Cross-classified Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) to evaluate hospital performance: the case of hospital differences in patient survival after acute myocardial infarction

Abstract

ObjectiveTo describe a novel strategy, Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) to evaluate hospital performance, by analysing differences in 30-day mortality after a first-ever acute myocardial infarction (AMI) in Sweden.DesignCross-classified study.Setting68 Swedish hospitals.Participants43 247 patients admitted between 2007 and 2009, with a first-ever AMI.Primary and secondary outcome measuresWe evaluate hospital performance by analysing differences in 30-day mortality after a first-ever AMI using a cross-classified multilevel analysis. We classified the patients into 10 categories according to a risk score (RS) for 30-day mortality and created 680 strata defined by combining hospital and RS categories.ResultsIn the cross-classified multilevel analysis the overall RS adjusted hospital 30-day mortality in Sweden was 4.78% and the between-hospital variation was very small (variance partition coefficient (VPC)=0.70%, area under the curve (AUC)=0.54). The benchmark value was therefore achieved by all hospitals. However, as expected, there were large differences between the RS categories (VPC=34.13%, AUC=0.77)ConclusionsMAIHDA is a useful tool to evaluate hospital performance. The benefit of this novel approach to adjusting for patient RS is that it allowed one to estimate separate VPCs and AUC statistics to simultaneously evaluate the influence of RS categories and hospital differences on mortality. At the time of our analysis, all hospitals in Sweden were performing homogeneously well. That is, the benchmark target for 30-day mortality was fully achieved and there were not relevant hospital differences. Therefore, possible quality interventions should be universal and oriented to maintain the high hospital quality of care.

Between-hospital variation in indicators of quality of care: a systematic review

“…Additionally, the studies show substantial variation in the extent to which casemix adjustment is applied, even for the same medical conditions. For example, mortality among AMI patients was assessed in three studies,1 27 28 each of which applied a different casemix adjustment model (which may be related to differences in, eg, data availability). Therefore, research should continue to focus on (further) development of casemix adjustment models for quality-of-care research, including standardised comorbidity indices29 supplemented with disease-specific adjustments.…”

Mapping socio-geographical disparities in the occurrence of teenage maternity in Colombia using multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA)

“…Considering previous references [37,47], the magnitude of the VPC null-logit after multilevel logistic regression model was classified as absent if the VPC in the null model, was between: 0-1%, small between 1-5%, moderate between 5-10%, large between 10-20%, and very large > 20%. See elsewhere for an extended explanation of the GCE concept [32,42,48].…”

“…Most intersectional analyses, including those related to teenage pregnancies, have used qualitative approaches [25,28,29]. More recently, an analytical approach has been developed to quantify the heterogeneity across social position [23,28,30,31] and risk factors [32,33] in health studies. To the best of our knowledge, an intersectional quantitative approach to map the distribution of teenage maternity remains little studied and underexplored.…”