Do Hospital Standardized Mortality Ratios Measure Patient Safety? HSMRs in the Winnipeg Regional Health Authority

Division of Research and Applied Learning, Winnipeg Regional Health Authority, Department of Community Health Sciences, University of Manitoba.
HealthcarePapers 02/2008; 8(4):8-24; discussion 69-75. DOI: 10.12927/hcpap.2008.19972
Source: PubMed

ABSTRACT The Canadian Institute for Health Information began publishing hospital standardized mortality ratio (HSMR) data for select Canadian hospitals in November 2007. This paper describes the experience of the Winnipeg Regional Health Authority in assessing the validity of the HSMR through statistical analysis, coding definitions and chart audits. We found a lack of empirical evidence supporting the use of the HSMR in measuring reductions in preventable deaths. We also found that limitations in standardization as well as differences in palliative care coding and place of death make inter-facility comparisons of HSMRs invalid. The results of our chart audit show that the HSMR is not a sensitive measure of adverse events as defined by "unexpected death" in the Canadian Adverse Events Study. It should not be viewed as an important indicator of patient safety or quality of care. We discuss the cumulative sum statistic as an alternative to the HSMR in monitoring in-hospital mortality.

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    • "Patient mortality is widely used, as the data are regularly available in administrative data bases. However, recent studies suggest that patient mortality, as currently used, was not a reliable indicator, largely because there was not sufficient attention paid to variations in case mix which limited standardisation (Gorton et al., 2005; Penfold et al., 2008). Preuss (2003) used hospital medication errors as the measure of quality of care, and found that increased employee knowledge directly impacted on decreasing medication errors. "
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    • "For studies in health care, quality of care is suggested as a relevant performance measure and has been measured as patient mortality, reduction in adverse events (most commonly impact on medication errors), patient satisfaction, and as a specific clinical outcome. Recent studies have suggested that patient mortality, as currently used, was not a reliable indicator, largely because insufficient attention is paid to variations in case mix which limited standardisation (Penfold et al., 2008, Gorton et al., 2005). Similarly hospital medication errors and other adverse events have been used as a measure of quality of care (Preuss, 2003), but studies have identified substantial underreporting of adverse events (Uribe et al., 2002), suggesting that it may not be a robust measure of quality of care. "
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    • "Indeed, the Canadian Institute for Health Information adopted HSMR analysis as recently as 2005 in order to drive their patent safety and improvement agenda.22 Certainly, the HSMR has its detractors and indeed many researchers do not consider the HSMR to be a suitable measure of, or surrogate marker for, patient safety.23 The pitfalls of HSMR analysis include the possibility for administrative errors such as miscoding and the possibility of missing data. "
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