Transcript Document

rtery Catheterization Coronary Artery
ypass Graft Pancreatic Resection Vagin
rth After Cesarean Bilateral Artery
atheterization Coronary Artery Bypass
raft Pancreatic Resection Vaginal Birth
fter Cesarean Bilateral Artery
atheterization Coronary Artery Bypass
raft Pancreatic Resection Vaginal Birth
fter Cesarean Bilateral Artery
atheterization Coronary Artery Bypass
Introduction
Why are IQIs so important?
Pancreatic
Discussion
AIMS
Resection
CoronaryReferences
Artery
Methods
Bypass Graft
Vaginal Birth
After Cesarean
Results
Congestive Heart Failure
Bilateral Cardiac Catheterization
Faculdade de Medicina da Universidade do Porto
HEALTH INDICATORS
Mortality Rates for Medical Conditions
Prevention Quality
Indicators
Volume of procedures
Inpatient Quality
Indicators [1][2]
Mortality Rates for Surgical Procedures
Patient Safety
Pediatric Quality
Area-level Utilization Rates
Indicators
Indicators
Hospital-level Procedure Utilization Rates
[1] Nationwide inpatient sample and state databases. Health care cost and utilization project. Agency for healthcare research and quality, Rockville, MD;
[2] Justin B. Dimick; H. Gilbert Welch; John D. Birkmeyer. Surgical Mortality as an Indicator of Hospital Quality: The Problem With Small Sample Size. JAMA,
August 18, 2004; 292: 847 – 851.
Faculdade de Medicina da Universidade do Porto
IQIs offer a window into the
medical care delivered in
hospitals.[3]
Why are IQIs
so important?
They can be used to flag potencial quality
problems and success stories,
which can be further investigated.[3]
Through them, we can identify differences between
hospitals, regions or communities.[3]
They provide a comprehensive
picture of the level and variation
of quality within four components
of health care quality:
effectiveness, safety, timeliness
and patient centeredness.[3]
[3] Nationwide inpatient sample and state databases. Health care cost and utilization project. Agency for healthcare research and quality, Rockville, MD
Faculdade de Medicina da Universidade do Porto
Evaluation of hospital´s quality of care : How can we
select good/valid inpatient quality indicators?
1
Aims
Analyze several IQI’s selection methods used in studies;
Select 5 IQIs and explore their advantages and limitations;
3
2
Compare IQIs and conclude on how well do they
reflect hospital care quality;
Conclude about the utilization of IQIs on the evaluation
of the quality of healthcare services.
4
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IQIs’
1
Faculdade de Medicina da Universidade do Porto
Analysis of a series of studies
Combination of results simultaneously adequate
and representative
Answer the central question
Faculdade de Medicina da Universidade do Porto
1
“How are IQIs selected and how well do they reflect
Formulation of the central question;
a hospital’s quality? – Five IQIs’ example”;
2
Definition of the criteria for selection of the
articles (inclusion/exclusion);
3
Bibliographic data base (MEDLINE and ISI Web of
Definition of the research strategy;
Knowledge);
4
Procedures frequently used in medical practice or
Selection of 5 IQIs to analyze.
common health problems .
Faculdade de Medicina da Universidade do Porto
QUERIES APPLIED
5
Statistics on theResearch
disease’sphase
prevalence/utilization
of procedure;
Definition of the
IQI;
[Bilateral Cardiac Catheterization]
or [Bilateral
Cardiac Catheterization AND
Advantages
and
disadvantages
its utilization.
Inpatient
Quality
Indicator,
Healthof
Care]
Data
collection
6
Evaluate the quality of the five IQIs on the
appraisement
of a hospital’s
[Coronary Artery Bypass Graft] or
[Coronary Artery
Bypassservices;
Graft AND Inpatient
Quality Indicator , Health Care] or [CABG]
Data process and analysis
[Pancreatic Resection] or [Pancreatic Resection AND Inpatient Quality Indicator
Answer the central question: conclude on
, Health Care]
how well do IQIs reflect a hospital’s quality.
