Hospital Death Rates: A Wide Variance : Differences Shown in Times Analysis of Medicare Data on Elderly

Death rates for elderly patients with common conditions vary tremendously among Southern California hospitals, according to a Times analysis of death-rate data on California’s Medicare patients.

For heart attacks, the most frequent cause of death in the United States, some large hospitals, including Cedars-Sinai Medical Center and four Kaiser Foundation hospitals, have death rates of 15.6% or less, compared to the statewide average of 20.4%. But other hospitals have death rates up to 40%.

For heart failure, the most frequent reason people over 65 are hospitalized, UCLA Medical Center and three others have death rates of less than 3%. But 12 other hospitals, including Hollywood Presbyterian Medical Center, have death rates more than five times as high. The state average death rate is 9.2%.

For orthopedic surgeries, the most frequent operations among the elderly, six hospitals, including Anaheim Memorial Hospital, Mercy Hospital and Medical Center in San Diego and UCLA Medical Center, have death rates of less than 1%, compared to the statewide average of 2.5%. Seven other hospitals, including Downey Community Hospital, Granada Hills Community Hospital and Torrance Memorial Hospital Medical Center, have death rates of 5% or more.

These are among the conclusions from a Los Angeles Times Poll analysis of recently released death-rate data on California’s patients on Medicare, the federal health insurance program for the elderly and disabled.

The raw mortality data was compiled and released in April by California Medical Review Inc., the San Francisco-based organization that monitors the Medicare program in the state. They cover about 1 million Medicare hospitalizations in the 50 most common disease categories for a two-year period ending in September, 1986. But California Medical Review provided no statistical guidance on how to interpret the data.

The Times analysis compared the mortality rates for individual hospitals to the statewide average for each condition and corrected for the number of patients treated. This was necessary because, in some cases, high or low death rates at hospitals may have occurred due to chance alone.

The review of data for 302 Southern California hospitals identified dozens of institutions with statistically significant high or low death rates for common conditions, when compared to the state average. The death rates indicate the percentage of patients with a particular condition who die in the hospital out of all such patients who are admitted.

The conditions analyzed by the Times--heart attack, heart bypass surgery, heart failure, major bowel surgery, orthopedic surgery, pneumonia and stroke--are among the most frequent reasons the elderly are hospitalized.

Despite the improvements in the data resulting from The Times analysis, health-care researchers caution that the figures cannot be used to judge the quality of hospitals without considering other factors, such as variations between hospitals in the ages of their patients and the severity of their illnesses and possible errors in collecting the data. A high death rate at a hospital does not necessarily indicate poor performance, nor a low death rate good performance.

Daniel Freeman Memorial Hospital in Inglewood, for example, said that more than 50% of its heart bypass surgery deaths followed emergency surgery on desperately ill patients who otherwise had “no hope of living.”

But many health-care experts believe that such data, properly interpreted, may be useful to patients in deciding where to seek medical care and to physicians and hospitals in motivating them to improve the quality of care.

Burden of Proof on Hospitals

“The burden of proof is on hospitals with extraordinarily high death rates,” said Jonathan Showstack of the Institute for Health Policy Studies at the UC Medical Center in San Francisco. “They have a lot of material to explain.”

“This kind of information provides an extremely important starting point for asking questions,” said Dr. John T. Kelly, California Medical Review’s acting medical director. “We use data such as this as a way of focusing our confidential review activities.”

The Times analysis also found:

- Death rates for major bowel surgery ranged from less than 3% at Midway Hospital Medical Center in Los Angeles, Saddleback Community Hospital, Laguna Hills and St. John’s Hospital and Health Center in Santa Monica to 14% or more at Doctors Hospital of Lakewood, Hospital of the Good Samaritan in Los Angeles and Palomar Memorial Hospital in Escondido. By comparison, the average death rate in the state after such surgeries is 8.6%.

- Seven hospitals had high death rates for three of the seven conditions reviewed--Doctors Hospital of Lakewood, Doctors Hospital of Montclair, Downey Community Hospital, Hollywood Presbyterian Medical Center, St. Francis Medical Center in Lynwood, Torrance Memorial Hospital Medical Center and Western Medical Center in Santa Ana.

