger patients should be incorporated into assessment of hospital outcomes to paint a more accurate hospital profile, the researchers say.

Dr Kumar Dharmarajan (Yale New Haven Health, CT) and colleagues report their findings September 26, 2017 in Annals of Internal Medicine.

The Centers for Medicare & Medicaid Services (CMS) uses data for Medicare fee-for-service beneficiaries aged 65 or older to calculate 30-day risk-standardized mortality rates (RSMRs) after AMI to rate hospital quality. But it's unclear whether outcomes for elderly patients reflect outcomes for younger patients, the researchers write.

"Data from Medicare beneficiaries are the only widely available source of hospital quality information. As a result, these data are almost universally used to guide hospital quality-improvement programs," Dharmarajan told | Medscape Cardiology.

"However, it was not known if Medicare data provides a generalizable signal of hospital quality for all patients, including younger ones," Dharmarajan noted. "Our results suggest that data for younger patients is needed to understand and report hospital quality more broadly within hospitals."

Missed Opportunity

For this report, the researchers analyzed data on 543,794 AMI patients treated over 4 years in 986 hospitals in the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry–Get With the Guidelines.

They calculated RSMRs within 30 days of admission for AMI and ranked hospitals based on those rates for patients 65 and older, patients 18 to 64 years, as well as all patients aged 18 and over.

Notably, say the researchers, about half of the patients hospitalized with AMI were younger than 65 years (n=276,031), and they observed differences in mortality rates for older vs younger patients.

Median hospital 30-day RSMRs were 9.4% for older patients, 3.0% for younger patients, and 6.2% for all patients.

Results also showed that most top- and bottom-performing hospitals for older patients were not top or bottom performers for younger patients, the researchers report.

In separate analyses using the CMS's methodology for its Hospital Value-Based Purchasing Program (HVBP), achievement scores for older patients correlated weakly with those for younger patients (R=0.30) but correlated strongly with those for all patients (R=0.92).

"Our results," write the researchers, "support the need to incorporate younger patients into hospital outcome assessment. Data from younger patients are needed to examine the presence and effect of age-related differences in hospital quality. These data are also needed for hospitals and clinicians to benchmark performance and continuously improve outcomes.

"The lack of focus on hospital outcomes for younger patients is a missed opportunity because initial hospital quality for AMI may influence long-term mortality," they add.

Rigorous Criteria

In a related editorial[2], Dr David Baker (Joint Commission, Oakbrook Terrace, IL) notes that while hospital quality of care may "truly differ by age, the more likely explanation for the poor correlation between hospital scores for older and younger patients is simply the relative lack of variation in RSMRs for younger patients.

"Although the conclusion that hospital mortality rankings for older patients with AMI inconsistently reflect those for younger patients is true, it belies the fact that hospital RSMR rankings for younger patients with AMI are likely to be unstable and overly influenced by random variation, because there are fewer deaths in this group," Baker writes.

"Although we should strive to include all patients in hospital measures of quality of care regardless of payer or data source, we must remember that measures should meet rigorous criteria for use in accountability programs before they are used at all," he adds.

Funding for the study was provided by the American College of Cardiology. Dharmarajan has a work contract with CMS and is a consultant and advisory board member for Clover Health. Disclosures for the coauthors are listed in the paper. Baker has disclosed no relevant financial relationships.

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