Effect of public reporting on intensive care unit discharge destination and outcomes

Abstract

Rationale: Public reporting of hospital performance is designed to improve healthcare outcomes by promoting quality improvement and informing consumer choice, but these programs may carry unintended consequences.

Objective: To determine whether publicly reporting in-hospital mortality rates for intensive care unit (ICU) patients influenced discharge patterns or mortality.

Methods: We performed a retrospective cohort study taking advantage of a natural experiment in which California, but not other states, publicly reported hospital-specific severity-adjusted ICU mortality rates between 2007 and 2012. We used multivariable logistic regression adjusted for patient, hospital, and regional characteristics to compare mortality rates and discharge patterns between California and states without public reporting for Medicare fee-for-service ICU admissions from 2005 through 2009 using a difference-in-differences approach.

Measurements and main results: We assessed discharge patterns using post-acute care use and acute care hospital transfer rates and mortality using in-hospital and 30-day mortality rates. The study cohort included 936,063 patients admitted to 646 hospitals. Compared with control subjects, admission to a California ICU after the introduction of public reporting was associated with a reduced odds of post-acute care use in post-reform year 2 (ratio of odds ratios [ORs], 0.94; 95% confidence interval [CI], 0.91-0.96) and increased odds of transfer to another acute care hospital in both post-reform years (year 1: ratio of ORs, 1.08; 95% CI, 1.01-1.16; year 2: ratio of ORs, 1.43; 95% CI, 1.33-1.53). There were no significant differences in in-hospital or 30-day mortality.

Conclusions: Public reporting of ICU in-hospital mortality rates was associated with changes in discharge patterns but no change in risk-adjusted mortality.

Keywords: health policy; intensive care; mortality.

Figure 1.

Patient sample.

Figure 2.

Adjusted mortality and discharge patterns in California compared with control hospitals by year. (A) In-hospital mortality. (B) 30-day mortality. (C) Post-acute care use rates. (D) Acute care hospital transfer rates. Error bars represent the 95% confidence intervals.