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HSMR_Poor_Instrument

Hospital standardised mortality ratio is a poor instrument to measure quality in healthcare: Learn why
by

Ulrik Gerdes

on 13 June 2016

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Transcript of HSMR_Poor_Instrument

Hospital standardised mortality ratio is a poor instrument to measure quality in healthcare
Copenhagen, September 2013 :: Performance indicators in health care
Research Network for Patient Safety and Quality in Health Care
Ulrik Gerdes
Troubles
Thank you for your attention!
The clinical frontline
[the sharp end]

Deaths
The
signal
Noise
Consultant, MD, DMSci, assistant professor
Center for Quality ∙ Region of Southern Denmark ∙ Middelfart
Institute of Regional Health Resarch ∙ University of Southern Denmark
Deaths are not a good place to look for problems with quality of care
Conclusions
Questions…?
Examples
The Capital Region of Denmark
The North Denmark Region
What's going on here?
Can quality improvements really happen so quickly?
Region Zealand
A 25% reduction in hospital mortality over the past 2 years! Really?
The Region of Southern Denmark
What's going on here?
Central Denmark Region
[...]
To increase your chances of surviving in a Danish hospital, simply stay on the right (= East) side of this bridge...?
Mysterious jumps in the HSMR for the largest Danish hospital (Odense University Hospital)
Oops! About 70 deaths were wrongly assigned to the first quarter of 2013
Health care is complex business!
Output = Input + Quality of care
A reasonable assumption
A reasonable derivation
Hospital Standardised Mortality Ratio (HSMR)
Relatively few patients die [in some period of time], and only few deaths are due to problems with quality of care
Whole country
This region
A difficult type of measurement
Variation in quality causes variation in the proportion of preventable deaths
But we try to measure variation in quality using variation in the number of all deaths (a proxy)
How many?
All deaths: 4-8%
Proportion of preventable deaths: 2-6%*
*Hayward & Hofer, 2001; Zegers et al., 2009; Hogan et al., 2012; Unpublished Danish study, 2013
There are many sources...
Calculations are based on data derived from routinely collected episode statistics
Quality of the data, and changes in patient populations and flows
Quality of the model, parameter estimates and data (in particular coding of primary and secondary diagnoses)
HMSR
Using standardised mortality ratios does not make it better, on the contrary
We need appropriate measures of quality of care for improving it
Full transcript