7
[Congestive Heart Failure] or [Congestive Heart Failure AND Inpatient Quality
Indicator , Health Care] or [CHF AND Inpatient Quality Indicator , Health Care]
[Vaginal Birth after Cesarean] or [Vaginal Birth after Cesarean AND Inpatient
Quality Indicator , Health Care] or [VBAC]
Faculdade de Medicina da Universidade do Porto
1
English
LANGUAGE
Criteria for
the selection
of articles
TIME
LIMITATION
Articles dated between 2004 and 2009;
2 reviewers
TITLE AND
ABSTRACT
EXCLUSION
Focus on both
procedure/health problem
and quality indicator
Faculdade de Medicina da Universidade do Porto
2
2 reviewers
Inpatient quality Indicators
Inclusion
criteria
Criteria for
the selection
of articles
Advantages/disadvantages concerning the
procedure/medical problem
Possible generalization of the results
Other types of quality indicators
Exclusion
criteria
Lack of data associated to the IQI
Over specific reviews
Faculdade de Medicina da Universidade do Porto
2
Faculdade de Medicina da Universidade do Porto
PR
VBAC
CABG
BCC
CHF
11 articles
9 articles
8 articles
4 articles
17 articles
7
6
6
2
9
4
3
2
Included articles
2
8
Excluded articles
Faculdade de Medicina da Universidade do Porto
[4] GIRALDES MDO R Efficiency versus quality in the NHS, in Portugal: methodologies for evaluation Acta
Med Port. 2008 Sep-Oct21(5):397-410. E.pub 2009 Jan 16.
VAGINAL
BIRTH
PANCREATIC
RESECTION
CORONARY
ARTERY
BYPASS
GRAFT
AFTER
CESAREAN
CONGESTIVE
HEART
FAILURE
BILATERAL
CARDIAC
CATHETERIZATION
Faculdade de Medicina da Universidade do Porto
Set limits regarding the number of PRP procedures,
to compare different hospitals;
Rare
procedure that requires technical
PR volumes are divided into: high,
low or medium.
proficiency;
Providers with higher volumes have lower mortality rates for the
procedure;
Errors
management
may lead to
Suggests
thatin
thiscirurgical
providers have
some characteristics,
either structurally or with
regard to
procedure thatcomplications;
clinical
significally
influences mortality[5].
VOLUME INDICATOR
Indicates the raw volume compared to annual
threshold (100 and 200 procedures);
Relationship between hospital volume and mortality is unclear[6];
Better processes of care and the increasing of hospital
Hospitals
performing
highrepresents
volume of procedures
procedures
may reduce
mortalityawhich
with an
increased complexity may have better
better quality
of care.
outcomes.
MORTALITY INDICATOR
Indicates the number of deaths per 100
pancreatic resection procedures;
High mortality may be associated with
poorer quality of care.
[5] LIEBERMAN, MICHAEL; KILBURN, H; LINDSAY M.A.; MICHAEL, PhD.; BRENNAN Murray F.; M.D; Relation of Perioperative Deaths to Hospital
Volume Among Patients Undergoing Pancreatic Resection for Malignancy; Ann Surg. 1995 Nov;222(5):638-45
[6] DIMICK JB; COWAN JAJr; COLLETI LM; Upchurch GR Jr; Hospital Teaching Status and Outcomes of Complex Surgical Procedures in the
United States; Arch Surg. 2008 Jan;206(1):13-6. Epub 2007 Oct 18.
Faculdade de Medicina da Universidade do Porto
Introduction of risk adjustment
for clinical factors (prevent
confunding bias);
Some factors (finantial conditions of the
hospitals and patients characteristics) may cause
illusory results [7];
MORTALITY INDICATOR
VOLUME INDICATOR
Proxy measure for quality – should be used
with other indicators.
Not performed frequently enough to judge
hospital quality – poor precision [8].
[7] Marques JR ET; Maciel Filho R; August PN; Overcoming health inequity: potential benefits of a patient-centered open-source public health infostructure; Cad
saude publica. 2008 Mar;24(3):547-57.
[8] DIMICK Justin B; WELCH H Gilbert; BIKMEYER John D; Surgical Mortality as an Indicator of hospital quality the problem with small sample size; JAMA. 2004;
292(7):847-851.
Faculdade de Medicina da Universidade do Porto
Coronary artery bypass graft is a form of
surgery that
create
new routesa good measure of
IndicatesIt raw
volumeto setbypass
is necessary
limits regarding
thecanTo
be considered
Indicates
thequality,
number
Indicates the number
aroundArea-level
narrowed
and
blocked
number
of CABG procedures
to compare
thecoronary
procedure must have both a
utilization
compared
to annual
of CABGs
per 100,000
of
per 100
Volume
Indicator
arteries, allowing
increased
blood flow
the Mortality
different
hospitals;
relatively
hightomortality
ratedeaths
and beIndicator
threshold
(100 and
200 CABG volume is divided
indicator
delivery
and nutrients to
the heart frequently;
population
CABG procedures
into: high, lowoxygen
or medium;
performed
procedures)
muscles.
