Relationship between discharge practices and intensive care unit in-hospital mortality performance: Evidence of a discharge bias

Context: Current intensive care unit performance measures include in-hospital mortality after intensive care unit admission. This measure does not account for deaths occurring after transfer to another hospital or soon after discharge and therefore, may be biased. Objective: Determine how transfer rates to other acute care hospitals and early post-discharge mortality rates impact hospital performance assessments using an in-hospital mortality model. DESIGN, SETTING, AND Participants: Data were retrospectively collected on 10,502 eligible intensive care unit patients across 35 California hospitals between 2001 and 2004. Measures: We calculated the rates of acute care hospital transfers and early post-discharge mortality (30-day overall mortality-30-day in-hospital mortality) for each hospital. We assessed hospital performance with standardized mortality ratios (SMRs) using the Mortality Probability Model III. Using regression models, we explored the relationship between in-hospital SMRs and the rates of hospital transfers or early post-discharge mortality. We explored the same relationship using a 30-day SMR. Results: In multivariable models, for each 1% increase in patients transferred to another acute care hospital, there was an in-hospital SMR reduction of -0.021 (-0.040-0.001). Additionally, a 1% increase in early post-discharge mortality was associated with an in-hospital SMR reduction of -0.049 (-0.142-0.045). Assessing hospital performance based upon 30-day mortality end point resulted in SMRs closer to 1.0 for hospitals at high and low ends of in-hospital mortality performance. Conclusions: Variations in transfer rates and potentially discharge timing appear to bias in-hospital SMR calculations. A 30-day mortality model is a potential alternative that may limit this bias.