Comparison of US accredited and nonaccredited

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1 International Journal for Quality in Health Care 2009; Volume 21, Number 2: pp Advance Access Publication: 4 February 2009 Comparison of US accredited and nonaccredited rural critical access hospitals M. NAWAL LUTFIYYA, AMRITA SIKKA, SONA MEHTA AND MARTIN S. LIPSKY Department of Family and Community Medicine, University of Illinois Chicago, College of Medicine at Rockford, Rockford, IL 61107, USA /intqhc/mzp003 Abstract Background. US critical access hospitals play an integral role in rural healthcare. Accreditation may be helpful in assuring that these hospitals provide high-quality care. Objective. To determine whether quality measures used in the US Centers for Medicare and Medicaid Services Hospital Compare database differed for critical access hospitals based on Joint Commission on Accreditation of Healthcare Organizations accreditation status. Research design. Cross-sectional with t-test statistics computed on weighted data to ascertain statistically significant differences (P 0.01). Main outcome measure. Differences between accredited and non-accredited rural critical access hospitals on quality care indicators related to acute myocardial infarction, heart failure, pneumonia and surgical infection. Subjects. US critical access hospitals. Results. The differences between accredited and non-accredited rural critical access hospitals for 4 out of 16 hospital quality indicators were statistically significant (P 0.01) and favored accredited hospitals. Also, accredited hospitals were more likely to rank in the top half of hospitals for 6 of the 16 quality measures. Conclusions. The results indicate that in the setting of critical access hospitals, external accreditation appears to result in modestly better performance. Keywords: hospital accreditation and quality care, quality indicators, critical access hospitals, US rural hospital care, disparities in hospital care Introduction The quality and access to healthcare varies widely in the USA [1, 2]. For the 20% of US residents living in rural settings, access to quality health care often depends on a critical access hospital [3]. These small hospitals have less than 25 beds, often function as the primary source of health care for a region and may even be the sole provider for a community s Medicare and Medicaid beneficiaries and uninsured individuals [4]. Their integral role in rural healthcare delivery makes it important for these hospitals to provide quality care. External monitoring, which offers an unbiased assessment of internal mechanisms and provides benchmarks for an organization, is one way to help assure quality care. Accreditation is one important external measure, and among the hospital accrediting organizations in the USA, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is the most widely recognized [5]. JCAHO is an independent, non-profit organization that conducts quality assessments in 80% of hospitals in the USA [6, 7]. Its stated mission is to improve the safety and quality of care through evaluation and accreditation of healthcare organizations [6, 7]. In seeking JCAHO accreditation, a hospital agrees to be measured against a consistent and objective set of standards in areas such as patient assessment and care, patients rights, human resources, organizational leadership, clinical ethics, management and information management. Factors such as size, case mix, ownership and cost can influence a hospital s decision to seek JCAHO accreditation. Cost is perhaps the key factor for a critical access hospital [8]. Given their limited resources, it is not surprising that there is a substantial difference in accreditation rates between urban and rural hospitals. More than 95% of urban hospitals Address reprint requests to: M. Nawal Lutfiyya, Department of Family and Community Medicine, University of Illinois Chicago, College of Medicine at Rockford, Rockford, IL 61107, USA. Tel: þ ; Fax: þ ; lutfiyya@uic.edu International Journal for Quality in Health Care vol. 21 no. 2 # The Author Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved 112

2 Accreditation and quality care are JCAHO accredited compared with 35% of critical access hospitals. Studies examining the link between accreditation status and quality reveal mixed results. One study concluded that while JCAHO accreditation correlated with a higher quality of care for acute myocardial infarction (AMI) and lower 30-day mortality rates, accreditation levels were of limited value in differentiating quality among surveyed hospitals [6]. Other studies fail to establish a correlation between accreditation scores and outcome measures such as mortality index, cost per case and length of stay [7] or demonstrate only a weak correlation between JCAHO scores and inpatient quality indicators [6, 9, 10]. In contrast, Longo et al. identified JCAHO accreditation as a key predictor for implementing patient safety initiatives [11]. However, many studies are limited because they examined only a single disease state or focused on larger non-rural hospitals, providing little insight into the association of JCAHO accreditation with the quality of healthcare at rural hospitals. This study sought to determine whether the process measures used in the US Centers for Medicare and