Public reporting of ICU mortality does not improve outcomes

May 19, 2014, American Thoracic Society

A large study of intensive care patients in California found that public reporting of patient outcomes did not reduce mortality, but did result in reduced admission of the sickest patients to the ICU and increased transfer of critically ill patients to other hospitals.

"Public reporting is designed to reduce mortality by steering towards high-quality hospitals and creating incentives for hospitals to adopt quality improvement programs," said Lora Reineck, MD, a postdoctoral scholar at the University of Pittsburgh. "But the reality does not necessarily meet the expectation."

In fact, said Reineck, the study demonstrated that large policy initiatives like California's can have unintended consequences. Whether those consequences left patients worse or better off is not a question the study was designed to answer.

"It could be that some hospitals didn't take certain surgical cases, fearing that the patients were at high risk of dying in intensive care after surgery," Dr. Reineck explained. "Or, it could be that the very sickest patients were not admitted to the ICU because they were not going to get better, and instead were transitioned to care that emphasized comfort rather than prolonging life."

In their , presented at the 2014 American Thoracic Society International Conference, Reineck and Pitt colleagues took advantage of a natural experiment created in 2007 when California required every ICU in the state to report severity-adjusted mortality rates. (California has since stopped collecting and reporting this information, and no other state has launched a similar initiative.)

As a control, the Pitt researchers looked at Arizona, Nevada, and Texas, which did not have a public report requirement. In all four states, the group gathered Medicare fee-for-service data from 2005 to 2009, two years before California initiated its program and continuing two years after the program was launched.

In all, they reviewed the records of 936,063 patients admitted to 646 hospitals. To determine the effect of public reporting, they compared changes over time in California ICUs to control ICUs. The researchers analyzed admission patterns in each ICU by determining the proportion of patients with 3 or greater comorbidities and the proportion of patients needing mechanical ventilation in each ICU. They reviewed discharge patterns by examining where ICU patients were sent when they left the hospital. And they assessed mortality rates, including deaths that occurred in the hospital and those that occurred within 30 days of hospital admission.

In their analysis, the team adjusted for patient and hospital characteristics, as well as regional characteristics that could affect . These regional factors included the age and racial distribution of residents and the number of hospitals in the region, a statistic that could affect how often critically ill patients were transferred to another ICU. In the first year after public reporting began, California ICUs experienced virtually identical changes in in-hospital and 30-day mortality rates as controls (OR 1, p=0. 97; OR 1, p=0 .84, respectively).

However, in the first year, both the admission and discharge patterns showed statistically significant changes. Patients with 3 or more comorbidities were less likely to be admitted to California ICUs than control ICUs (OR .98, p=0.03). They were also more likely to be transferred to another acute care facility (OR 1.08, p=0.03).

In the second year of pubic reporting, these patterns continued. Changes in mortality rates in California were similar to controls (in-hospital mortality OR 0.99, p = 0.72; 30-day mortality OR 0.99, p = 0.55). Admission of patients with 3 or more comorbidities was reduced compared to controls, but this was not statistically significant (OR 0.98, p=0. 13). And were more likely to be transferred to another hospital than in control states—a pattern more pronounced in year two than in year one (OR 1.43, p<0.001).

The Pitt researchers also looked at the number of patients who were transitioned to skilled nursing homes or long-term care facilities. They hypothesized that hospitals would try to improve their mortality rates by sending patients to these facilities.

"We expected that the proportion of patients discharged to these post-acute care facilities would have increased, but it didn't," Reineck said.

Reineck noted that a similar, but much smaller, study conducted in Cleveland, OH, supported their original hypothesis. The study, which analyzed the effect of publicly reporting ICU in-hospital mortality rates during the 1990s, found that discharges to post-acute care facilities increased while in-hospital mortality decreased. (Sirio CA, Shepardson LB, Rotondi AJ, et al. Community-wide assessment of intensive care outcomes using a physiologically based prognostic measure: implications for critical care delivery from Cleveland Health Quality Choice. Chest 1999; 115:793-801.) Reineck also noted that initial media stories in California erroneously credited public reporting of ICU mortality rates with reducing mortality.