- Five hospitals had low death rates for three or more of the conditions--Anaheim Memorial Hospital, CIGNA Hospital of Los Angeles, Green Hospital of the Scripps Clinic in La Jolla, Hoag Memorial Hospital Presbyterian in Newport Beach and Kaiser Foundation Hospital in Bellflower.

- Six hospitals had low death rates for some diseases but high death rates for others--Kaiser Foundation Hospital in Los Angeles, Kaiser Foundation Hospital in West Los Angeles, Pioneers Memorial Hospital District in Brawley, Sharp Memorial Hospital in San Diego, Twin Cities Community Hospital in Templeton and UCLA Medical Center.

Only about 15% of hospitals with high death rates offered specific explanations to California Medical Review of why this was the case. All the hospitals had been sent advance copies of their data and given the opportunity to submit written comments, which were made public by the oversight organization in April as well. The specific comments included detailed letters from some institutions, including Torrance Memorial Hospital Medical Center and Pacific Hospital of Long Beach.

“The failure of many hospitals with high death rates to offer any explanation is worrisome,” said Dr. Sidney M. Wolfe of the Washington-based Public Citizens Health Research Group, a leading advocate of health-care data disclosure. “Until they do so, people have good reason to be fearful about going to these hospitals.”

Some of the hospitals that did not provide specific explanations of their high death rates, such as Hollywood Presbyterian Medical Center and Mercy Hospital of Bakersfield, told The Times that they are conducting audits of patient deaths to see if any problems exist.

Daniel Freeman Memorial Hospital initially sent a brief letter to California Medical Review citing its generally “very favorable mortality statistics.” But after its mortality data was made public, it prepared a detailed explanation for its 21.1% death rate for heart bypass surgery, compared to the statewide average of 7.2%.

Shock Patients Cited

That explanation cited the high number of patients who “went into surgery in shock or in the middle of a heart attack.”

Not all hospitals with low death rates took credit for providing better-than-average care.

“It doesn’t mean a goddamn thing,” said Dr. Mark S. Blumberg, director of special studies for the Kaiser Foundation Health Plan Inc. in Oakland. “It is too much of a scatter-gun to know what is going on.”

When asked specifically about the nine instances in which Kaiser Foundation Hospitals had low death rates, Blumberg said: “I wish you could say we are doing a great job, but I don’t think you can get there from this data.”

In contrast, Eisenhower Medical Center in Rancho Mirage maintains that the data is very meaningful.

“You are going to find very few doctors agreeing with me, but the data should be available to make institutions better,” said Dr. Jack J. Sternlieb, chief of cardiac surgery at Eisenhower. “Something is needed to assure a certain degree of quality, and the most basic thing in quality is life and death.”

Health-care experts caution that such mortality data should be used only to compare individual hospitals to average death rates for groups of hospitals--and not to rank individual hospitals. But that statistical caveat has not stopped at least one hospital, Eisenhower Medical Center, from doing just that.

The hospital has a 0.7% death rate for heart bypass surgery, compared to the statewide average of 7.2%, according to the California Medical Review data. And it has advertised in The Times, The Wall Street Journal and other newspapers boasting that it has “the lowest mortality in the country” for heart bypass surgery.

Officials at hospitals that had low death rates for some conditions but high death rates for others said the statistics needed to be interpreted differently for each condition.

‘Complexity’ of Cases

At Sharp Memorial Hospital in San Diego, spokeswoman Cindy Cohagen said the hospital’s high death rate for pneumonia patients resulted from the “severity and complexity” of the cases, while the low death rate for heart attack patients reflected the “very best care” that the patients received.

Dr. Raymond Schultze, director of the UCLA Medical Center, said he was satisfied that the hospital’s low death rates for orthopedic surgery and heart failure patients resulted from “very good performance.”

On the other hand, Schultze said UCLA’s death rate of 12.3% for heart bypass surgery reflected the sickness of the patients, not a quality of care problem.

When California Medical Review, the Medicare watchdog group, finds clusters of an apparently excessive number of patient deaths, it has the power to audit the patients’ medical records. If it concludes that the care had been substandard, the organization can bring sanctions against physicians or hospitals, including fines or dismissal from the Medicare program.

Kelly, the organization’s acting medical director, said a statistical analysis of the data had not been issued because the group wanted to focus on the first step of making the information public. “This is an evolutionary process,” he said. “It is our plan in any subsequent data release to provide information so the data will be more meaningful.”