The limits do not correspond to a
certain amount but are derived from an
evaluation of the association between
hospitals’ CABG volume and in-hospital
mortality.
This rate depends on certain factors,
including the finantial conditions of the
hospital – the mortality rate is higher in
hospitals less developed [9].
[9] Dimick J, Welch H, Birkmeyer. Surgical Mortality as an indicator of Hospital Quality: The Problem With Small Sample Size. JAMA. 2004
Faculdade de Medicina da Universidade do Porto
The association between CABG procedures and mortality rates is not constant;
Patients at high-volume CABG hospitals are at a lower mortality risk than patients
at lower volume hospitals [10][11];
This association
been declining over time
because ofIndicator
the improvement of
Volumehas
Indicator
Mortality
cirurgical training and technical advances[12];
Other studies: the correlation between the number of surgeries and mortality is
weak[13] and depends on the age of the studies’ participants[14].
[10] Rathore S, Epstein A, et al. Hospital Coronary Artery Bypass Surgery Volume and Patient Mortality, 1998-2000. Annals of Surgery. January 2004
[11] Shahian D, O’Brien S, Normand S, et al. Association of hospital coronary artery bypass volume with processes of care, mortality, morbidity, and the Society of Thoracic
Surgeons composite quality score. The Journal of Thoracic and Cardiovascular Surgery. February 2010
[12] Volume and outcome of CABG surgery: are more and less the same?
[13] Mesquita ET, Ribeiro A, Araújo MP, Campos LA, Fernandes MA, Colafranceschi AS, Silveira CG, Nunes E, Rocha AS. Indicators of healthcare quality in isolated coronary artery
bypass graft surgery performed at a tertiary cardiology center. Arq Bras Cardiol. May 2008
[14] Adogwa O, Costich JF, Hill R, Slavova S. Does higher surgical volume predict better patient outcomes? J Ky Med Assoc.. January 2009
Faculdade de Medicina da Universidade do Porto
Provider-level indicator that
Represents the relative risks and
estimates vaginal births per 100
benefits of a trial of labor in
discharges (fix volume of labors
patients with previous cesarean
in a hospital) with a diagnosis of
delivery
previous cesarean delivery
Observed differences represent
true differences in provider
Disadvatanges
performance rather than random
variation
reduce medical costs substantially;[15]
Higheranemia
rates represent
better
long term risks of a cesarean section include uterine rupture, maternal
infection,
Underused and
procedure
quality
perinatal death and others);[15]
unsuccessful trial of labor (TOL), in which a woman undergoes a repeated cesarean delivery
instead of a vaginal delivery, has a higher rate of complications compared to a VBAC and elective
repeat cesarean delivery (ERCD);
Advantages
the overall benefits of TOL are directly related to having a VBAC as these women
typically have
the lowest morbidity;
maternal mortality is low: 3.8 per 100 000 women who undergo a TOL die versus 13.4 per 100
000 women who undergo a ECRD die;
[15] McGrath P, Phillips E; Bioethics and birth: insights on risk decision-making for an elective caesarean after a prior caesarean delivery; Monash Bioeth Rev. 2009 Sep;28(3):22.1-19
Faculdade de Medicina da Universidade do Porto
the delivery category with fewest complications is repeat cesarean – 72% had no
complications[16];
IQI measure is associated to a personal choice (whether to take or not risks on a surgery);
VBAC posed a higher risk than an elective cesarean (EC)[16];
dependent on medical advisement[17];
facts tend to change a mother’s choice[17];
[16] McGrath P, Phillips E; Bioethics and birth: insights on risk decision-making for an elective caesarean after a prior caesarean delivery; Monash Bioeth Rev. 2009 Sep;28(3):22.1-19
[17] Gregory KD, Korst LM, Fridman M, Shihady I, Broussard P, Fink A, Burnes Bolton L.; Vaginal birth after cesarean: clinical risk factors associated with adverse outcome; Am J
Obstet Gynecol. 2008 Apr;198(4):452.e1-10; discussion 452.e10-2.
