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Indian Health Service Hospitals: Does Data Support Poor Quality Consensus?

The Indian Health Service (IHS) has been the focus of a lot of negative attention in 2016. A US Senate committee hearing in February highlighted serious failures in care delivery, management and oversight, and funding at the system’s 55 hospitals. Anecdotal reports have described events in which patients were discharged prematurely or misdiagnosed and in some cases led to death. An analysis of Definitive Healthcare data suggests that there are significant quality variations between IHS hospitals, with some performing better or worse than similar facilities elsewhere in the state, but they face several unique challenges that make comparisons to normal hospitals more complicated.

The lack of publicly reported quality data at many IHS hospitals makes it difficult to assess their performance as a whole. Most have too few inpatient admissions to form useable statistics. Of all the IHS inpatient facilities, only 12 had more than 1,000 discharges in FY 2015. The largest 12 are located in five states: Alaska, Arizona, New Mexico, Oklahoma, and South Dakota. Combined, they represented 76 percent of all IHS discharges for 2015. To adjust for patient health variants, the 12 hospitals were compared to other hospitals in each state with more than 1,000 discharges and case mixes within .20 points.

Overall, IHS hospitals have slightly higher all-cause readmission rates than other facilities, as well as greater serious complication rates. Readmissions for heart failure and pneumonia are also equal or higher than those of the comparison group, but many IHS facilities had superior mortality rates, especially in Alaska.

Though the quality differences appear to be relatively modest, it’s important to note the limits of a data-driven analysis of the IHS system.  Most of the criticism of IHS’ operations focuses on care access and management, critical elements of healthcare delivery that can’t be accounted for in publicly reported outcomes data. For instance, many IHS facilities do not operate as fully comprehensive hospitals, but refer patients to private facilities better equipped for treating certain conditions or performing select procedures. While the referral comes at no additional cost to the patient, only about 50 percent of the referrals are adequately funded, meaning many do not receive the recommended care.

Neither is the data itself entirely reliable. According to a recent OIG review, the regional IHS offices responsible for collecting quality data readily admitted its limitations. Reports of patient harm are infrequently gathered, and staff often depend on patient complaints to identify problems. For many hospitals, CMS had to use its resources to train leaders and other personnel on quality reporting methodologies and best practices, even at the expense of timely certification surveys.

In the absence of comprehensive hard data, reasonable inferences and anecdotal evidence are all that’s left to judge the current state of the IHS, and as multiple reports have already established, the health system needs serious improvement. Fortunately, IHS has received assistance in the form of a new CMS contract with HealthInsight to rebuild or redesign hospital infrastructure, and the Indian Health Service Accountability Act of 2016, if passed, will expand physician recruitment efforts at the system. In time, it may be possible to build a more comprehensive assessment of care quality and patient outcomes at IHS.

IHS Hospital Quality Vs Comparable Facilities, Selected Measures, 2015

Alaska IHS Other
Case Mix High Case Mix Low Case Mix High Case Mix Low
All-Cause Readmission Rate 15.6% 14.6% 14.0% 15.3%
Serious Complication Rate 1.14 0.90 0.96 0.86
Heart Failure Mortality Rate 13.9% 11.8% 13.2% 12.7%
Heart Failure Readmission Rate 23.8% 20.8% 22.5% 22.3%
Pneumonia Mortality Rate 19.0% 17.6% 19.0% 17.6%
Pneumonia Readmission Rate 18.1% 16.3% 16.0% 16.6%

 

Arizona IHS Other
Case Mix High Case Mix Low Case Mix High Case Mix Low
All-Cause Readmission Rate 15.1% 16.0% 15.4% 15.5%
Serious Complication Rate 0.97 0.84 0.92
Heart Failure Mortality Rate 11.2% 12.4% 12.0% 8.6%
Heart Failure Readmission Rate 22.6% 23.2% 21.7% 21.1%
Pneumonia Mortality Rate 15.2% 14.8% 16.0% 14.4%
Pneumonia Readmission Rate 18.5% 16.4% 17.1% 16.2%

 

Oklahoma IHS Other
Case Mix High Case Mix Low Case Mix High Case Mix Low
All-Cause Readmission Rate 15.4% 15.4% 15.6% 15.5%
Serious Complication Rate 0.96 0.90 0.86 0.86
Heart Failure Mortality Rate 11.4% 11.8% 12.3%
Heart Failure Readmission Rate 22.0% 21.9% 22.3%
Pneumonia Mortality Rate 15.6% 15.4% 16.8% 14.8%
Pneumonia Readmission Rate 16.6% 16.7% 16.5% 17.4%

 

New Mexico IHS Other
All-Cause Readmission Rate 15.9% 15.4%
Serious Complication Rate 0.95 0.92
Heart Failure Mortality Rate 11.2% 11.5%
Heart Failure Readmission Rate 21.8%  22.4%
Pneumonia Mortality Rate 15.7% 16.0%
Pneumonia Readmission Rate 16.7% 16.7%

 

South Dakota IHS Other
All-Cause Readmission Rate 15.6%  14.9%
Serious Complication Rate 0.88 0.90
Heart Failure Mortality Rate  13.9%
Heart Failure Readmission Rate  21.3%
Pneumonia Mortality Rate 15.3%  17.4$
Pneumonia Readmission Rate 16.9% 16.5%

 

Definitive Healthcare has the most up-to-date, comprehensive and integrated data on over 7,700 hospitals, 1.4 million physicians, and numerous other healthcare providers. Users can search for hospitals by a wide variety of quality and clinical metrics.

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