Quality of care in the US territories

Abstract

Background: Health care quality in the US territories is poorly characterized. We used process measures to compare the performance of hospitals in the US territories and in the US states.

Methods: Our sample included nonfederal hospitals located in the United States and its territories discharging Medicare fee-for-service (FFS) patients with a principal discharge diagnosis of acute myocardial infarction (AMI), heart failure (HF), or pneumonia (PNE) (July 2005-June 2008). We compared risk-standardized 30-day mortality and readmission rates between territorial and stateside hospitals, adjusting for performance on core process measures and hospital characteristics.

Results: In 57 territorial hospitals and 4799 stateside hospitals, hospital mean 30-day risk-standardized mortality rates were significantly higher in the US territories (P<.001) for AMI (18.8% vs 16.0%), HF (12.3% vs 10.8%), and PNE (14.9% vs 11.4%). Hospital mean 30-day risk-standardized readmission rates (RSRRs) were also significantly higher in the US territories for AMI (20.6% vs 19.8%; P=.04), and PNE (19.4% vs 18.4%; P=.01) but was not significant for HF (25.5% vs 24.5%; P=.07). The higher risk-standardized mortality rates in the US territories remained statistically significant after adjusting for hospital characteristics and core process measure performance. Hospitals in the US territories had lower performance on all core process measures (P<.05).

Conclusions: Compared with hospitals in the US states, hospitals in the US territories have significantly higher 30-day mortality rates and lower performance on every core process measure for patients discharged after AMI, HF, and PNE. Eliminating the substantial quality gap in the US territories should be a national priority.

Figure 1

RSMRs for fee-for-service Medicare beneficiaries admitted for AMI, HF, and PNE, stratified by hospital location in the US states or the US territories. The upper boundaries of the boxes represent the 75th percentile; the black horizontal line within each box, the median or 50th percentile; and the lower boundaries of the boxes, the 25th percentile. AMI indicates acute myocardial infarction; HF, heart failure; PNE, pneumonia; and RSMRs, 30-day risk-standardized rates for all-cause mortality.

Figure 2

RSRRs for fee-for-service Medicare beneficiaries admitted for AMI, HF, and PNE, stratified by hospital location in the US states or the US territories. The upper boundaries of the boxes represent the 75th percentile; the black horizontal line within each box, the median or 50th percentile; and the lower boundaries of the boxes, the 25th percentile. AMI indicates acute myocardial infarction; HF, heart failure; PNE, pneumonia; and RSRRs, 30-day risk-standardized rates for all-cause readmission.

Figure 3

State-level and territorial-level mean RSMRs and RSRRs for fee-for-service Medicare beneficiaries admitted for AMI, presented by performance quintile. Quintiles were determined for each outcome measure. The fifth quintile represents the poorest performing states and/or territories on average; the first quintile, the best performing states and/or territories on average. AMI indicates acute myocardial infarction; RSMRs, 30-day risk-standardized rates for all-cause mortality; and RSRRs, 30-day risk-standardized rates for all-cause readmission.

Figure 4

State-level and territorial-level mean RSMRs and RSRRs for fee-for-service Medicare beneficiaries admitted for HF, presented by performance quintile. Quintiles were determined for each outcome measure. The fifth quintile represents the poorest performing states and/or territories on average; the first quintile, the best performing states and/or territories on average. HF indicates heart failure; RSMRs, 30-day risk-standardized rates for all-cause mortality; and RSRRs, 30-day risk-standardized rates for all-cause readmission.

Figure 5

State-level and territorial-level mean RSMRs and RSRRs for fee-for-service Medicare beneficiaries admitted for PNE, presented by performance quintile. Quintiles were determined for each outcome measure. The fifth quintile represents the poorest performing states and/or territories on average; the first quintile, the best performing states and/or territories on average. PNE indicates pneumonia; RSMRs, 30-day risk-standardized rates for all-cause mortality; and RSRRs, 30-day risk-standardized rates for all-cause readmission.