FIGURING HOSPITAL MORTALITY RATES The Los Angeles Times Poll, directed by I.A. Lewis, compiled the lists of Southern California hospitals with high and low death rates through a computerized statistical analysis called “confidence intervals.”

The analysis was based on data released in April by California Medical Review Inc., the San Francisco-based organization that monitors Medicare in the state. Those data cover a million Medicare hospitalizations in the 50 most common disease categories over two years ending in September, 1986. California Medical Review provided no statistical guidance on how to interpret the data.

The Times analysis compared mortality rates for individual hospitals to the statewide average for each condition and corrected for the number of patients treated.

As a result, there is a less than 5% probability that a hospital would be listed as having either a high or low mortality rate because of chance, except for heart bypass surgery where the probability is less than 10%.

The analysis does not allow death rates at individual hospitals with either high or low death rates to be compared directly to each other--but only to the statewide average. Thus, for example, differences in death rates between the three hospitals with low death rates for heart bypass surgery or the 18 hospitals with high death rates for heart attack patients may not be statistically significant.

MORTALITY RATES IN SOUTHERN CALIFORNIA HOSPITALSThese Southern California hospitals show statistically significant high or low death rates for conditions common among those over age 65, according to an analysis by the Times Poll of mortality rate data from California Medical Review Inc. The data represent Medicare patients from October, 1984, through September, 1986. These rates should not be used to judge quality of hospitals without considering other factors, such as the age of patients and severity of illnesses, experts say. Only hospitals that treated more than 60 Medicare patients for each condition are listed.

HEART ATTACK Total Deaths Patients By % Statewide 49,458 20.4%

High Mortality Rates Total Deaths Patients By % Alhambra Community Hospital 111 31.5% AMI Mission Bay Hospital, San Diego 114 29.0% Beverly Hospital, Montebello 210 26.7% Corona Community Hospital 63 34.9% Doctors Hospital of Montclair 73 32.8% Downey Community Hospital 182 29.1% Foothill Presbyterian Hospital, Glendora 100 30.0% Fresno Community Hospital and Medical Center 385 27.5% Harbor-UCLA Medical Center, Torrance 70 31.4% Hollywood Presbyterian Medical Center 197 26.9% Memorial Hospital of Glendale 166 27.1% Ojai Valley Community Hospital, Ojai 71 30.9% Saddleback Community Hospital, Laguna Hills 416 24.8% San Dimas Community Hospital 75 33.3% St. Francis Medical Center, Lynwood 190 29.5% San Joaquin Community Hospital, Bakersfield* 180 31.6% South Bay Hospital, Redondo Beach 91 29.6% Western Medical Center, Santa Ana 114 40.3%

Low Mortality Rates Total Deaths Patients By % Alta Hospital District, Dinuba 188 12.8% Anaheim Memorial Hospital 142 12.0% Cedars-Sinai Medical Center, Los Angeles 773 15.4% CIGNA Hospital of Los Angeles 60 5.0% Humana Hospital West Hills, Canoga Park 201 11.0% Kaiser Foundation Hospital, Bellflower 318 13.8% Kaiser Foundation Hospital, Fontana 456 15.6% Kaiser Foundation Hospital, Los Angeles 363 14.6% Kaiser Foundation Hospital, Panorama City 435 14.9% Sharp Memorial Hospital, San Diego 146 12.3% Twin Cities Community Hospital, Templeton 84 10.7%

HEART BYPASS SURGERY Total Deaths Patients By % Statewide 8,402 7.2%

High Mortality Rates Total Deaths Patients By % Brotman Medical Center, Culver City 104 13.5% Daniel Freeman Memorial Hospital, Inglewood 71 21.1% UCLA Medical Center, Westwood 114 12.3%

Low Mortality Rates Total Deaths Patients By % Alvarado Hospital Medical Center, San Diego 343 2.3% Eisenhower Medical Center, Rancho Mirage 146 0.7% Little Company of Mary Hospital, Torrance 132 3.0% Scripps Memorial Hospital, La Jolla 209 2.4%