Medicaid Services (CMS) Hospital Compare database differed for critical access hospitals based on accreditation status. The Hospital Compare website is a tool used by the Hospital Quality Alliance to convey information about quality to the public. The results should provide one objective assessment of whether there is a link between JCAHO accreditation and the quality of care provided by a critical access hospital and insight into how well the JCAHO process meets its mission to improve safety and quality of care in the setting of smaller rural hospitals. Methods Context This study used the Hospital Compare database to examine the critical access hospital outcome measures by accreditation status (accredited versus non-accredited). These data are collected by the CMS along with the Hospital Quality Alliance. The Hospital Quality Alliance is a public private collaboration of several organizations including: the American Medical Association, Blue Cross and Blue Shield Association, National Business Coalition on Health and the JCAHO. By recording and making certain hospital quality measures publicly available, the Hospital Quality Alliance hopes to encourage hospitals to improve their quality of care [12]. Study design This was a cross-sectional study examining secondary data from the 45 US states with at least one critical access hospital that submitted data to the Hospital Compare database. The study was approved by the University of Illinois Chicago, College of Medicine at Rockford s Institutional Review Board. Population and sample (hospitals/patients) In March 2006, there were roughly 1300 critical access hospitals in the USA. The study analyzed data from all 730 critical access hospitals that reported to Hospital Compare a 56% participation rate [13]. All critical access hospitals coded as accredited in the Hospital Compare database were contacted to confirm their JCAHO accreditation. The 16 quality measure variables included in this analysis encompassed data from a total of patients. Variables Table 1 displays the quality indicators available from the website. The indicators include eight AMI/heart attack care measures, four measures related to heart failure care, six pneumonia care measures and two measures related to surgical infection prevention. Because of inadequate amounts of data, four quality measures with less than 2000 cases reported for each measure were not included in the study. The discarded measures were: (i) the use of an angiotensinconverting enzyme (ACE) inhibitor for left ventricular systolic dysfunction (LVSD), (ii) whether patients received percutaneous coronary intervention (PCI) within 2 h of hospital arrival for an AMI, (iii) the delivery of smoking cessation counseling for patients experiencing an AMI and (iv) whether patients received a thrombolytic agent within 30 min of hospital arrival for a heart attack. Data collection methods Both large, urban acute care hospitals [13] and small, remote critical access hospitals voluntarily provide data to Hospital Compare [14, 15]. Starting with 2004 discharges, eligible urban acute care hospitals received an incentive payment if they reported on a starter set of 10 initial quality performance measures and agreed to make this information publicly available [16]. In contrast, critical access hospitals were not eligible for a financial incentive but voluntarily choose to report on one or more of the 20 performance measures and whether to make their data publicly available. Statistical analysis Data from the Hospital Compare website were exported into a customized database for analysis using Statistical Package for Social Scientists (version 16.0, Chicago, IL, USA). The data were aggregated by accreditation status accredited versus non-accredited and then aggregated by each hospital quality indicator combining all states. All observations were weighted in proportion to the total number of eligible patients for a specific indicator to account for the differences in eligible patients for each indicator. The weighting variable was determined by dividing the total number of eligible patients for a specific indicator in an individual hospital by the mean sample size for the indicator. After applying the weighting variable, a two-tailed t-test for independent samples was computed for each hospital quality indicator to compare the accredited versus non-accredited critical access hospitals. Statistical significance was set at an a of To further explore the relationship between accreditation status and the quality indicators, we examined how an individual 113

