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Are all deaths recorded equally? The impact of hospice care on risk-adjusted mortality

Kozar, Rosemary A. MD, PhD; Holcomb, John B. MD; Xiong, Wei MSc; Nathens, Avery B. MD, PhD

Journal of Trauma and Acute Care Surgery: March 2014 - Volume 76 - Issue 3 - p 634–641
doi: 10.1097/TA.0000000000000130
AAST 2013 Plenary Papers

BACKGROUND Hospice care provides dignity and comfort at the end of life. While patients transferred to hospice die, they are often not recorded as in-hospital deaths in trauma registries or in some administrative discharge data. Mortality rates for the purpose of database research, performance improvement, or public reporting may therefore be artificially low. The current study sought to determine the impact of discharges to hospice on risk-adjusted mortality for trauma deaths reported to the Trauma Quality Improvement Program.

METHODS Performance from Trauma Quality Improvement Program centers in 2011 was evaluated using risk-adjusted mortality with observed-to-expected mortality ratios derived from a logistic regression model. The impact of discharge to hospice on performance was measured by determining changes in performance if hospice cases were treated as survivors rather than deaths. Differences between groups were compared by nonparametric Wilcoxon rank-sum test.

RESULTS From the 167 centers with 126,259 injured patients, there were 8,862 deaths: 746 (8.4%) were discharged to a hospice, and the remainder was counted as in-hospital deaths. Overall, 106 centers (63.5%) reported at least one discharge to hospice, with the proportion of deaths ranging from 1.6% to 57%. Logistic regression demonstrated that age greater than 70 years (odds ratio [OR], 4.3; 95% confidence interval [CI], 3.5–5.1), male sex (OR, 0.7; 95% CI, 0.6–0.8), nonblack race (OR, 1.9; 95% CI, 1.3–2.7), noncommercial insurance (OR, 1.4; 95% CI, 1.1–1.7), and comorbidity counts greater than 2 (OR, 1.3; 95% CI, 1.1–1.6) were associated with hospice care. If patients transferred to a hospice were treated as survivors in the estimation of risk-adjusted mortality, 34 centers (20%) would have a change in status. Changes would be in both directions for average-performing centers, while high-performing centers would seem worse and poor-performing centers would seem better. For centers that reported hospice deaths, the relative risk-adjusted mortality decreased by 8.8% for every 10% increase in the proportion of deaths recorded as discharged to a hospice.

CONCLUSION Given the large variation in the proportion of deaths recorded as discharged to a hospice rather than as in-hospital deaths, there is the potential for significant distortion of actual performance. Failure to consider this potential may misguide efforts directing performance improvement, research, and national reporting. Discharges to a hospice should be included with in-hospital deaths when reporting risk-adjusted mortality.

From the Department of Surgery (R.A.K., J.B.H.), and Center for Translational Injury Research (J.B.H.), The University of Texas Health Sciences Center at Houston, Houston, Texas; and Department of Surgery (W.X., A.B.N.), Sunnybrook Health Sciences Centre, Toronto, Canada.

Submitted: September 13, 2013, Revised: November 11, 2013, Accepted: November 12, 2013.

This study was presented at the 72nd annual meeting of the American Association of Surgery for Trauma, September 18–21, 2013, in San Francisco, California.

Address for reprints: Rosemary Kozar, MD, PhD, 6431 Fannin, MSB 4.284; email:

© 2014 Lippincott Williams & Wilkins, Inc.