Using severity-adjusted stroke mortality rates to judge hospitals.

Mortality rates are commonly used to judge hospital performance. In comparing death rates across hospitals, it is important to control for differences in patient severity. Various severity tools are now actively marketed in the United States. This study asked whether one would identify different hospitals as having higher- or lower-than-expected death rates using different severity measures. We applied 11 widely-used severity measures to the same database containing 9407 medically-treated stroke patients from 94 hospitals, with 916 (9.7%) in-hospital deaths. Unadjusted hospital mortality rates ranged from 0 to 24.4%. For 27 hospitals, observed mortality rates differed significantly from expected rates when judged by one or more, but not all 11, severity methods. The agreement between pairs of severity methods for identifying the worst 10% or best 50% of hospitals was fair to good. Efforts to evaluate hospital performance based on severity-adjusted, in-hospital death rates for stroke patients are likely to be sensitive to how severity is measured.