WASHINGTON — In what the government termed a major step forward in assuring quality health care, the U.S. Health Care Financing Administration on Thursday released comprehensive information on death rates for Medicare patients at most of the nation's hospitals.
The statistics reveal which hospitals have unusually high or low overall death rates, as well as high or low death rates for common causes of death in the elderly and disabled, such as heart diseases, lung diseases and strokes.
In California, 13 hospitals with more than 200 Medicare patients had higher than predicted overall mortality rates, and three had low overall values--Century City Hospital in Los Angeles, Green Hospital of Scripps Clinic in La Jolla and UCLA Medical Center.
The seven-volume report is based on a computerized analysis of about 10 million admissions for elderly and disabled patients at nearly 6,000 hospitals during 1986.
Aimed at Improvement
The report's "first and foremost usage should be by doctors and hospitals to improve what they do for patients," said the administration's Dr. William L. Roper, who oversees the Medicare program. "So I expect that all across America there's going to be a lot of board meetings in hospitals and hospital staff meetings asking pointed questions of doctors that have a high number of their patients die."
Three California hospitals also had lower than expected death rates for both severe acute and severe chronic heart disease, the most common causes of death in the elderly: Cedars-Sinai Medical Center, Kaiser Foundation Hospital, Los Angeles, and Sequoia Hospital in Redwood City.
The statistics allow each hospital's actual mortality rates to be compared to the government's calculations of a range of its predicted death rates, based on the characteristics of its patients, such as age, sex, previous hospitalizations and the additional illnesses from which they suffer.
The performance statistics are not intended to be used to make comparisons among hospitals and are not a direct measure of the quality of medical care. They do not take into account variations in the severity of illness between different patients with similar conditions--an important factor in predicting which patients are most likely to die, despite good medical care.
Because of these limitations, health care experts suggest that the statistics be used as starting points for asking questions when high mortality rates are found, not as hospital report cards.
Roper hailed the data disclosure as one of his most important accomplishments and pledged that his agency would release more meaningful hospital performance data next year.
But the completeness of the data release was significantly curtailed by what Dr. Henry Krakauer, a Health Care Financing medical officer who played a key role in preparing the report, called "political sensitivities."
The federal agency, for example, chose not to compile any summary statistics, such as national or statewide mortality rates, as is almost always done when such data is published in a medical journal. Such statistics might have facilitated comparisons between hospitals. It did not reveal the actual predicted death rates for hospitals, another standard reporting procedure for health care data.
The agency also used a calculation method that minimized the number of hospitals whose death rates would have turned out to be higher or lower than their predicted ranges. As a result, there were 146 hospitals, or 2.4% of the total, that exceeded the upper bound of the range of their predicted overall mortality and 180, or 3.0%, which were below the lower bound, according to Health Care Financing.
But if another accepted calculation method had been used, then the number of hospitals with higher than predicted overall mortality would have risen to about 11%, or about 660 hospitals, according to the report's technical appendix.
In a telephone interview from his Baltimore office, Krakauer defended these decisions. Asked about the choice of the more restrictive statistical technique, he said it is just as important for patients, physicians and hospitals to be concerned about the performance of hospitals near the upper bounds of their predicted mortality rates as the performance of those hospitals that exceeded their bounds.
"The political reason why we are so reluctant to bandy numbers about is that they are likely to be misused," Krakauer said. "You fall into the fallacy of misplaced concreteness--just because a number can be written down doesn't mean that it carries a precision. . . . It is a very difficult problem; it has caused us an immense amount of agony."
The release of mortality information for almost all acute-care hospitals significantly expands on Health Care Financing's initial data release in March, 1986, which only included some of the hospitals that were found to have high or low death rates.