Health Policy and Management (보건행정학회지)

Korean Academy of Health Policy and Management (한국보건행정학회)
권호 표지
DOI QR코드

DOI QR Code

Does performing high- or low-risk coronary artery bypass graft surgery bias the assessment of risk-adjusted mortality rates of hospitals?

관상동맥우회로술의 위험 수준이 병원내사망률 평가 결과에 미친 영향 분석

  • Lee, Kwang-Soo (Department of Hospital Management, College of Medicine, Eulji University) ;
  • Lee, Sang-Il (Department of Preventive Medicine, College of Medicine, University of Ulsan) ;
  • Lee, Jung-Soo (Forestry Sciences, Kwangwon University)
  • 이광수 (을지대학교 의과대학 의료경영학과) ;
  • 이상일 (울산대학교 의과대학 예방의학교실) ;
  • 이정수 (강원대학교 산림과학대학)
  • Published : 2007.09.30
Download PDF
⟨ Previous Next ⟩

Abstract

The purpose of this study was to analyze whether nonemergency, isolated coronary artery bypass graft (CABG) surgery for high- or low-risk patients biases the assessment of the risk-adjusted mortality rates of hospitals. This study used 2002 National Health Insurance claims data for tertiary hospitals in Korea. The study sample consisted of 1,959 patients from 23 tertiary hospitals. The risk-adjustment model used the patients' biological, admission, and comorbidity data identified in the claims. The subjects were classified into high- and low-risk groups based on predicted surgical risk. The crude mortality rates and risk-adjusted mortality rates for low-risk, high-risk, and all patients in a hospital were compared based on the rank and the four intervals defined by quartile. Also, the crude mortality rates of the three groups were compared with their 95% confidence intervals of predicted mortality rates. The C-statistic (0.83) and Hosmer-Lemeshow test ($X^2$=11.47, p=0.18) indicated that the risk-adjustment model performed well. Presenting crude mortality rates with their 95% confidence intervals of predicted rates showed higher agreements among the three groups than using the rank or intervals of mortality rates defined by quartile in the hospital performance assessment. The crude mortality rates for the low-risk patients in 21 of the 23 hospitals were located on the same side of their 95% confidence intervals compared to that for all patients. High-risk patients and all patients differed at only one hospital. In conclusion, the impact of risk selection by hospital on the assessment results was the smallest when comparing the crude inpatient mortality rates of CABG patients with the 95% confidence intervals of predicted mortality rates. Given the increasing importance of quality improvements in Korean health policy, it will be necessary to use the appropriate method of releasing the hospital performance data to the public to minimize any unwanted impact such as risk-based hospital selection.

