Brinkman and colleagues nicely demonstrate that the problem of discharge bias is not limited to the United States health system (1,2). Similar to our study (3), they found that using 30-day mortality rather than in-hospital mortality significantly altered hospital performance. Yet their preferred prescription, linking ICU registries to population-based data using dates of death, will be extremely challenging for most health systems, particularly in the context of regulations curtailing use of protected health data such as the Health Insurance Portability and Accountability Act (4). As electronic health records mature and secure data sharing becomes easier, we hope that more systems can achieve the high quality of the Dutch NICE registry. In the United States, we are slowly but surely moving in that direction (5).
Until then, it is important not to let perfect be the enemy of good. A more immediate solution is to stratify reporting of in-hospital ICU mortality by hospital bed-size. Although this does not completely eliminate the bias inherent in measuring in-hospital ICU mortality, it can mitigate the effect of discharge bias and is easier to implement in practice than calculating time-specific mortality rates.
Footnotes
Copyright form disclosures: Dr. Kahn lectured for the National Association of Long-term Care Hospitals, received in-kind support from Cerner Corporation, consulted for the US Department of Veteran’s Affairs, and received support for article research from the National Institutes of Health (NIH). His institution received grant support form the US Department of Health and Human Services. Dr. Reineck received support for article research from the NIH. Her institution received grant support from the NIH.
Contributor Information
Lora A. Reineck, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine.
Jeremy M. Kahn, CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine Department of Health Policy and Management, University of Pittsburgh School of Public Health.
References
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