Missed opportunities in hospital quality measurement during the COVID-19 pandemic: a retrospective investigation of US hospitals' CMS Star Ratings and 30-day mortality during the early pandemic.

OBJECTIVES: In the USA and UK, pandemic-era outcome data have been excluded from hospital rankings and pay-for-performance programmes. We assessed the relationship between US hospitals' pre-pandemic Centers for Medicare and Medicaid Services (CMS) Overall Hospital Star ratings and early pandemic 30-day mortality among both patients with COVID and non-COVID to understand whether pre-existing structures, processes and outcomes related to quality enabled greater pandemic resiliency. DESIGN AND DATA SOURCE: A retrospective, claim-based data study using the 100% Inpatient Standard Analytic File and Medicare Beneficiary Summary File including all US Medicare Fee-for-Service inpatient encounters from 1 April 2020 to 30 November 2020 linked with the CMS Hospital Star Ratings using six-digit CMS provider IDs. OUTCOME MEASURE: The outcome was risk-adjusted 30-day mortality. We used multivariate logistic regression adjusting for age, sex, Elixhauser mortality index, US Census Region, month, hospital-specific January 2020 CMS Star rating (1-5 stars), COVID diagnosis (U07.1) and COVID diagnosis×CMS Star Rating interaction. RESULTS: We included 4 473 390 Medicare encounters from 2533 hospitals, with 92 896 (28.2%) mortalities among COVID-19 encounters and 387 029 (9.3%) mortalities among non-COVID encounters. There was significantly greater odds of mortality as CMS Star Ratings decreased, with 18% (95% CI 15% to 22%; p<0.0001), 33% (95% CI 30% to 37%; p<0.0001), 38% (95% CI 34% to 42%; p<0.0001) and 60% (95% CI 55% to 66%; p<0.0001), greater odds of COVID mortality comparing 4-star, 3-star, 2-star and 1-star hospitals (respectively) to 5-star hospitals. Among non-COVID encounters, there were 17% (95% CI 16% to 19%; p<0.0001), 24% (95% CI 23% to 26%; p<0.0001), 32% (95% CI 30% to 33%; p<0.0001) and 40% (95% CI 38% to 42%; p<0.0001) greater odds of mortality at 4-star, 3-star, 2-star and 1-star hospitals (respectively) as compared with 5-star hospitals. CONCLUSION: Our results support a need to further understand how quality outcomes were maintained during the pandemic. Valuable insights can be gained by including the reporting of risk-adjusted pandemic era hospital quality outcomes for high and low performing hospitals.

Impact of repeated hospital accreditation surveys on quality and reliability, an 8-year interrupted time series analysis.

OBJECTIVE: To evaluate whether hospital re-accreditation improves quality, patient safety and reliability over three accreditation cycles by testing the accreditation life cycle model on quality measures. DESIGN: The validity of the life cycle model was tested by calibrating interrupted time series (ITS) regression equations for 27 quality measures. The change in the variation of quality over the three accreditation cycles was evaluated using the Levene's test. SETTING: A 650-bed tertiary academic hospital in Abu Dhabi, UAE. PARTICIPANTS: Each month (over 96 months), a simple random sample of 10% of patient records was selected and audited resulting in a total of 388 800 observations from 14 500 records. INTERVENTIONS: The impact of hospital accreditation on the 27 quality measures was observed for 96 months, 1-year preaccreditation (2007) and 3 years postaccreditation for each of the three accreditation cycles (2008, 2011 and 2014). MAIN OUTCOME MEASURES: The life cycle model was evaluated by aggregating the data for 27 quality measures to produce a composite score (YC) and to fit an ITS regression equation to the unweighted monthly mean of the series. RESULTS: The results provide some evidence for the validity of the four phases of the life cycle namely, the initiation phase, the presurvey phase, the postaccreditation slump and the stagnation phase. Furthermore, the life cycle model explains 87% of the variation in quality compliance measures (R2=0.87). The best-fit ITS model contains two significant variables (ß1 and ß3) (p≤0.001). The Levene's test (p≤0.05) demonstrated a significant reduction in variation of the quality measures (YC) with subsequent accreditation cycles. CONCLUSION: The study demonstrates that accreditation has the capacity to sustain improvements over the accreditation cycle. The significant reduction in the variation of the quality measures (YC) with subsequent accreditation cycles indicates that accreditation supports the goal of high reliability.

The impact of hospital accreditation on quality measures: an interrupted time series analysis.

