Measuring quality outcomes across hospital systems: Using a claims data model for risk adjustment of mortality rates.

Healthcare delivery systems around the world are designing care through value-based models where value is defined as a function of quality of care outcomes and cost. Mortality is a sentinel outcome measure of quality of care, of fundamental importance to patients and providers. Discovery Health (DH), an administrative funder of healthcare in South Africa (SA), uses service claims data of client medical schemes to examine standardised mortality rates (SMRs) at condition level across hospital systems for the purpose of healthcare system improvement. To accurately examine and contrast variation in condition-level SMRs across acute hospital systems, this outcome metric needs to be risk-adjusted for patient characteristics that make mortality more, or less, likely to occur. This article describes and evaluates the validity of risk-adjustment methods applied to service claims data to accurately determine SMRs across hospital systems. While service claims data may have limitations regarding case risk adjustment, it is important that we do not lose the important opportunity to use claims data as a reliable proxy to comment on the quality of care within healthcare systems. This methodology is robust in its demonstration of variation of performance on mortality outcomes across hospital systems. For the measurement period January 2014 - December 2016, the average risk-adjusted SMRs across hospital systems where DH members were hospitalised for acute myocardial infarction, stroke, pneumonia and coronary artery bypass graft procedures were 9.7%, 8.0%, 5.3% and 3.2%, respectively. This exercise of transparently examining variation in SMRs at hospital system level is the first of its kind in SA's private sector. Our methodological exercise is used to establish a local pattern of variation of SMRs in the private sector as the base off which to scrutinise reasons for variation and off which to build quality of care improvement strategies. High-performing healthcare systems must seek out opportunities for learning and continuous improvement such as those offered by examining important quality of care outcome measures across hospitals.