These data come from information that hospitals record primarily for billing purposes. This type of record, referred to as “administrative data,” consists of diagnoses and procedures along with information about the patient’s age, gender, accompanying medical conditions and discharge status. While administrative data cannot be used as a conclusive source of information on health care quality, it can provide important insights into the quality of care being delivered by hospitals.

The NHQC data reflect only the care provided to patients who were admitted to the hospital in calendar year 2011. Patient and physician names are removed to preserve confidentiality. However, when only five or fewer patients in a facility had a specific procedure, no data are included in the report as a further step to protect confidential patient information. If a hospital had fewer than 30 patients with a specific diagnosis or procedure, no statistical analyses were performed because the results would have been less reliable.

Hospital comments regarding their performance on these indicators are included in the report and are available on the NHQC’s Web site.

For many years, the federal government has supported research into what factors affect quality of health care services, including care delivered in hospitals. The federal Agency for Healthcare Research and Quality has conducted extensive research REMOVE; in July 2002, AHRQ released software that analyzes administrative data and assesses performance on quality-related indicators.

Research has confirmed that the rate of patient deaths for certain procedures and conditions may be associated with quality of care. While research can predict an expected range of patient deaths for a given procedure or condition, mortality rates above or below the expected range may have quality implications. For some procedures, research has shown that overuse, under use and misuse (utilization) may affect patient outcomes. For certain procedures, the number of times (volume) the procedure is performed in a hospital has been linked to the patient’s outcome, and the presence of certain types of errors, or high rates of errors may also be associated with the quality of care.

AHRQ developed the AHRQ Quality Indicators (QIs) with the intention that they would be used for researching national, state-wide, regional and hospital-specific performance. They were not developed with the intention that they be used for publicly released hospital quality reports. However, experts and scholars across the nation have determined that the AHRQ Quality Indicators (QIs) represent the current state-of-the-art in assessing quality of care using administrative data. As noted by the Centers for Medicare and Medicaid services, these indicators must be used “cautiously” for public reporting.

This report is based on administrative data. Recording administrative data – or coding – varies among hospitals. Individual judgment often is required. Codes do not provide specific details about a patient’s condition at the time of admission, nor capture everything that occurs during the hospital stay. Especially when reviewing mortality rates, remember that medicine is not an exact science and death may occur even when all standards of care are followed. These reports provide some information about hospital performance, but consider the limitations of the data in your decision-making process. NHQC recommends that consumers discuss these data with their physician.

Because of their expertise, some hospitals treat more high-risk patients, and some patients arrive at hospitals sicker than others. That makes it difficult to compare hospital mortality and utilization rates for patients with the same condition but different health status. To compensate for this fact, the NHQC has “risk adjusted” each hospital’s data to reflect the score the hospital would have had if it had provided services to the average mix of sick, complicated patients. The risk and severity adjustments allow researchers and statisticians to separate the effects the patient and his or her degree of illness have from the hospital stay.

NHQC used a risk adjustment methodology developed by 3M Corporation. Detailed information about the process used to organize and adjust the data for study purposes can be obtained on the AHRQ website.

If you want to evaluate all NHQC measures for up to 3 specific hospitals, click on the compare button. 

Then, you’ll see data from all of the three locations you’ve chosen to compare.

If you want to evaluate a specific type of care, click on the + button.  

1. Familiarize yourself with the indicators.
2. Decide which quality indicator is most relevant to you, and review that Graph for that indicator. Look to see if the hospital you are interested in is listed. If not, it means that the hospital did not have any cases for that indicator. You might wish to look at another quality indicator for that hospital’s performance.
3. Hospitals are arranged alphabetically by region. You may wish to compare the performance of hospitals state-wide, in your area, or only those that are covered by your health insurance plan. Each Graph provides the results for specific hospitals as well as a statewide average. Note that each Graph provides guidance on how to interpret the findings.
4. View the hospital’s comments, if the facility provided them. It is especially important to view the hospital’s comments if performance is lower than expected. Click on the hospital’s name in the Graph to access the hospital’s specific comments.
5. Do not try to compare the results of these reports with other reports you may find online or elsewhere. The results are sure to be different, unless the exact same methodology is used.