HEART FAILURE Total Deaths Patients By % Statewide 81,480 9.2%

High Mortality Rates Total Deaths Patients By % Charter Suburban Hospital, Paramount 143 16.8% Doctors Hospital of Montclair 140 15.0% Downey Community Hospital 302 12.9% Garfield Medical Center, Monterey Park 290 13.8% Hemet Valley District Hospital, Hemet 597 12.9% Hollywood Presbyterian Medical Center 333 13.8% Kaiser Foundation Hospital, San Diego 146 14.4% Lompoc District Hospital 72 16.7% Los Robles Regional Medical Center, Thousand Oaks 176 14.2% Pacific Hospital of Long Beach* 212 15.6% Pacifica Community Hospital, Huntington Beach* 130 16.2% Parkview Community Hospital, Riverside* 190 13.7% Pleasant Valley Hospital, Camarillo 147 15.6% Riverside General Hospital 105 16.2% St. Agnes Medical Center, Fresno 481 13.1% St. Bernardine Medical Center, San Bernardino 531 13.8% St. Luke Hospital, Pasadena 248 16.1% San Antonio Community Hospital 431 13.5% San Gorgonio Pass Memorial Hospital, Banning 156 14.1% San Joaquin Community Hospital, Bakersfield* 206 16.0% Santa Ana Hospital Medical Center 65 21.5% Sierra Hospital, Fresno 63 23.8% Torrance Memorial Hospital Medical Center, Torrance 306 12.8% Twin Cities Community Hospital, Templeton 97 17.5% Verdugo Hills Hospital, Glendale 173 16.2% Western Medical Center, Santa Ana 268 14.2%

Low Mortality Rates Total Deaths Patients By % Anaheim General Hospital 112 3.6% Beverly Hills Medical Center, Los Angeles 116 0.0% Chino Community Hospital 129 2.3% CIGNA Hospital of Los Angeles 161 3.7% Corona Community Hospital 119 3.3% County-USC Medical Center, Los Angeles 262 5.3% Green Hospital of Scripps Clinic, La Jolla 97 3.1% Hoag Memorial Hospital Presbyterian, Newport Beach 419 6.2% Kaiser Foundation Hospital, West Los Angeles 345 5.5% Lancaster Community Hospital 331 5.7% La Palma Intercommunity Hospital 146 4.1% Monterey Park Hospital 145 2.7% Pioneers Memorial Hospital District, Brawley 98 3.1% St. John’s Hospital and Health Center, Santa Monica 292 5.5% Scripps Memorial Hospital, Encinitas 153 3.9% Simi Valley Adventist Hospital 123 3.2% UCLA Medical Center, Los Angeles 245 2.9%

MAJOR BOWEL SURGERY Total Deaths Patients By % Statewide 22,037 8.6%

High Mortality Rates Total Deaths Patients By % Hospital of the Good Samaritan, Los Angeles 143 14.7% Doctors Hospital of Lakewood 76 18.4% Palomar Memorial Hospital, Escondido 172 14.0%

Low Mortality Rates Total Deaths Patients By % Midway Hospital Medical Center, Los Angeles 76 1.3% Saddleback Community Hospital, Laguna Hills 192 4.1% St. John’s Hospital and Health Center, Santa Monica 167 2.4%

ORTHOPEDIC SURGERY Total Deaths Patients By % Statewide 55,383 2.5%

High Mortality Rates Total Deaths Patients By % Daniel Freeman Marina Hospital, Marina del Rey 76 6.6% Doctors Hospital of Lakewood 127 6.3% Downey Community Hospital 189 5.8% Granada Hills Community Hospital* 61 9.8% Mercy Hospital, Bakersfield 286 4.5% Pomerado Hospital, Poway 145 6.9% Torrance Memorial Hospital Medical Center* 170 5.3% Western Medical Center, Santa Ana 134 5.9%

Low Mortality Rates Total Deaths Patients By % Anaheim Memorial Hospital 185 0.0% Green Hospital of Scripps Clinic, La Jolla 314 0.0% Kaiser Foundation Hospital, Bellflower 211 0.0% Mercy Hospital and Medical Center, San Diego 645 0.8% Orthopaedic Hospital, Los Angeles 245 0.4% UCLA Medical Center, Los Angeles 370 0.5%

