calculation of adjusted death rates, hsmr experience in sweden hans rutberg, senior medical adviser...
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Calculation of adjusted death Calculation of adjusted death rates, HSMR rates, HSMR EExperience in Swedenxperience in Sweden
Hans Rutberg, Senior medical adviserHans Rutberg, Senior medical adviserSwedish National Board of Health and Welfare Swedish National Board of Health and Welfare
ÖSTERGÖTLANDS LÄNLinköping
SwedenInhabitants ~ 9 million
County Councils: 21
Hospitals ~ 70
Age, sex, admission method, los, Age, sex, admission method, los, diagnosis, HSMRs - hospital standardised diagnosis, HSMRs - hospital standardised
mortality ratios 1995-2001 (mortality ratios 1995-2001 (99%99% CIs) CIs)
0
20
40
60
80
100
120
140
RT3RCF
RBDREF
RLZRM
FRCD
RAJRCC
RTKRRK
RDZRVW
RJSRD3
RQQRNQ
RH2RJH RTP
RVLRNH
RDEREX
RE7
HS
MR
s (9
5% C
Is)
1995
/6 t
o 20
00/1
Source: Sir Brian Jarman
Walsall change of HSMR Walsall change of HSMR Observed – expected deaths (for top 80% all deaths) by 19 March 2005Observed – expected deaths (for top 80% all deaths) by 19 March 2005= a reduction of 303 deaths (379 death if scaled to 100% deaths, 0.147/bed/year = a reduction of 303 deaths (379 death if scaled to 100% deaths, 0.147/bed/year reduction)reduction)
50
60
70
80
90
100
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150
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
HS
MR
(w
ith 9
5% c
onfi
denc
e in
terv
als) First publication of HSMRs Jan 2001
Start of improvement interventions
Source: Sir Brian Jarman
Walsall Hospital Standardised Mortality Ratio, Walsall Hospital Standardised Mortality Ratio, HSMR, England 2000-01distribution and Walsall 19/3/2005 HSMR, England 2000-01distribution and Walsall 19/3/2005
0
20
40
60
80
100
120
140
RN
J
RW
G
RH
8
RP
R
RG
T
RJ
7
RL
Q
RX
C
RR
2
RC
C
RC
D
RA
9
RE
M
RM
3
RJ
N
RW
F
RV
W
RJ
2
RE
9
RT
G
RW
P
RC
9
RA
P
RW
D
RM
4
RD
U
RF
W
RB
N
RA
S
RM
C
HS
MR
s 2000-0
1 E
nglish
acu
te T
rust
s
Walsall 2000/1Walsall 19 March 2005, but with wide CIs
Source: Sir Brian Jarman
Evaluation of HSMR in SwedenEvaluation of HSMR in Sweden
• A project initiated by the National Board of Health and Welfare, the Federation of County Councils and the Southeast health care region.
• A national interest to use HSMR to compare hospitals and county councils
• A possible indicator for comparison of the Nordic countries?
Swedish Hospital Discharge Register started in the Swedish Hospital Discharge Register started in the 1960:s. Since 1987 it covers all public, in-patient care in 1960:s. Since 1987 it covers all public, in-patient care in SwedenSweden
• Data on patient:
Personal id-number, sex, age, place of residence
• Data on hospital:
County council, hospital, department
• Administrative data
Date of admission/discharge, LoS, acute/planned
admissions, admitted from, discharged to
• Medical data
Main and secondary diagnoses, surgical procedures,
external cause of injury and poisoning
HSMR in SwedenHSMR in Sweden
Variables:
• Sex• Age• Length of stay• Way of admission, transfer from other hospital• Acute/planned admission• Main diagnosis
HSMR in SwedenHSMR in SwedenMain diagnosis
• The main diagnoses accounting for80 % of hospital mortality
• 58 diagnoses• 370 000 admissions yearly, ~ 25 % of all
admissions
• 27 000 deaths annually
HSMR in SwedenHSMR in SwedenDischarged as dead
• Good quality
• 27 000 registrations per year
• 30 days mortality ??
