The Relationship between Hospital Market Competition, Evidence-Based Performance Measures, and Mortality for Chronic Heart Failure

Article excerpt

Using data from the Joint Commission's OR YX initiative and the Medicare Provider Analysis and Review file from 2003 to 2006, this study employed a fixed-effects approach to examine the relationship between hospital market competition, evidence-based performance measures, and short-term mortality at seven clays, 30 days, 90 days, and one year for patients with chronic heart failure. We found that, on average, higher adherence with most of the Joint Commission's heart failure performance measures was not associated with lower mortality; the level of market competition also was not associated with any differences in mortality. However, higher adherence with the discharge instructions and left ventricular function assessment indicators at the 80th and 90th percentiles of the mortality distribution was associated with incrementally lower mortality rates. These findings suggest that targeting evidence-based processes of care might have a stronger impact in improving patient outcomes.


Heart failure is one of the most common and costly reasons for hospitalization. In 2009, more than 1 million hospitalizations had a principal diagnosis of heart failure and they cost the U.S. health care system about $10.7 billion for inpatient care alone (Wier et al. 2011). Heart failure is also the most frequent cause of hospitalization and mortality among Medicare beneficiaries (Fonarow and Peterson 2009).

Despite evidence-based guidelines and available therapies that have been demonstrated to improve patient outcomes for heart failure, there are wide variations in the application of heart failure treatment in routine clinical practice (Fonarow and Peterson 2009). As part of a national effort to monitor and assess heart failure quality improvement in hospitals, the Joint Commission, in collaboration with the American College of Cardiology/American Heart Association, developed standardized heart failure performance measures in the ORYX program (Bonow et al. 2005). ORYX was developed by the Joint Commission as a way to evaluate the performance and quality improvement efforts of hospitals, and to integrate performance and outcome measures into a continuous accreditation process (Williams et al. 2005). The ORYX performance measures have been endorsed by the National Quality Forum and are aligned with the Centers for Medicare and Medicaid Services (CMS) Hospital Compare. performance measures.

Several cross-sectional studies have provided some insights into hospital performance for heart failure since the widespread implementation of standardized performance measures (Williams et al. 2005; Joint Commission 2007; Jha et al. 2005; Kroch et al. 2007). These reports suggest that there have been substantial improvements in hospital performance (Williams et al. 2005; Joint Commission 2007; Jha et al. 2005; Kroch et al. 2007); however, little is known about the relationship between increased hospital performance and patient outcomes from longitudinal studies, as well as the potential mediators of performance (Maeda 2010).

The performance measures for heart failure are based on clinical research studies that have been demonstrated to decrease morbidity and mortality of left ventricular systolic dysfunction (LVSD) (Bonow et al. 2005). The heart failure performance measures have been restricted to areas of care where there is strong evidence showing that the absence of performance would lead to suboptimal patient outcomes (Fonarow et al. 2007: Fonarow 2007). The current Joint Commission heart failure performance measures include left ventricular (LV) function assessment, angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) for LVSD, discharge instructions, and smoking cessation counseling (Bonow et al. 2005; Joint Commission on the Accreditation of Healthcare Organizations 2004).

While the performance measures were intended to increase hospitals' compliance with evidence-based processes of care, hospitals may be motivated to improve their quality because of market competition. …


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