No Mortality Benefit With Private Hospital Accreditation

Debra L. Beck

October 25, 2018

Results of an observational study show that — contrary to what might be expected — hospitals accredited by independent organizations, such as the Joint Commission, are associated with no better patient outcomes than hospitals reviewed by a state survey agency.

"Private hospital accreditation — including by the Joint Commission — is not associated with lower mortality, 30-day readmissions, or improved patient experience compared with hospitals undergoing a state survey," said first author Miranda B. Lam, MD, MBA, Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, in an email exchange with theheart.org | Medscape Cardiology.

Their findings were published online October 18 in BMJ.

The Joint Commission has recently been under attack for questionable standards and offering an expensive hospital-accreditation process that yields few benefits to hospital or patients.

In early October, the Wall Street Journal reported stepped-up federal oversight of hospital-accreditation organizations. This followed an earlier Journal report, which indicated that problem-plagued hospitals didn't lose their accreditation even when found to have serious safety violations.

Hospital accreditation by either a private organization, like the Joint Commission, or by a state survey agency is required by the Centers for Medicare and Medicaid Services as part of their Conditions of Participation. With about 80% of the nation's hospitals opting for Joint Commission accreditation, the organization has turned into an important safety watchdog.

To earn and maintain the Joint Commission's "Gold Seal of Approval," an organization undergoes an on-site survey at least every 3 years, and it can be pricey. According to the Journal, the Commission charged an average of $18,000 for an inspection in 2015, on top of an annual fee for participants of up to $37,000. Review and certification by a state survey agency is generally free.

In their analysis, researchers, led by Ashish Jha, MD, MPH, director of the Harvard Global Health Institute, studied Medicare data on more than 4.2 million patients admitted for 15 common medical conditions and six common and "costly" surgical procedures.

The main results showed:

  • Thirty-day risk-adjusted mortality at accredited hospitals was slightly but not statistically significantly lower than that seen by hospitals reviewed by a state survey agency (10.2% vs 10.6%; difference, 0.4%; (95% confidence interval [CI], 0.1% - 0.8%; = .03).

  • Mortality rates for the six surgical conditions were nearly identical (2.4% vs 2.4%; difference 0.0%; 95% CI, –0.3% to 0.3%; = .99).

  • Thirty-day readmissions for the 15 medical conditions were significantly lower, albeit only one percentage point different, favoring accredited hospitals (22.4% vs.23.2%; P < .001), a difference the researchers called "modest," but no difference was seen for the surgical procedures (15.9% vs 15.6%; P = .75).

  • Patient experience scores were "modestly" but not significantly better at hospitals accredited by state survey agencies (summary star rating, 3.4 vs 3.2; P = .06). Similarly, no difference in patient satisfaction was seen between the Joint Commission hospitals and those accredited by other independent organizations.

The researchers used risk adjustment to counter the risk for potential confounders and baseline differences between institutions.

"We hypothesized that hospitals able to undergo private accreditation (including with the Joint Commission) may have more resources to direct toward improving patient care and outcomes. Therefore, the bias may have been that privately accredited hospitals would have better outcomes," said Lam. "Instead, results show no difference between hospital accreditation and state survey."

Regarding the controversy over poorly performing hospitals, Lam said she hopes the accreditation process is improved, not eliminated.

"It is unclear to us why and how some of these hospitals continue to maintain accreditation, but we hope that our study will help the hospital accreditation process re-evaluate their methods and refocus on metrics that are related to patient outcomes."

Responding to the findings, Maureen Lyons, Corporate Communications at the Joint Commission, provided a statement that took issue with the interpretation of the data.

"Although the study employed some questionable methods, the published data showed positive associations between Joint Commission accreditation and both mortality and readmissions," Lyons told theheart.org | Medscape Cardiology.

"For patients with the medical conditions, Joint Commission–accredited hospitals had lower mortality (10.2%) than state-surveyed hospitals (10.6%), a difference that reached conventional levels of statistical significance (P = .03)," she noted. "Similarly, patients with medical conditions admitted to Joint Commission–accredited hospitals had lower readmission rates (22.4% vs 23.2%; < .001).

"While the authors considered these differences 'modest,' they matter to patients," Lyons added. "Applying these differences to the more than 3 million patients with medical conditions included in this study, the findings indicate that patients treated in Joint Commission–accredited hospitals experienced 12,000 fewer deaths and 24,000 fewer readmissions.

"Like any study, this one is best viewed in context with the full body of literature and evidence. More than 100 published studies document the positive impacts of Joint Commission accreditation and certification on improving healthcare," she concluded.

Publication of the Harvard research prompted spirited responses on the health policy Twitter scene, with both policy experts and clinicians applauding the findings as evidence that the system of hospital accreditation needs to change.

"In 2003, we published a paper in Health Affairs that concluded: 'JCAHO accreditation levels have limited usefulness in distinguishing individual performance among accredited hospitals,'" Harlan Krumholz (@hmkyale), MD, Yale University School of Medicine, New Haven, Connecticut, tweeted. "Not sure there has been progress."

Healthcare analyst Matthew Loxton (@mloxton) called the findings, "good news."

"It suggests that facilities that lack resources to pay Joint Commission rates could do well using cheaper State accreditation," he tweeted. "The bigger question is, do either result in better patient outcomes than no accreditation at all?"

Merger on Cardiac Certification

The BMJ publication comes on the heels of the announcement that the American Heart Association (AHA) and the Joint Commission will merge their cardiac certification programs on January 1, 2019.

The new certification seeks to combine the AHA's Cardiovascular Center of Excellence accreditation and its focus on cardiovascular science, research, and quality improvement, with the Joint Commission's expertise in working with healthcare organizations to evaluate and correct deficiencies in care delivery, an AHA press release says.

"The expanded collaboration between the American Heart Association and The Joint Commission will allow us to help a greater number of hospitals across the country to provide safe, high-quality, and appropriate timely care to cardiovascular patients," said Mark R. Chassin, MD, president and CEO, The Joint Commission, in an earlier announcement.

Organizations currently certified or accredited under current AHA or Joint Commission programs will automatically transition to the Comprehensive Cardiac Center Certification, but will be required to undergo a recertification review at the end of their current certification cycle.

This is not the first time the AHA and Joint Commission have joined forces. They already collaborate on Primary Stroke Center Certification, Comprehensive Stroke Center Certification, Acute Stroke Ready Certification, Thrombectomy-capable Stroke Center Certification, and Advanced Certification for Heart Failure.

"American Heart Association and Joint Commission certification ensures that a hospital's treatment practices and procedures meet the highest standards of cardiovascular care based on proven treatment guidelines," commented Gregg C. Fonarow, MD, David Geffen School of Medicine at UCLA, in a release.

To facilitate the merger, the AHA and Joint Commission reviewed both organizations' program requirements alongside the latest practice guidelines to identify opportunities to revise and strengthen standards for collaborative and comprehensive cardiac care, continuous quality improvement, and population health needs.

Prepublication revisions to the Comprehensive Cardiac Center Certification standards, which become effective January 1, 2019, are available online.

Lam reported no relevant conflicts of interest other than that she is employed by the Brigham and Women's Hospital and the Dana Farber Cancer Institute, which are both academic centers accredited by the Joint Commission.

BMJ. Published online October 18, 2018. Abstract.

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