3 Lutfiyya et al. Table 1 Hospital quality indicators Condition Measure Number of patients eligible for quality indicator Number of patients receiving quality indicator Included in analysis... AMI ACE inhibitor or angiotensin-receptor No blocker (ARB) for LVSD AMI Aspirin at arrival Yes AMI Aspirin at discharge Yes AMI b-blocker at arrival Yes AMI b-blocker at discharge Yes AMI PCI received within 120 min of hospital 0 0 No arrival AMI Smoking cessation No AMI Thrombolytic agent received within 30 min No of hospital arrival Heart failure ACE inhibitor or ARB for LVSD Yes Left ventricular function assessment Yes Comprehensive discharge instructions Yes Smoking cessation Yes Pneumonia Pneumococcal vaccination status Yes Pneumonia Initial antibiotic received within 4 h of Yes hospital arrival Pneumonia Oxygenation assessment Yes Pneumonia Smoking cessation Yes Pneumonia Appropriate initial antibiotic selection Yes Pneumonia Blood culture performed before first Yes antibiotic received Surgical infection Prophylactic antibiotic received within 1 h Yes prevention prior to surgical incision Surgical infection prevention Prophylactic antibiotics discontinued within 24 h after surgery end time Yes 2006 US Department of Health and Human Services Hospital Quality Indicators for AMI, heart failure, pneumonia and surgical infection prevention. hospital scored on each quality measure and determined the likelihood of whether a hospital was placed in the top or bottom half for the measure by accreditation status. In addition, a composite quality score was calculated for each hospital by assigning an individual hospital four points each time they scored in the top quartile for a measure, three points for placing in the next quartile and then two or one point for the following other quartiles. We added the scores received for each quality measure on which the hospital provided data to determine the composite quality indicator score. Unadjusted odds ratios (ORs) were then calculated for each quality indicator for top or bottom half placement by accreditation status. The same was calculated for the composite quality indicator score. Results Of the 730 critical access hospitals studied, 72% (525) were non-accredited, while 28% (205) were JCAHO accredited. The number of critical access hospitals by state ranged from 1 in Alaska to 55 in Iowa. Table 2 presents the comparison of aggregated hospital quality indicators by hospital accreditation status. For 4 of the 16 hospital quality indictors, the differences between non-accredited and accredited hospitals were statistically significant (P 0.01). All four favored the accredited hospitals and included indicators for AMI, heart failure and pneumonia. While Hospital Compare sets the target for all quality measures at 100%, accredited hospitals scored above 90% in only two instances: the percent of AMI patients given aspirin at arrival and percent of pneumonia patients assessed for oxygenation. Non-accredited hospitals scored above 90% only in the percent of pneumonia patients assessed for oxygenation. Of the four AMI quality measures, patients in the accredited hospital were more likely to receive aspirin upon arrival. For the other three quality indicators, the percent of individuals at the non-accredited hospitals was higher for receiving aspirin at discharge, a b-blocker at arrival and a b-blocker at discharge, but these differences did not achieve statistical significance. Patients with heart failure were significantly more likely to be given an ACE inhibitor at an 114

4 Accreditation and quality care Table 2 Comparison of hospital quality indicators by hospital accreditation status Quality indicator Non-accredited hospitals (aggregated patients) Accredited hospitals (aggregated patients) % Number of cases % Number of cases % Difference between non-accredited and accredited hospitals a (99% CI)... AMI: percent of patients given aspirin at arrival AMI: percent of patients given aspirin at discharge AMI: percent of patients given b-blocker at arrival AMI: percent of patients given b-blocker at discharge Heart failure: percent of patients given ACE inhibitor for LVSD Heart failure: percent of patients given assessment of left ventricular function Heart failure: comprehensive discharge instructions Heart failure: percent of patients given adult smoking cessation advice/counseling Pneumonia: percent of patients aged 65 and older who were screened for pneumococcal vaccine status and administered the vaccine prior to discharge, if indicated Pneumonia: percent of inpatients who receive their first dose of antibiotic within 4 h of arrival to the hospital Pneumonia: percent of patients who had an assessment of arterial oxygenation by arterial blood gas measurement or pulse oximetry within 24 h prior to or after arrival at the hospital Pneumonia: percent of patients with a history of smoking cigarettes, who were given smoking cessation advice or counseling during a hospital stay Pneumonia: appropriate initial antibiotic selection Pneumonia: blood culture performed before first antibiotic received Surgical infection prevention: prophylactic antibiotic received within 1 h prior to surgical incision Surgical infection prevention: prophylactic antibiotics discontinued within 24 h after surgery end time (25.74, 20.11) b (22.81, 4.89) (21.23, 6.88) (22.51, 5.35) (28.36, 21.15) b (27.96, 1.02) (27.12, 4.47) (217.02, 25.00) b (23.81, 5.62) (20.03, 3.63) (20.26, 0.64) (211.20, 20.98) b (24.32, 1.05) (22.58, 1.34) (24.67, 3.97) (21.17, 8.36) 2006 US Department of Health and Human Services Hospital Quality Indicators for AMI, heart failure, pneumonia and surgical infection prevention. a Differences may not be exact due to rounding. b Results statistically significant. 115