PNEUMONIA

Total Deaths Patients By % Statewide 56,836 12.3%

High Mortality Rates Total Deaths Patients By % Bakersfield Memorial Hospital 271 16.6% Canoga Park Hospital 78 26.9% Doctors Hospital of Montclair 109 22.0% Fresno Community Hospital and Medical Center 456 16.9% Granada Hills Community Hospital* 149 18.1% Hollywood Community Hospital 77 20.8% Kaiser Foundation Hospital, Los Angeles 204 17.2% Kaiser Foundation Hospital, West Los Angeles 147 21.1% Medical Center of North Hollywood 112 19.6% Panorama Community Hospital, Panorama City 149 18.1% Placentia-Linda Community Hospital, Placentia* 87 19.5% Redlands Community Hospital 194 19.6% Riverside Gen. Hospital--University Medical Center 112 28.6% St. Francis Medical Center, Lynwood 347 20.7% St. Joseph Medical Center, Burbank 532 18.0% Santa Ana Hospital Medical Center* 186 21.5% Sharp Memorial Hospital, San Diego 208 17.3% Torrance Memorial Hospital Medical Center* 219 23.3% Western Medical Center, Santa Ana 143 20.3%

Low Mortality Rates Total Deaths Patients By % Barstow Community Hospital 118 4.2% Bay Hospital Medical Center, Chula Vista 152 5.9% Centinela Hospital Medical Center, Inglewood 114 5.2% Circle City Hospital, Corona 152 4.0% Eisenhower Memorial Hospital, Rancho Mirage 226 7.1% Green Hospital of Scripps Clinic, La Jolla 78 3.9% Henry Mayo Newhall Memorial Hospital, Valencia 94 5.3% Hoag Memorial Hospital Presbyterian, Newport Beach 278 1.1% Kern Valley District Hospital, Lake Isabella 93 4.3% Lancaster Community Hospital 205 6.8% Loma Linda University Medical Center 195 6.2% Madera Community Hospital 103 1.9% Monterey Park Hospital 67 2.9% St. Francis Hospital of Santa Barbara 91 2.2% Selma District Hospital 129 4.7% Tri-City Medical Center, Oceanside 345 7.8% Twin Cities Community Hospital, Templeton 119 4.2%

STROKE Total Deaths Patients By % Statewide 53,914 15.6%

High Mortality Rates Total Deaths Patients By % AMI Valley Medical Center, El Cajon 170 22.4% Antelope Valley Hospital Medical Center, Lancaster 124 24.2% Christian Hospital Medical Center, Perris 90 27.8% Doctors Hospital of Lakewood 174 23.6% Downey Community Hospital 220 26.4% Hanford Community Hospital 66 27.3% Hollywood Presbyterian Medical Center 202 21.3% Medical Center of North Hollywood 122 26.2% Northridge Hospital Medical Center 145 24.1% Pioneers Memorial Hospital District, Brawley 73 27.4% Placentia-Linda Community Hospital, Placentia 65 26.2% Pomona Valley Community Hospital* 363 20.1% Riverside Community Hospital* 294 22.4% Riverside General Hospital 69 34.8% St. Francis Medical Center, Lynwood 374 20.3% San Antonio Community Hospital, Upland 224 21.0% Twin Cities Community Hospital, Templeton 93 23.7% Westside Hospital, Los Angeles 88 26.1%

Low Mortality Rates Total Deaths Patients By % Anaheim Memorial Hospital 167 9.6% CIGNA Hospital of Los Angeles 111 5.4% French Hospital, San Luis Obispo 91 7.7% Green Hospital of Scripps Clinic, La Jolla 64 4.7% Hoag Memorial Hospital Presbyterian, Newport Beach 264 8.3% Kaiser Hospital, Bellflower 172 8.1% Kaiser Hospital, Los Angeles 328 9.8% Kaiser Hospital, Panorama City 224 8.0% Mercy Hospital and Medical Center, San Diego 394 10.9% White Memorial Medical Center, Los Angeles 158 7.6%

The above conditions are based on what Medicare calls Diagnosis Related Groups (DRG), which are categories by which admissions are classified. The DRGs analyzed were acute heart attack (DRG 121-3), heart bypass surgery and cardiac catheterization (DRG 106), heart failure and shock (DRG 127), orthopedic surgery (DRG 209-210), major bowel surgery (DRG 148), pneumonia and pleurisy (DRG 89) and stroke (DRG 14).

*Hospitals that submitted specific comments explaining this high mortality rate to California Medical Review Inc.