Do Common Risk Adjustment Methods Do Their Job Well if Center Effects are Correlated With the Center-Specific Mean Values of Patient Characteristics?

BACKGROUND: Direct and indirect standardization are well-established approaches to performing risk adjustment when comparing outcomes between healthcare providers. However, it is an open question whether they work well when there is an association between the center effects and the distributions of the patient characteristics in these centers.

OBJECTIVES AND METHODS: We try to shed further light on the impact of such an association. We construct an artificial case study with a single covariate, in which centers can be classified as performing above, on, or below average, and the center effects correlate with center-specific mean values of a patient characteristic, as a consequence of differential quality improvement. Based on this case study, direct standardization and indirect standardization-based on marginal as well as conditional models-are compared with respect to systematic differences between their results.

RESULTS: Systematic differences between the methods were observed. All methods produced results that partially reflect differences in mean age across the centers. This may mask the classification as above, on, or below average. The differences could be explained by an inspection of the parameter estimates in the models fitted.

CONCLUSIONS: In case of correlations of center effects with center-specific mean values of a covariate, different risk adjustment methods can produce systematically differing results. This suggests the routine use of sensitivity analyses. Center effects in a conditional model need not reflect the position of a center above or below average, questioning its use in defining the truth. Further empirical investigations are necessary to judge the practical relevance of these findings.