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Pressure to reduce healthcare costs and improve quality of care has led some insurers to adopt a pay-for-performance system that incorporates quality indicators. Recently, an insurer evaluated the quality of Massachusetts hospitals using mortality rate for patients admitted under the DRG code of acute stroke. Based on the assumption that mortality is an outcome that reflects quality of care, the insurer identified a higher mortality rate for this patient group in 2004 at Tufts-NEMC than at most other academic centers in Massachusetts. The insurer also identified significant increase in mortality rate in this group from 200 to 2004 at Tufts-NEMC, prompting an internal committee to review all charts for this patient group. The committee evaluated details of patient demographics, severity of illness, code status at the time of death, length of hospitalization, and hospital transfers and concluded that no significant contribution from medical error led to patient mortality. The committee found that simply reviewing DRG code data and in-hospital mortality rates was insufficient to accurately and reliably determine quality of healthcare for the admission diagnosis of acute stroke. A Review of Stroke DRG Mortality Rate as a Quality of Care Measure Peer-Reviewed Research