Keywords

References

  1. 건강보험심사평가원. 허혈성심장(관상동맥)질환급여적정성평가결과. 서울: 2005
  2. 권영대,안형식,신영수. 관상동맥우회술의 중증도 측정과 병원 사망률 비교에 관한 연구,예방의학회지 2001; 34(3):244-252
  3. 김윤. 우리나라 평가결과에 따른 가감지급의 적용방안. 요양급여 적정성 평가결과 활용을 위한 심포지움. 건강보험심사평가원;서울: 2005
  4. 박형근, 안형식, 권영대, 신유철, 이진석, 김해준. 관상동맥우회술 수술환자의 수술 후 사망률 예측 모형의 개발. 예방의학회지 2001; 34(1):21-27
  5. 윤석준, 안형식, 이상일, 이준영, 박형근, 서현주. 진료결과에 대한 위험도 보정방법 개발에 대한연구. 서울:건강보험심사평가원; 2004
  6. 이광수, 이상일. 관상동맥우회술 환자의 위험도에 따른 수술량과 병원내 사망의 관련성, 예방의학회지 2006; 39(1):13-20
  7. AHRQ Quality Indicators-Guide to Inpatient Quality Indicators: Quality of Care in Hospitals-Volume, Mortality, and Utilization. Rockville, MD: Agency for Healthcare Research and Quality, AHRQ Pub. No. 02-R0204; 2002
  8. Altman DG. Practical Statistics for Medical Research. London England: Chapman and Hall: 1991
  9. Dzuiban SW, Mcllduff JB, Miller SJ, Dal Col RH. How a New York State cardiac surgery program uses outcomes data. Ann Thorac Surg 1994; 58:1871-1876 https://doi.org/10.1016/0003-4975(94)91730-2
  10. Freeman T. Using performance indicators to improve health care quality in the public sector: a review of the literature. Health Services Management Research 2002; 15: 126-137 https://doi.org/10.1258/0951484021912897
  11. Glance LG, Dick AW, Mukamel DB, Osler TM. Is the hospital volume-mortality relationship in coronary artery bypass surgery the same for low-risk versus high-risk patients? Ann Thorac Surg 2003; 76: 1155-1162 https://doi.org/10.1016/S0003-4975(03)00114-0
  12. Hannan EL, Kilburn H, Bernard H, O'donnell JF, Lukacik G, Shields EP. Coronary artery bypass surgery: the relationship between inhospital mortality rate and surgical volume after controlling for clinical risk factors. Med Care 1991; 29(11): 1094-1107 https://doi.org/10.1097/00005650-199111000-00003
  13. Hannan EL, Kilburn H, Lindsey ML, Lewis R. Clinical versus administrative data base for CABG surgery. Med Care 1992; 30(10): 892-907 https://doi.org/10.1097/00005650-199210000-00002
  14. Hannan EL, O'Donnell JF, Kilburn H Jr, Bernard HR, Yazici A. Investigation of the relationship between volume and mortality for surgical procedures performed in New York State. JAMA 1989; 7: 503-510
  15. Hannan EL, Siu AL, Kumar D, Hacz M, Pryor DB, Chassin MR. Assessment of coronary artery bypass graft surgery performance in New York. Is there a bias against taking high-risk patients? Med Care 1997; 35(1):49-56 https://doi.org/10.1097/00005650-199701000-00004
  16. Iezzoni LI. Risk adjustment for measuring healthcare outcomes, 2nd ed. Chicago, Illinois: Health Administration Press: 1997a, 349
  17. Iezzoni LI. The risk of risk adjustment. JAMA 1997b; 278(9): 1600-1607 https://doi.org/10.1001/jama.278.19.1600
  18. Nallamothu BK, Saint S, Ramsey SD, Hofer TP, Vijan S, Eagle KS. The role of hospital volume in coronary artery bypass grafting: is more always better? J Am Coll Cardio 2001; 38(7):1923-1930 https://doi.org/10.1016/S0735-1097(01)01647-3
  19. Park HK, Yoon SJ, Ahn HS, Ahn LS, Sea HJ, Lee SI, Lee KS. Comparison of risk-adjustment models using administrative or clinical data for outcome prediction in patients after myocardial infarction or coronary bypass surgery in Korea. Int J Clin Pract 2007; 61(7): 1086-1090 https://doi.org/10.1111/j.1742-1241.2007.01345.x
  20. Pennsylvania Health Care Cost Containment. Coronary Artery Bypass Graft Surgery-1945-95 Data Research Methods and Results. 1998
  21. Peterson ED, Coombs LP, Delong ER, Haan CK, Ferguson TB. Procedural volume as a market of quality for CABG Surgery. JAMA 2004; 291(2): 195-201 https://doi.org/10.1001/jama.291.2.195
  22. Quan H, Parsons GA, Ghali WA. Validity of information on comorbidity derived from ICD-9-CM administrative data. Med Care, 2002; 40(8); 675-685 https://doi.org/10.1097/00005650-200208000-00007
  23. Rathore SS, Epstein AJ, Volpp KG, Krumholz HM. Hospital coronary artery bypass graft surgery volume and patient mortality, 1998-2000. Ann Surg 2004; 239(1): 110-117 https://doi.org/10.1097/01.sla.0000103066.22732.b8
  24. Roos LL, Stranc L, James RC, Li J. Complications, comorbidities, and mortality: improving classification and prediction. Health Serv Res 1997: 32(2); 239-242
  25. Rosenthal GE, Vaughan Sarrazin M, Hannan EL. In-hospital mortality following coronary artery bypass graft surgery in veterans health administration and private sector hospitals. Med Care 2003; 41(4): 522-535 https://doi.org/10.1097/00005650-200304000-00008
  26. Schiff RI, Ansell DA, Schlosser JE, Idris AH, Morrison A. Whitman S. Transfers to a public hospital: a prospective study of 467 patients. N Engl J Med 1986; 314(9):552-7 https://doi.org/10.1056/NEJM198602273140905
  27. Tu JV, Sykora K, Naylor CD. Assessing the outcomes of coronary artery bypass graft surgery: how many risk factors are enough? J Am Coll Cardio 1997; 30(5): 1317-1323 https://doi.org/10.1016/S0735-1097(97)00295-7
  28. Vaughan-Sarrazin MS, Hannan EL, Gormley CJ, Rosenthal GE. Mortality in medicare beneficiaries following coronary artery bypass graft surgery in States with and without certificate of need. JAMA 2002; 288(15): 1859-1866 https://doi.org/10.1001/jama.288.15.1859