Faculdade de Medicina da Universidade do Porto
Progressive cronic disease and a relatively common
admission with substantial short-term mortality
Mortality rate
from CHF has
progressively
declined over
time[19] mainly
because it can
be significally
reduced with
appropriate
terapy [20]
CHF is an important public
health problem, in part
because survival following
diagnosis is poor[18]
As better processes of care
may reduce short-term
mortality, CHF mortality rates
could be used to indicate the
quality of health care facilities
CHF mortality rate is a mortality
indicator for inpatient
conditions and measures the
number of deaths per 100
discharges with principal
diagnosis code of CHF
CHF mortality has been widely
used as a quality indicator: it is
precise [21] and captures an
aspect of quality that is
regarded as important
[18] Goff, DC, Jr., Pandey DK, Chan FA, et al. Congestive heart failure in the United States: is there more than meets the I(CD code)? The Corpus Christi Heart Project. Arch Intern Med 2000
[19] Ni H, Hershburger FE. Was the decreasing trend in hospital mortality from heart failure attributable to improved hospital care? The Oregon experience, 1991-1995. Am J Manage care 1999
[20] Maclntyre K, Capewell IS, Stewart S, et al. Evidence of improving prognosis in heart failure: trends in case fatality in 66547 patients hospitalized between 1986 and 1995. Circulation 2000
[21] Nationwide Inpatient Sample and State Databases.Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality, Rockville, MD.
Faculdade de Medicina da Universidade do Porto
Bias caused by the
admitting decision – failing to
admit the
sickest
patients
Mortality
rate
may
depend
Mortality
is greatly
influenced
could
a hospital’s
theimprove
type of that
healthcare
byon
other
factors
can lead
survival
rate [24]
facility
to
bias.
Specialized hospitals have
modestly
lower risk and
rate of short
In-hospital
mortality
Differences
in mortality
rates
term
mortality than
general hospitals
measureshospitals
may
between
can be
[23] encourage
early
Patients
at post-operative
teaching
hospitals have
attributed
to unobserved
better
survival
rates
than those
discharge
shift
patientsand
andthereby
hospital
among other hospitals [24]
deaths
to skilled [22].
nursing
characteristics
facilities or outpatient
settings [25]
GENERAL
[22] Werner, RM, Bradlow, ET. Relationship between Medicare’s
Hospital compare performance measures and mortality rates.
JAMA 2006
[23] Nallamothu, BK, Wang, Y, Cram, P, et al. Acute myocardial
infarction and congestive heart failure outcomes at specialty
cardiac hospitals. Circulation 2007
[24] Poses, RM, McClish, DK, Smith, WR, et al. Results of report
cards for patients with congestive heart failure depend on the
method used to adjust for severity. Ann Intern Med 2000
[25] Rosenthal, GE, Baker, DW, Noris, DG, et al. Relationships
between in-hospital and 30-day standardized hospital mortality:
implications for profiling hospitals. Health Services Research 2000
Faculdade de Medicina da Universidade do Porto
PARTICULAR
[26] Rosenthal, GE, Baker, DW, Noris, DG, et al. Relationships
between in-hospital and 30-day standardized hospital
mortality: implications for profiling hospitals. Health Services
Research 2000
Ascertaining deaths that
CHF
is aafter
condition
that
Hospitals
in
regions
withisa
occur
discharge
increases
exponentially
larger
elderly
population
will
tedious
and expensive
ifwith
done
aging.
As
the
size
of
the
have
higher primary
mortalitydata
rate,
through
elderly
population
increases,
without being
directly
collection
and may
raise
the
substancial
morbidity
and
associated
with
quality
concerns about risks toof
the
mortality
attributable
to
CHF
care.
patient confidentiality
[26].
will continue to increase [26].
Faculdade de Medicina da Universidade do Porto
BCC is considered
appropriate in the
presence of certain
clinical indications
Less influenced by
discharge variation
Signal ratio very high
at 96,2%
- observed
Hospital-level
differences in provider
Procedure
Utilization
performance likely
Rates
represent
true
differences, rather
than random
variations
Based onPrecise
empirical
evidence – very
precise [28]
[28]Nationwide inpatient sample and state
databases. Health care cost and utilization
project. Agency for healthcare research and
quality, Rockville, MD
Cardiac catheterization is a
diagnostic test that can show
if blood vessels to the heart
are narrowed or blocked;
A liquid dye is injected into the
arteries of the heart through a
catheter, a long narrow tube that
is fed through
artery, usually in
Generalanprocedure
the thigh, to arteries in the
heart[27]
[27]http://www.dshs.state.tx.us/THCIC/publications/hospitals/IQIReport2004/Chart25.pdf
The validity rests on
the assumption that
the prevalence of this
clinical indication is
low and relatively
uniformed
Substantial variation in
the use of BCC at two
large community
hospitals was found,
even after adjusting for
clinical indications [29]
Other source of potential
[29] Malone ML,bias:
Bajwa large
TK, Battiola
RJ, et al.of
number
Variation among cardiologists in the utilization
catheterizations
of right heart catheterization
at time of
performed
on an
coronary angiography
[see comments].
