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Assessing all health conditions and heart attack severity at admission helps assess patients' risk of dying

Public reporting of hospital mortality rates for heart attack patients is intended to improve health care quality by directing patients to hospitals with lower-than-expected mortality rates based on their patients' severity of illness. Generally, hospital administrative data on heart attack patients is used to adjust patients' risk of dying, and includes information on cardiac risk factors such as diabetes and cerebrovascular disease. However, these data do not include patients' other health conditions or heart attack severity present at hospital admission. A new risk model that includes these two variables improves assessment of risk of dying among hospitalized heart attack patients.

Using a more comprehensive risk model may lead to more accurate comparisons of quality-of-care differences for heart attack patients among hospitals. George J. Stukenborg, Ph.D., of the University of Virginia Medical School, and colleagues used an acute myocardial infarction (AMI or heart attack) mortality risk adjustment model, which adjusts for coexisting disease and for AMI severity reported at admission, to predict mortality risk for heart attack patients at California hospitals from 1996 through 1999.

They compared results from the new model to two mortality risk-adjustment models used to assess hospital AMI mortality outcomes by the State of California and to two other models used in prior research.

Their model obtained better discrimination between predicted survival and inpatient death, measured a wider range of mortality risk, and had more explanatory power than the other models they considered. Besides shock, the categories of coexisting disease that contributed most to the model's performance were coma, stupor, and brain damage; acute and unspecified renal disease; respiratory failure, insufficiency, and cardiac arrest; and acute cerebrovascular disease.

In addition to infarct location, the new model included four other conditions related closely to heart attack severity present at admission: cardiac arrest and ventricular fibrillation, heart disease related closely to AMI, coronary atherosclerosis, and other related heart disease. The study was supported by the Agency for Healthcare Research and Quality (HS10134 and HS11419).

See "Present-at-admission diagnoses improved mortality risk adjustment among acute myocardial infarction patients," by Dr. Stukenborg, Douglas P. Wagner, Ph.D., Frank E. Harrell Jr., Ph.D., and others, in the February 2007 Journal of Clinical Epidemiology 60, pp. 142-154.

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