BACKGROUND: Developing countries frequently use hospital accreditation to guarantee quality and patient safety. However, implementation of accreditation standards is demanding on organisations. Furthermore, the empirical literature on the benefits of accreditation is sparse and this is the first empirical interrupted time series analysis designed to examine the impact of healthcare accreditation on hospital quality measures. METHODS: The study was conducted in a 150-bed multispecialty hospital in Abu Dhabi, United Arab Emirates. The quality performance outcomes were observed over a 48 month period. The quality performance differences were compared across monthly intervals between two time segments, 1 year pre- accreditation (2009) and 3 years post-accreditation (2010, 2011 and 2012) for the twenty-seven quality measures. The principal data source was a random sample of 12,000 patient records drawn from a population of 50,000 during the study period (January 2009 to December 2012). Each month (during the study period), a simple random sample of 24 percent of patient records was selected and audited, resulting in 324,000 observations. The measures (structure, process and outcome) are related to important dimensions of quality and patient safety. RESULTS: The study findings showed that preparation for the accreditation survey results in significant improvement as 74% of the measures had a significant positive pre-accreditation slope. Accreditation had a larger significant negative effect (48% of measures) than a positive effect (4%) on the post accreditation slope of performance. Similarly, accreditation had a larger significant negative change in level (26%) than a positive change in level (7%) after the accreditation survey. Moreover, accreditation had no significant impact on 11 out of the 27 measures. However, there is residual benefit from accreditation three years later with performance maintained at approximately 90%, which is 20 percentage points higher than the baseline level in 2009. CONCLUSIONS: Although there is a transient drop in performance immediately after the survey, this study shows that the improvement achieved from accreditation is maintained during the three year accreditation cycle.

The impact of hospital accreditation on clinical documentation compliance: a life cycle explanation using interrupted time series analysis.

OBJECTIVE: To evaluate whether accredited hospitals maintain quality and patient safety standards over the accreditation cycle by testing a life cycle explanation of accreditation on quality measures. Four distinct phases of the accreditation life cycle were defined based on the Joint Commission International process. Predictions concerning the time series trend of compliance during each phase were specified and tested. DESIGN: Interrupted time series (ITS) regression analysis of 23 quality and accreditation compliance measures. SETTING: A 150-bed multispecialty hospital in Abu Dhabi, UAE. PARTICIPANTS: Each month (over 48 months) a simple random sample of 24% of patient records was audited, resulting in 276,000 observations collected from 12,000 patient records, drawn from a population of 50,000. INTERVENTIONS: The impact of hospital accreditation on the 23 quality measures was observed for 48 months, 1 year preaccreditation (2009) and 3-year postaccreditation (2010-2012). MAIN OUTCOME MEASURES: The Life Cycle Model was evaluated by aggregating the data for 23 quality measures to produce a composite score (YC) and fitting an ITS regression equation to the unweighted monthly mean of the series. RESULTS: The four phases of the life cycle are as follows: the initiation phase, the presurvey phase, the postaccreditation slump phase and the stagnation phase. The Life Cycle Model explains 87% of the variation in quality compliance measures (R(2)=0.87). The ITS model not only contains three significant variables (ß1, ß2 and ß3) (p≤0.001), but also the size of the coefficients indicates that the effects of these variables are substantial (ß1=2.19, ß2=-3.95 (95% CI -6.39 to -1.51) and ß3=-2.16 (95% CI -2.52 to -1.80). CONCLUSIONS: Although there was a reduction in compliance immediately after the accreditation survey, the lack of subsequent fading in quality performance should be a reassurance to researchers, managers, clinicians and accreditors.

The impact of a fast track area on quality and effectiveness outcomes: a Middle Eastern emergency department perspective.

BACKGROUND: Emergency department (ED) overcrowding is a ubiquitous problem with serious public health implications. The fast track area is a novel method which aims to reduce waiting time, patient dissatisfaction and morbidity. |The study objective was to determine the impact of a fast track area (FTA) on both effectiveness measures (i.e. waiting times [WT] and length of stay [LOS]) and quality measures (i.e. LWBS rates and mortality rates) in non-urgent patients. The secondary objective was to assess if a FTA negatively impacted on urgent patients entering the ED. METHODS: The study took place in a 500 bed, urban, tertiary care hospital in Abu Dhabi, United Arab Emirates. This was a quasi-experimental, which examined the impact of a FTA on a pre-intervention control group (January 2005) (n = 4,779) versus a post-intervention study group (January 2006) (n = 5,706). RESULTS: Mean WTs of Canadian Triage Acuity Scale (CTAS) 4 patients decreased by 22 min (95% CI 21 min to 24 min, P < 0.001). Similarly, mean WTs of CTAS 5 patients decreased by 28 min (95% CI 19 min to 37 min, P < 0.001) post FTA. The mean WTs of urgent patients (CTAS 2/3) were also significantly reduced after the FTA was opened (P < 0.001). The LWBS rate was reduced from 4.7% to 0.7% (95% CI 3.37 to 4.64; P < 0.001). Opening a FTA had no significant impact on mortality rates (P = 0.88). CONCLUSION: The FTA improved ED effectiveness (WTs and LOS) and quality measures (LWBS rates) whereas mortality rate remained unchanged.