Cathet
Cardiovasc Diagn 1996;37(2):125-30.
outpatient basis
Faculdade de Medicina da Universidade do Porto
3
Faculdade de Medicina da Universidade do Porto
Higher procedure volume has lower mortality rates as it
depends on technical profeciency and pacient’s characteristics
(low precision);
Must have a relatively high mortality rate and
be performed frequently. The association
between CABG procedures and mortality rate
depends on the volume of procedure of each
hospital. It also depends on several factors as
financial conditions. The analysis must not be
done separating the volume from the mortality
rate (imprecise predictor of quality);
IQI combination
must be done
to allow a
precise
evaluation of a
hospital’s
quality
High rates represent better quality. Factors related with
the mother’s health (for instance, obesity and uterine
conditions) can influence the success rates (good
measure).
Better processes of treatment
can contribute for reducing
short term mortality (that
depends on the characteristic
of each hospital and patient).
It is a precise indicator and
serves as base for comparative
studies of care’s quality;
It is considered appropriate in the presence
of certain clinical factors and
contraindicated in most patients so lower
rates represent better quality. Significance
of the result isn’t affected by external
factors (high precision rates);
Faculdade de Medicina da Universidade do Porto
The collection of inpatient quality indicators represents a part of the actual state
of care’s quality using literature data. However, this indicators must be used
cautiously because the research done has limitation.
Language
Articles which seemed to have good information were
not available free of charge and were not able to obtain
even after contacting the corresponding author
Availability
Contradiction
Led to the inclusion of articles since 1990 and might
have resulted in outdated information
Adaptation
problems
Paucity of
information
(the
volume
of procedures
may bethe
lower,
theso
incidence
of to
The
data
found
concerns mostly
USA
it is hard
diseases may be different and the technology available is not the
transpose the conclusions to the reality of Portugal
same)
Faculdade de Medicina da Universidade do Porto
Although this information represents a rich data source that can provide valiable
information it should not be used as a definitive source.
This review allowed to reveal real quality problems for which quality improvement
programs can be initiated
It also showed that additional clinical information is required to understand
the quality issues.
These indicators provide a starting point for further
investigations that might explore severity of illness
differences
Need for establishing
patterned
For example, hospitals
with
criteria thathigher
allowthan
classification
of a
average mortality
hospital's volume
procedures
(high,or
rates forofspecific
procedures
conditions
probe the
medium
or low should
volume)
underlying reasons:
• [1] Nationwide inpatient sample and state databases. Health care cost and utilization project. Agency for healthcare research and quality,
Rockville, MD
http://www.ahrq.gov/data/hcup
• [2] Justin B. Dimick; H. Gilbert Welch; John D. Birkmeyer; Surgical Mortality as an Indicator of Hospital Quality: The Problem With Small
Sample Size; JAMA, August 18, 2004; 292: 847 – 851
• [3] Nationwide inpatient sample and state databases. Health care cost and utilization project. Agency for healthcare research and quality,
Rockville, MD (http://www.ahrq.gov/data/hcup)
• [4] GIRALDES MDO R Efficiency versus quality in the NHS, in Portugal: methodologies for evaluation; Acta Med Port. 2008 SepOct21(5):397-410. E.pub 2009 Jan 16.
• [5] LIEBERMAN, MICHAEL; KILBURN, H; LINDSAY M.A.; MICHAEL, PhD.; BRENNAN Murray F.; M.D; Relation of Perioperative Deaths to
Hospital Volume Among Patients Undergoing Pancreatic Resection for Malignancy; Ann Surg. 1995 Nov;222(5):638-45
• [6] DIMICK JB; COWAN JAJr; COLLETI LM; Upchurch GR Jr; Hospital Teaching Status and Outcomes of Complex Surgical Procedures in the
United States; Arch Surg. 2008 Jan;206(1):13-6. Epub 2007 Oct 18.
• [7] Marques JR ET; Maciel Filho R; August PN; Overcoming health inequity: potential benefits of a patient-centered open-source public
health infostructure; Cad saude publica. 2008 Mar;24(3):547-57.
