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A 30-Day Mortality Rate Mystery

Tinker Ready, for HealthLeaders Media, April 24, 2014

Daily death rates for cardiac surgery patients in one large study jumped at the 30-day mark. Was it because physicians were treating the performance measure instead of the patient? What are the unintended consequences of quality of care and performance measures, anyway?

Cheryl Clark is on vacation.

From time to time, Bryan Maxwell, MD, hears colleagues jokingly remark that a decision about a patient's care will have to wait 30 days, as in the 30-day mortality rate, a standard quality of care measure.

Maxwell, an anesthesiologist and critical care specialist at Johns Hopkins, says he has begun to wonder whether these doctors are only half joking. Are they making care decisions based on the needs of the patients? Or is clinical care being guided by the push to meet performance measures?

"I became interested in looking at it because in anecdotal, informal, unofficial, conversations with people, that idea would come up that way," says Maxwell. In a study published in Health Services Research, he and his team found daily death rates for about 600,000 cardiac surgery patients jumped at the 30-day mark.

Maxwell, then at Stanford University and now at Johns Hopkins, concluded that "the abrupt increase in mortality at day 30 has no clear organic etiology. This analysis raises the possibility that this observed shift may be related to clinician behavior because of the use of 30-day mortality as a quality metric, but further studies will be required to establish causality."

No one disagrees on the need for more research. But some bristle at the notion that the 30-day mortality rate could be a death panel in reverse.

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