"That turned out not to be true," she said. "We determined that decreased in the control states at the same rate as California, meaning that the quality of care of all ICU patients improved during the study period irrespective of the public reporting initiative in California."

Explore further: Use of in-hospital mortality to assess ICU performance may bias quality measurement

More information: Abstract 50098, The Impact Of Publicly Reporting Intensive Care Unit (ICU) In-Hospital Mortality On ICU Case-Mix And Outcomes, Scientific Abstract , 04.07 - ICU Management/Outcome (CC) , L.A. Reineck, T.Q. Le, C.W. Seymour, A.E. Barnato, D.C. Angus, J.M. Kahn; University of Pittsburgh - Pittsburgh, PA/US

Related Stories

Use of in-hospital mortality to assess ICU performance may bias quality measurement

May 21, 2012
In-hospital mortality for ICU patients is often used as a quality measure, but discharge practices may bias results in a way that disadvantages large academic hospitals, according to a recently conducted study.

Antidepressant use associated with increased mortality among critically ill patients?

May 22, 2012
Researchers at Beth Israel Deaconess Medical Center, in Boston, and the Massachusetts Institute of Technology in Cambridge, have found that critically ill patients were more likely to die if they were taking the most commonly ...

Burden of futile care in ICU studied: Patients waiting for care affected negatively, study presented

October 28, 2013
Researchers at UCLA studied the opportunity costs of providing futile care to patients in the ICU, finding that care was delayed or compromised for waiting patients when futile care was being provided in a full ICU. Futile ...

Sepsis involved in high percentage of hospital deaths

May 18, 2014
An analysis that included approximately 7 million hospitalizations finds that sepsis contributed to 1 in every 2 to 3 deaths, and most of these patients had sepsis at admission, according to a study published by JAMA. The ...

Difference in ICU care between the US and UK reflect extremes of bed availability

April 13, 2011
Patients who receive intensive care services are very different in the United States than in the United Kingdom, according to a new study that compared admission and mortality statistics from ICUs in each country. The study ...

Study finds physical signs of depression common among ICU survivors

April 24, 2014
Depression affects more than one out of three survivors of critical illness, according to a Vanderbilt study released in The Lancet Respiratory Medicine, and the majority of patients experience their symptoms physically rather ...

Recommended for you

Air pollution may shorten telomeres in newborns

January 24, 2018
A study conducted before and after the 2004 closure of a coal-burning power plant in Tongliang, China, found children born before the closure had shorter telomeres than those conceived and born after the plant stopped polluting ...

Number of older people with four or more diseases will double by 2035, say researchers

January 23, 2018
A study published today in Age and Ageing, the scientific journal of the British Geriatrics Society, reports that the number of older people diagnosed with four or more diseases will double between 2015 and 2035. A third ...

Placental accumulation of flame retardant chemical alters serotonin production in rats

January 22, 2018
A North Carolina State University-led research team has shown a connection between exposure to a widely used flame retardant chemical mixture and disruption of normal placental function in rats, leading to altered production ...

Marijuana use does not lower chances of getting pregnant

January 22, 2018
Marijuana use—by either men or women—does not appear to lower a couple's chances of getting pregnant, according to a new study led by Boston University School of Public Health (BUSPH) researchers.

Women run faster after taking newly developed supplement, study finds

January 19, 2018
A new study found that women who took a specially prepared blend of minerals and nutrients for a month saw their 3-mile run times drop by almost a minute.

Americans are getting more sleep

January 19, 2018
Although more than one in three Americans still don't get enough sleep, a new analysis shows first signs of success in the fight for more shut eye. According to data from 181,335 respondents aged 15 and older who participated ...


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.