The Effect of Intensive Care Unit Admission Patterns on Mortality-based Critical Care Performance Measures

Rationale: Current mortality-based critical care performance measurement focuses on intensive care unit (ICU) admissions as a single group, conflating low-severity and high-severity ICU patients for whom performance may differ and neglecting severely ill patients treated solely on hospital wards. Objectives: To assess the relationship between hospital performance as measured by risk-standardized mortality for severely ill ICU patients, less severely ill ICU patients, and severely ill patients outside the ICU. Methods: Using a state wide, all-payer dataset from the Pennsylvania Healthcare Cost Containment Council, we analyzed discharge data for patients with nine clinical conditions with frequent ICU use. Using a validated severity-of-illness measure, we categorized hospitalized patients as either high severity (predicted probability of in-hospital death in top quartile) or low severity (all others). We then created three mutually exclusive groups: high-severity ICU admissions, low-severity ICU admissions, and high-severityward patients. We used hierarchical logistic regression to generate hospital-specific 30-day risk standardized mortality rates for each group and then compared hospital performance across groups using Spearman's rank correlation. Measurements and Main Results: We analyzed 87 hospitals with 22,734 low-severity ICU admissions (mean per hospital, 261 +/- 187), 10,991 high-severity ICU admissions (mean per hospital, 126 +/- 105), and 6,636 high-severity ward patients (mean per hospital, 76 +/- 48). We found little correlation between hospital performance for high-severity ICU patients versus low-severity ICU patients (r = 0.15; P = 0.17). There were 29 hospitals (33%) that moved up or down at least two quartiles of performance across the ICU groups. There was weak correlation between hospital performance for high severity ICU patients versus high-severity ward patients (r = 0.25; P = 0.02). There were 24 hospitals (28%) that moved up or down at least two quartiles of performance across the high-severity groups. Conclusions: Hospitals that perform well in caring for highseverity ICU patients do not necessarily also perform well in caring for low-severity ICU patients or high-severity ward patients, indicating that risk-standardized mortality rates for ICU admissions as a whole offer only a narrow window on a hospital's overall performance for critically ill patients.