5 Lutfiyya et al. Table 3 Likelihood of top half/bottom half placement by accreditation status and quality indicator Quality indicator... AMI: percent of patients given aspirin at arrival AMI: percent of patients given aspirin at discharge AMI: percent of patients given b-blocker at arrival AMI: percent of patients given b-blocker at discharge Heart failure: percent of patients given ACE inhibitor for LVSD Heart failure: percent of patients given assessment of left ventricular function Heart failure: comprehensive discharge instructions Heart failure: percent of patients given adult smoking cessation advice/counseling Pneumonia: percent of patients aged 65 and older who were screened for pneumococcal vaccine status and administered the vaccine prior to discharge, if indicated Pneumonia: percent of inpatients who receive their first dose of antibiotic within 4 h of arrival to the hospital Pneumonia: percent of patients who had an assessment of arterial oxygenation by arterial blood gas measurement or pulse oximetry within 24 h prior to or after arrival at the hospital Pneumonia: percent of patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during a hospital stay Pneumonia: appropriate initial antibiotic selection Pneumonia: blood culture performed before first antibiotic received Surgical infection prevention: prophylactic antibiotic received within 1 h prior to surgical incision Surgical infection prevention: prophylactic antibiotics discontinued within 24 h after surgery end time Cumulative quality indicator score accredited hospital and to receive smoking cessation advice or counseling. However, both groups performed equally poorly on the measure regarding comprehensive discharge instructions for patients with heart failure. Accredited hospitals also performed significantly better than non-accredited hospitals regarding smoking cessation advice or counseling to pneumonia patients with a history of tobacco use. However, neither group of hospitals scored well. Both groups also performed poorly in screening for and administering pneumococcal vaccines as required. Differences in the two surgical infection prevention measures were not significant. Table 3 displays the OR generated by a bivariate analysis of placement in the top rather than bottom half of a quality measure by accreditation status. For six quality indicators, accredited hospitals were more likely to place in the top half compared with non-accredited hospitals. These indicators were: percent of patients given aspirin at arrival (OR 1.39, 95% CI ), percent of patients given ACE inhibitor for LVSD (OR 1.29, 95% CI ), percent of patients given assessment of left ventricular function (OR 1.50, 95% CI ), percent of patients given comprehensive discharge instructions (OR 1.65, 95% CI ), percent of patients aged 65 and older who were screened for pneumococcal vaccine status and administered the vaccine prior to discharge, if indicated (OR 1.96, 95% CI ) and percent of patients given appropriate initial antibiotic selection (OR 1.56, 95% CI ). The OR for the composite quality score was also statistically significant with accredited hospitals 40% (OR 1.39, 95% CI ) more likely to score in the top rather than bottom half. Discussion Unadjusted ORs (95% CI) 1.39 ( ) a 1.12 ( ) b 1.05 ( ) b 1.05 ( ) b 1.29 ( ) a 1.50 ( ) a 1.65 ( ) a 1.26 ( ) b 1.96 ( ) a 1.20 ( ) b 1.02 ( ) b 1.07 ( ) b 1.56 ( ) a 1.21 ( ) b 1.03 ( ) b 1.00 ( ) b 1.39 ( ) a 2006 US Department of Health and Human Services Hospital Quality Indicators for AMI, heart failure, pneumonia and surgical infection prevention. a Likelihood of top half placement statistically significant favoring accredited critical access hospitals. b Statistically insignificant. This study found that accredited critical access hospitals performed better on 4 of 16 Hospital Compare database quality indicators than non-accredited critical access hospitals. Of note, the indicators that differed significantly between the two groups, such as aspirin administration for AMI should be within the scope of services provided by critical access hospitals. Among the remaining indicators, accredited critical access hospitals scored better on some measures and worse on others, but no other difference achieved statistical significance. Overall, critical access hospitals scored below 90% for most measures, suggesting opportunities for improvement regardless of accreditation status. In addition to single measures, examining hospital performance is another way of evaluating a link between quality scores and JCAHO certification [17]. Our findings indicated that JCAHO accredited critical access hospitals were more likely to be in the upper half of critical access hospitals for compliance 116

6 Accreditation and quality care with 6 of the 16 Hospital Compare measures, while nonaccredited hospitals did not score in the upper half for any measure. While our findings suggest a modest benefit associated with accreditation, the differences in the Hospital Compare measures should be interpreted cautiously and in the context of a rural setting. Some advocate that measures more relevant to rural care, such as time to transfer a patient with an AMI to a tertiary care center, or using outcomes, such as mortality rates rather than process measures like smoking cessation counseling, are better measures of quality. One study examining hospital compare measures and mortality rates predicted only small differences in adjusted mortality rates [18]. These authors concluded that efforts should be made to develop quality measures more tightly linked to specific outcomes such as mortality. It is not surprising that the Hospital Compare measures might not correlate tightly with