A widely used federal hospital safety metric may be fundamentally misrepresenting the quality of emergency stroke care in the United States, according to a new study from UCLA Health. Researchers warn that the measure could unintentionally penalize hospitals that provide lifesaving treatment to the sickest stroke patients—and may even discourage critical interventions.

The study, published in the Journal of NeuroInterventional Surgery, evaluated Patient Safety Indicator 04 (PSI 04), a “failure-to-rescue” metric developed by the U.S. Agency for Healthcare Research and Quality (AHRQ). PSI 04 tracks in-hospital deaths following potentially treatable complications after surgical procedures and is widely used for public reporting, hospital rankings, and Medicare pay-for-performance programs.

Designed for Elective Surgery—Not Emergency Stroke Care

PSI 04 was originally intended to identify preventable deaths in patients undergoing elective procedures who develop complications such as pneumonia, sepsis, shock, blood clots, or gastrointestinal bleeding. However, UCLA researchers found that applying this metric to endovascular thrombectomy (EVT)—an emergency procedure used to remove clots in patients with severe ischemic stroke—is inappropriate and misleading.

“These patients arrive critically ill, often with devastating strokes,” said Dr. Melissa Marie Reider-Demer, the study’s first author and a Doctor of Nursing Practice at UCLA Health. “When PSI 04 is applied to emergency stroke care, it flags unavoidable consequences of severe strokes rather than failures of care.”

National Data Reveal Alarming Distortions

Using the Nationwide Inpatient Sample, the researchers analyzed 73,580 stroke thrombectomy procedures performed between 2016 and 2019. Their findings revealed striking discrepancies:

PSI 04 occurred in 20.5% of stroke thrombectomy cases nationally, compared with a median rate of just 0.10% across the other 17 federal patient safety indicators

The PSI 04 rate for stroke procedures was significantly higher than the 14.3% rate for all surgical procedures combined

Among all 18 federal safety indicators, PSI 04 showed by far the highest event rate, raising concerns about the metric’s overall validity

Case Reviews Show No Preventable Safety Failures

To assess whether PSI 04 flags reflected true safety concerns, the UCLA team conducted detailed case reviews at UCLA’s Comprehensive Stroke Center. Every thrombectomy case flagged by PSI 04 between 2016 and 2018 was reviewed by an expert panel of neurointerventionalists and neurologists.

Their conclusions were unequivocal:

All deaths were caused by the severity of the initial stroke, not by complications of the thrombectomy procedure

EVT accounted for 7.2% of neurosurgical PSI 04 flags, despite representing only 1.5% of neurosurgical procedures

Not a single case represented a preventable patient safety issue

Why the Metric Fails in Stroke Care

The researchers identified two core reasons why PSI 04 is flawed when applied to stroke thrombectomy:

The complications tracked by PSI 04 are common consequences of severe stroke itself, regardless of intervention

Stroke patients are critically ill before treatment, unlike elective surgical patients, and have far less physiological reserve to survive complications

“We’re essentially penalizing hospitals for trying to save patients who are already dying from stroke,” Dr. Reider-Demer said. “These procedures offer the only chance for survival or meaningful recovery, yet the metric makes it appear as though hospitals are delivering poor care.”

Risk of Harmful Incentives

The study warns that misapplied safety metrics can have real-world consequences. Previous research has shown that public reporting of surgical outcomes led some physicians to avoid treating high-risk patients to protect performance ratings.

“There’s a serious concern that hospitals may become reluctant to offer thrombectomy to the most severe stroke patients,” said Dr. Jeffrey Saver, the study’s senior author and vice chair for Clinical Research in UCLA’s Department of Neurology. “Centers that care for the sickest patients could be unfairly penalized in quality rankings and reimbursement.”

This issue is becoming increasingly urgent as recent clinical trials have expanded thrombectomy eligibility to patients with large, severe strokes, who face high mortality even with treatment—though outcomes remain significantly worse without intervention.

Call for Smarter Quality Measures

The authors urge policymakers, payers, and quality organizations to reconsider how federal safety metrics are applied to emergency and high-acuity care. They emphasize the need for stroke-specific, risk-adjusted measures that accurately reflect clinical realities rather than discourage lifesaving treatment.

As the use of thrombectomy continues to expand, the study highlights a critical need to align hospital quality metrics with patient-centered outcomes—ensuring that hospitals are rewarded, not punished, for delivering care to those who need it most.

Source: https://www.news-medical.net/news/20260108/Federal-hospital-safety-metric-fails-to-accurately-assess-emergency-stroke-care.aspx