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Results of Report Cards for Patients with Congestive Heart Failure Depend on the Method Used To Adjust for Severity

Roy M. Poses, MD; Donna K. McClish, PhD; Wally R. Smith, MD; Elizabeth C. Huber, MD; F. Lynne W. Clemo, MD; Brian P. Schmitt, MD; Donna Alexander, PhD; Edward M. Racht, MD; and Christopher C. Colenda III, MD
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Copyright ©2004 by the American College of Physicians


Ann Intern Med. 2000;133(1):10-20. doi:10.7326/0003-4819-133-1-200007040-00003
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Background: The validity of outcome report cards may depend on the ways in which they are adjusted for risk.

Objectives: To compare the predictive ability of generic and disease-specific survival prediction models appropriate for use in patients with heart failure, to simulate outcome report cards by comparing survival across hospitals and adjusting for severity of illness using these models, and to assess the ways in which the results of these comparisons depend on the adjustment method.

Design: Analysis of data from a prospective cohort study.

Setting: A university hospital, a Veterans Affairs (VA) medical center, and a community hospital.

Patients: Sequential patients presenting in the emergency department with acute congestive heart failure.

Measurements: Unadjusted 30-day and 1-year mortality across hospitals and 30-day and 1-year mortality adjusted by using disease-specific survival prediction models (two sickness-at-admission models, the Cleveland Health Quality Choice model, the Congestive Heart Failure Mortality Time-Independent Predictive Instrument) and generic models (Acute Physiology and Chronic Health Evaluation [APACHE] II, APACHE III, the mortality prediction model, and the Charlson comorbidity index).

Results: The community hospital's unadjusted 30-day survival rate (85.0%) and the VA medical center's unadjusted 1-year survival rate (60.9%) were significantly lower than corresponding rates at the university hospital (92.7% and 67.5%, respectively). No severity model had excellent ability to discriminate patients by survival rates (all areas under the receiver-operating characteristic curve < 0.73). Whether the VA medical center, the community hospital, both, or neither had worse survival rates on simulated report cards than the university hospital depended on the prediction model used for adjustment.

Conclusions: Results of simulated outcome report cards for survival in patients with congestive heart failure depend on the method used to adjust for severity.

Figures

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Figure 2.
Results of simulated report cards for 30-day survival after exclusion of patients who were not hospitalized.SA-30SA-180CHQCCHFM-TIPIAPACHEMPM 0 CCIP

Lines with squares represent the university hospital, lines with triangles represent the Veterans Affairs (VA) medical center, and lines with crosses represent the community hospital. The university hospital and the VA medical center differed significantly for survival adjusted by the sickness-at-admission (30-day survival) ( ) model; the sickness-at-admission (180-day survival) ( ) model; the Cleveland Health Quality Choice ( ) model; the Congestive Heart Failure Mortality Time-Insensitive Predictive Instrument ( ); Acute Physiology and Chronic Health Evaluation ( ) II; APACHE III; admission mortality prediction model ( ); and Charlson comorbidity index ( ). The VA medical center and the community hospital did not differ significantly. The university hospital and the community hospital differed significantly for unadjusted survival and for survival adjusted by the SA-30 model, the SA-180 model, APACHE II, MPM, and CCI. For all comparisons,  < 0.05.

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Figure 3.
Results of simulated report cards for 1-year survival for the entire cohort.SA-30SA-180CHQCCHFM-TIPIAPACHEMPM 0 P

Lines with squares represent the university hospital, lines with triangles represent the Veterans Affairs (VA) medical center, and lines with crosses represent the community hospital. The university hospital and the VA medical center differed significantly for unadjusted survival and for survival adjusted by the sickness-at-admission (30-day survival) ( ) model; the sickness-at-admission (180-day survival) ( ) model; the Cleveland Health Quality Choice ( ) model; the Congestive Heart Failure Mortality Time-Insensitive Predictive Instrument ( ); Acute Physiology and Chronic Health Evaluation ( ) II; APACHE III; and admission mortality prediction model ( ). The VA medical center and the community hospital differed significantly for survival adjusted by APACHE III. The university hospital and the community hospital differed significantly for survival adjusted by the SA-180 model, APACHE II, and CCI. For all comparisons,  < 0.05.

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Figure 1.
Results of simulated report cards for 30-day survival for the entire cohort.SA-30APACHECCISA-180MPM 0 P

Lines with squares represent the university hospital, lines with triangles represent the Veterans Affairs (VA) medical center, and lines with crosses represent the community hospital. The university hospital and the VA medical center differed significantly for survival adjusted by the sickness-at-admission (30-day survival) ( ) model, Acute Physiology and Chronic Health Evaluation ( ) II, and APACHE III. The VA medical center and the community hospital differed significantly for survival adjusted by Charlson comorbidity index ( ). The university hospital and the community hospital differed significantly for unadjusted survival and for survival adjusted by the SA-30 model, the sickness-at-admission (180-day survival) ( ) model, APACHE II, admission mortality prediction model ( ), and CCI. For all comparisons,  < 0.05. CHFM-TIPI = Congestive Heart Failure Mortality Time-Insensitive Predictive Instrument; CHQC = Cleveland Health Quality Choice.

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