short-term mortality, since the Hospital Compare database incorporates processes such as discharge instructions and timely administration of antibiotics, which may not be associated with a reduction in hospital mortality [19]. Also, several Hospital Compare measures are more aligned with improvement in long-term outcomes rather than short-term hospital mortality. Bradley et al. suggest that multiple measures that reflect both a variety of process and outcomes will be required to fully characterize hospital performance [20]. However, JCAHO measurements and assessment are more than static; they are designed to initiate a process for hospitals to address standard performance measures, to encourage quality improvement and in turn to improve outcomes [20]. It should be noted that the absolute differences for the measures achieving statistical significance between the accredited and non-accredited hospitals were relatively small. For example, the difference of 3% more AMI patients receiving an aspirin means that about 33 patients would need to present with an AMI before one additional patient received aspirin. However, aspirin is a low cost, low-tech treatment that reduces myocardial infarction mortality by 20 25% [21 23] and a 3% increase would result in about one less death per 150 AMI patients. Therefore, although small, this difference can be considered as having a favorable cost per year of life saved, given the low cost of administering aspirin and the combined numbers of AMI patients seen across all the critical access hospitals. Accredited hospitals were also more likely to provide smoking cessation advice or counseling to both heart failure and pneumonia patients. Since rural residents are more likely to smoke [24, 25], this should be of particular interest for critical access hospitals and is an example of how accreditation might benefit patient care. Even though accredited hospitals performed better about providing smoking cessation advice to patients with congestive heart failure and pneumonia, our findings revealed that both groups scored poorly on this quality indicator and also for screening and administering the pneumococcal vaccine to appropriate patients. JCAHO encourages hospitals to use checklists or standing orders for immunizations, both of which improve vaccination and documentation [26]. JCAHO accreditation might result in a wider use of these orders and also encourage the use of guidelines for conditions like pneumonia and AMI, which are known to improve process measures and also lead to improved clinical outcomes and 30-day mortality [27, 28]. There are several potential limitations to our study. First, the data are self-reported from hospitals and as such is subject to potential bias. Accredited hospitals may also be more likely to report to Hospital Compare in order to help maintain their accreditation status, and perhaps only those unaccredited hospitals who believe their results are good may choose to report voluntarily. Secondly, although Hospital Compare is audited to verify that the data are consistent and reproducible, only a small sample of medical records is used for this validation process and may be insufficient to assure the accuracy of the data. Thirdly, this study focuses on only four disease states, which may not reflect overall care. Nevertheless, AMI, heart failure and pneumonia are three of the most common clinical conditions encountered in an inpatient setting. It is also possible that the measures that were not included because of insufficient data might have altered the results. Fourthly, outcome measures may arguably be a better reflection of quality than the process measures used in this study. However, process measures have an advantage since the comparisons do not require adjusting for a hospital s patient mix. For instance, it is not necessary to adjust for the administration of a medicine, such as a b-blocker or aspirin, since the reporting guidelines exclude patients with contraindications. Fifthly, another potential bias is that not all critical access hospitals reported data. It is difficult to ascertain the impact this has on the generalizability of the findings. Finally, this study consisted of only US hospitals. However, the hospitals studied are small, staffed primarily with primary care physicians and typically have less advanced technology, a setting apt to compare with many rural hospitals in other countries, both developed and developing. In conclusion, our results indicate that in the setting of critical access hospitals the JCAHO accreditation process results in modestly better performance as assessed by Hospital Compare measures suggesting an association of accreditation to higher quality. However, the reasons for the differences between accredited and non-accredited critical access hospitals and how this affects the outcome for patients remain uncertain. Since cost may be a barrier for critical access hospitals to seek JCAHO accreditation, future studies looking at the cost to benefit ratio would be helpful for hospitals facing the decision whether to commit limited resources to the accreditation process. References 1. McGlynn EA, Asch SM, Adams J et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348: Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press,

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