Fourth, the decline in overall standardized mortality over the 4 years of data collection and dissemination may suggest improvements in care over time.- However, further analyses indicated that rates of discharge to skilled nursing facilities also increased over time, and that these patients had markedly higher severity of illness than patients discharged home. Moreover, excluding such discharges from analysis attenuated temporal declines in mortality. These findings have important ramifications regarding the utility of hospital discharge status as an accurate or appropriate end point to measure outcomes of ICU care. Traditionally, ICU discharge status has been viewed as an inadequate marker of ICU performance as it may be significantly influenced by discharge timing, especially among terminal patients who are transferred out of the ICU to die in non-ICU settings. The increasing use of skilled nursing facilities, rehabilitation centers, and nursing homes may signal that the adequate evaluation of critical care requires long-term follow-up of patients after hospital discharge.
When interpreting our findings, several method-ologic issues should be considered add comment contraceptive pills. First, our analysis was limited to a single outcome measure. Although hospital mortality is a widely used indicator, quality of care encompasses multiple dimensions. Thus, the implications of our findings for other aspects of the quality of critical care, such as the appropriateness and process of care, functional outcomes, patient satisfaction, and long-term mortality, are uncertain.
Second, we did not directly examine responses by clinicians and hospital administrators to the reported ICU outcomes data. Thus, the degree to which changes in outcomes over time can be attributed to dissemination of these data is unknown. Indeed, a recent study found similar declines in mortality rates for coronary artery bypass surgery in states with and without initiatives to publicly disseminate severity-adjusted mortality data.