• [8] DIMICK Justin B; WELCH H Gilbert; BIKMEYER John D; Surgical Mortality as an Indicator of hospital quality the problem with small
sample size; JAMA. 2004; 292(7):847-851.
• [9] Dimick J, Welch H, Birkmeyer. Surgical Mortality as an indicator of Hospital Quality: The Problem With Small Sample Size. JAMA. 2004
• [10] Rathore S, Epstein A, et al. Hospital Coronary Artery Bypass Surgery Volume and Patient Mortality, 1998-2000. Annals of Surgery.
January 2004
• [11] Shahian D, O’Brien S, Normand S, et al. Association of hospital coronary artery bypass volume with processes of care, mortality,
morbidity, and the Society of Thoracic Surgeons composite quality score. The Journal of Thoracic and Cardiovascular Surgery. February
2010
• [12] Volume and outcome of CABG surgery: are more and less the same?
• [13] Mesquita ET, Ribeiro A, Araújo MP, Campos LA, Fernandes MA, Colafranceschi AS, Silveira CG, Nunes E, Rocha AS. Indicators of
healthcare quality in isolated coronary artery bypass graft surgery performed at a tertiary cardiology center. Arq Bras Cardiol. May
2008
• [14] Adogwa O, Costich JF, Hill R, Slavova S. Does higher surgical volume predict better patient outcomes? J Ky Med Assoc.. January
2009
• [15] McGrath P, Phillips E; Bioethics and birth: insights on risk decision-making for an elective caesarean after a prior caesarean
delivery; Monash Bioeth Rev. 2009 Sep;28(3):22.1-19
• [16] McGrath P, Phillips E; Bioethics and birth: insights on risk decision-making for an elective caesarean after a prior caesarean
delivery; Monash Bioeth Rev. 2009 Sep;28(3):22.1-19
• [17] Gregory KD, Korst LM, Fridman M, Shihady I, Broussard P, Fink A, Burnes Bolton L.; Vaginal birth after cesarean: clinical risk
factors associated with adverse outcome; Am J Obstet Gynecol. 2008 Apr;198(4):452.e1-10; discussion 452.e10-2.
• [18] Goff, DC, Jr., Pandey DK, Chan FA, et al. Congestive heart failure in the United States: is there more than meets the I(CD code)?
The Corpus Christi Heart Project. Arch Intern Med 2000
• [19] Ni H, Hershburger FE. Was the decreasing trend in hospital mortality from heart failure attributable to improved hospital care?
The Oregon experience, 1991-1995. Am J Manage care 1999
• [20] Maclntyre K, Capewell IS, Stewart S, et al. Evidence of improving prognosis in heart failure: trends in case fatality in 66547
patients hospitalized between 1986 and 1995. Circulation 2000
• [21] Nationwide Inpatient Sample and State Databases.Healthcare Cost and Utilization Project. Agency for Healthcare Research and
Quality, Rockville, MD. (http://www.ahrq.gov/data/hcup)
• [22] Werner, RM, Bradlow, ET. Relationship between Medicare’s Hospital compare performance measures and mortality rates. JAMA
2006
• [23] Nallamothu, BK, Wang, Y, Cram, P, et al. Acute myocardial infarction and congestive heart failure outcomes at specialty cardiac
hospitals. Circulation 2007
• [24] Poses, RM, McClish, DK, Smith, WR, et al. Results of report cards for patients with congestive heart failure depend on the
method used to adjust for severity. Ann Intern Med 2000
• [25] Rosenthal, GE, Baker, DW, Noris, DG, et al. Relationships between in-hospital and 30-day standardized hospital mortality:
implications for profiling hospitals. Health Services Research 2000
• [26] Rosenthal, GE, Baker, DW, Noris, DG, et al. Relationships between in-hospital and 30-day standardized hospital mortality:
implications for profiling hospitals. Health Services Research 2000
• [27]http://www.dshs.state.tx.us/THCIC/publications/hospitals/IQIReport2004/Chart25.pdf
• [28]Nationwide inpatient sample and state databases. Health care cost and utilization project. Agency for healthcare research and
quality, Rockville, MD (http://www.ahrq.gov/data/hcup)
• [29] Malone ML, Bajwa TK, Battiola RJ, et al. Variation among cardiologists in the utilization of right heart catheterization at time of
coronary angiography [see comments]. Cathet Cardiovasc Diagn 1996;37(2):125-30.
THE
END