Value of hospital standardized mortality ratio unclear, administrators say.

administrators continue to express concern about the effects of hospital standardized mortality ratios (HSMRs) — particularly, negative press — proponents say it’s proving to be an effective quality improvement tool. Representatives of two regional health authorities that received unflattering scores in each of the first three reports on HSMRs in Canadian hospitals released by the Canadian Institute for Health Information (www.cihi.ca /CIHI-ext-portal/internet/EN/Tabbed Content/health+system+performance /quality+of+care+and+outcomes/hsmr /cihi022025), say they have ongoing concerns about how the indicator is represented and calculated. But at an international meeting of health information experts in Toronto, Ontario, in October 2010, the HSMR was cast in a uniformly positive light. The HSMR “is one more indicator that allows hospitals to measure and monitor their progress to improve quality of care,” Dr. Eugene Wen, manager of health indicators at CIHI, told delegates to the World Health Organization — Family of International Classifications network, which includes representatives from 30 countries on five continents. Developed in the United Kingdom during the mid-1990s, the HSMR is a ratio of a hospital’s rate of unexpected deaths to a national average, adjusted for age, sex and diagnoses of patients. CIHI started calculating an HSMR for each Canadian hospital from discharge summaries as of 2004–05. It describes the indicator as “big-dot” — a systemlevel measure that can be used as a screening tool. Wen states its real value lies in yearover-year trending for an individual hospital, and in drilling down to analyze deaths in the 65 disease groups covered. Canada is among the first countries to use the HSMR, although the indicator has since been piloted or tested in the United States, Holland and Australia. But when the first HSMR report was released, it amounted to shock treatment for some administrators contacted by CMAJ. “I was surprised,” says John Malcom, chief executive officer of the Cape Breton District Health Authority, which oversees six hospitals. “And quite frankly, I thought I’d be out of a job.” The results came as a “bit of shock” to Arden Krystal, former executive director of the Burnaby Hospital in British Columbia. “The staff were quite devastated,” she says. “It did not square with what their lived experience had been. We also heard from our patients and donors that it didn’t seem right.” Although CIHI stresses that the HSMR should be used only to improve quality, not to compare hospitals, even Wen noted during the Toronto session that public release of the data hit the front pages in an often negative context. Wen recalled that former Ontario health minister George Smitherman called it “revolutionary” and talked openly about what could be done to protect patients in hospitals with poor scores. Malcom and Krystal say negative publicity undermined community confidence in their hospitals. “When information like this goes out to the media, it’s just too juicy for the media not to report it,” Krystal says, adding that the “scorecard” nature of the HSMR lent itself to interhospital comparisons. Wen says CIHI has tried to discourage such a divisive view. “We didn’t want a ranking, with hospitals fighting each other,” he says. CIHI has since changed the methodology from the original UK measure, in which the national average changed each year and News CMAJ