Research

Use of In-Hospital Mortality as Sepsis Quality Metric May Unfairly Penalize Safety-Net Hospitals 

Sepsis is a leading cause of death and disability and a key target of state and federal quality measures for hospitals. In-hospital mortality of patients with sepsis is frequently measured for benchmarking, both by researchers and policymakers. Safety-net hospitals (which face unique challenges, including fewer resources to care for a disproportionately high share of underinsured and high-risk patients) have been reported in prior studies to have higher risk-adjusted in-hospital mortality among patients with sepsis than nonsafety-net hospitals. 

However, among critically ill patients, in-hospital mortality may not adequately reflect short-term mortality fairly across all hospitals. In-hospital mortality is influenced by other variables, including hospital transfer practices, that shift the attribution of short-term death from the hospital to other sites. Safety-net hospitals may have different access or ability to transfer patients compared to nonsafety-net hospitals. 

In a study published in JAMA Network Open, BU researchers found that safety-net hospitals have higher in-hospital mortality than nonsafety-net hospitals, but their 30-day mortality—an unbiased measure of short-term mortality—is not different. 

“While the differences in mortality rates are numerically small, the difference in outcome metrics is enough to significantly affect hospital rankings. Current or future state and federal quality measures that use in-hospital mortality as a quality metric may unfairly penalize safety-net hospitals,” explains corresponding author Anica Law, MD, MS, assistant professor of medicine. 

The researchers performed a retrospective analysis of patients with sepsis who were age 66 and older and were admitted to an intensive care unit between January 1, 2011, and December 31, 2019, at both safety and nonsafety-net hospitals. 

“Although in-hospital mortality is often selected as an outcome measure because of its availability in claims databases and hospital medical records without need for post-hospitalization follow-up, the 30-day measure is important to accurately understand true short-term mortality rates,” Law says.