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Invited Commentary
December 20, 2019

Getting Better at Measuring Hospital Mortality

Author Affiliations
  • 1The Joint Commission, Oakbrook Terrace, Illinois
JAMA Intern Med. 2020;180(3):355-356. doi:10.1001/jamainternmed.2019.6574

The call for quality measurement to focus on outcomes rather than care processes is loud and persistent. However, robust consideration of problems with the validity of outcome measures is often lacking. In this issue of JAMA Internal Medicine, Silva and colleagues1 make an important contribution to that discussion. They used data from the Veterans Health Administration to examine trends in mortality 30 days following hospital admission for veterans with heart failure or pneumonia. Risk-adjustment models that used only comorbidity data to assess risk of death overestimated declines in risk-adjusted mortality compared with models that used measures of severity of illness. This finding is important by itself, but it also has broader ramifications.

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    1 Comment for this article
    Outcomes Based Medicine
    George Anstadt, MD | U of Rochester
    Mark Chassin’s excellent commentary recognizes high quality patient outcomes as the gold standard of good medical practice. He shares well-reasoned criteria for good outcome measures, including relevance to practice, accuracy, and valid risk adjustment. He draws attention to the shortcomings of claims-based comorbidity as the basis for risk adjustment, and convincingly recommends severity adjustment. Hence, the importance of “Getting Better at Measuring Hospital Mortality” may be larger than either the authors or reviewer have envisioned. This better methodology can reach beyond the hospital, and be game changing; outcome measures that we all trust for fair assessment of the quality of physician work can unite medicine around value creation (good patient outcomes per dollar of care). Informatics systems are now capable of affordably using this better methodology to provide each of us with this improved data. The better the outcomes data, the more we can learn, and improve. Outcomes based medicine can set us free from the current reimbursement system, which is based on the volume of care provided in accordance with process measures of quality; this billing clerk arbitrated system is both a cost and quality failure. Properly risk- and- severity adjusted outcomes measurement of promise to:
    • return practice decision autonomy to physicians;
    • document our value to both our customers and patients;
    • increase our speed of practice improvement, as we learn from our data; and, if we accept reimbursement based on the value we create,
    • inform a transparent, value-based revenue stream that allows each doctor to profit from creating new value in the vast space beyond guidelines medicine.