Swedish deaths 2001 by CCS* groupSwedish deaths 2001 by CCS* group(*Clinical Classification System. Elixhauser A, Andrews RM, Fox, S. Clinical classifications for health policy (*Clinical Classification System. Elixhauser A, Andrews RM, Fox, S. Clinical classifications for health policy research: Discharge statistics by principal diagnosis and procedure. Provider Studies Research Note 17. research: Discharge statistics by principal diagnosis and procedure. Provider Studies Research Note 17. Rockville, MD:Rockville, MD:Agency for Health Care Policy and Research; 1993. AHCPR Pub. No. 93-0043. www.ahrq.orgAgency for Health Care Policy and Research; 1993. AHCPR Pub. No. 93-0043. www.ahrq.org ))
0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000
Coronary atherosclerosis and other heart disease
Non-Hodgkin's lymphoma
Pulmonary heart disease
Leukemias
Chronic obstructive pulmonary disease and bronchiectasis
Cardiac arrest and ventricular fibrillation
Peripheral and visceral atherosclerosis
Respiratory failure, insufficiency, arrest (adult)
Secondary malignancies
Cancer of breast
Aortic, peripheral, and visceral artery aneurysms
Cancer of pancreas
Cancer of colon
Cancer of prostate
Septicemia (except in labor)
Cancer of bronchus, lung
Pneumonia (except that caused by tuberculosis or sexuallytransmitted disease)
Congestive heart failure, nonhypertensive
Acute myocardial infarction
Acute cerebrovascular disease
Source: Sir Brian Jarman
HSMR in SwedenHSMR in SwedenLength of stayLength of stay,,1998-20041998-2004
OR 95 % CI
0-7 days 0.52 0.51 0.53
8-14 days 0.48 0.47 0.49
15-28 days 0.71 0.70 0.72
29-365 days 1.00 --
HSMR in SwedenHSMR in Sweden1998-20041998-2004
OR 95 % Ci• Transfer from other hospital 1,26 1,24-1,28
• Not planned 2,53 2,50-2,56
HSMRHSMR in Sweden in SwedenAdmission dataAdmission data
Example: Transfer from other Transfer from an Total number ofclinic, same hospital other hospital admissions 2003-2004
Sahlgrenska 1,2% 2,8% 212 706
Ryhov 4,4% 4,8% 56 700
Norrlands universitetssj 5,6% 7,6% 65 865
Linköping 5,4% 10,6% 83 700
Huddinge sjukhus 8,5% 6,2% 96 000
MAS 8,4% 2,2% 98 900
Akademiska sjukhuset 10,1% 43,5% 105 600( Uppsala )
All hospitals 4,1% 8,0% 2 819 000
Swedish preliminary HSMRs 1998-2004 Swedish preliminary HSMRs 1998-2004 (some exclusions will be necessary)(some exclusions will be necessary)
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170
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ith 9
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s)
Swedish preliminary county HSMRs 1998-Swedish preliminary county HSMRs 1998-2004 (some exclusions will be necessary)2004 (some exclusions will be necessary)
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60
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80
90
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110
120
130
HS
MR
(w
ith 9
5% c
onfi
denc
e in
terv
als)
HSMR, County Council, The Swedish Hospital Discharge Register,1998-2004. HSMR, County Council, The Swedish Hospital Discharge Register,1998-2004.
OR 95 % CI
Stockholm 0,850,8
4 0,86
Uppsala 0,870,8
4 0,89
Dalarna 0,910,8
9 0,94
Jönköping 0,930,9
0 0,95
Västerbotten 0,960,9
4 0,99
Östergötland 0,980,9
5 1,00
Halland 0,980,9
5 1,01
Västra Götaland 0,980,9
7 1,00
Kronoberg 1,000,9
7 1,04
Jämtland 1,020,9
8 1,05
Kalmar 1,041,0
1 1,06
Gotland 1,051,0
0 1,12
Västernorrland 1,061,0
3 1,08
Skåne 1,061,0
4 1,07
Blekinge 1,091,0
5 1,13
Norrbotten 1,091,0
6 1,12
Gävleborg 1,141,1
1 1,17
Värmland 1,151,1
2 1,18
Örebro 1,181,1
5 1,21
Södermanland 1,181,1
5 1,21
Västmanland 1,211,1
8 1,25
OR 95 % CI
Stockholm 0,85
0,84 0,86
Dalarna 0,900,8
8 0,93
Östergötland 0,950,9
2 0,98
Kronoberg 0,950,9
2 0,99
Halland 0,960,9
3 0,98
Västra Götaland 0,980,9
6 0,99
Jämtland 0,980,9
5 1,02
Västerbotten 0,990,9
6 1,02
Jönköping 1,000,9
7 1,03
Gotland 1,020,9
6 1,08
Västernorrland 1,041,0
1 1,06
Skåne 1,041,0
2 1,05
Uppsala 1,041,0
1 1,07
Norrbotten 1,051,0
2 1,08
Kalmar 1,061,0
3 1,09
Gävleborg 1,081,0
6 1,11
Värmland 1,091,0
6 1,12
Blekinge 1,091,0
5 1,13
Västmanland 1,171,1
4 1,21
Örebro 1,201,1
7 1,23
Södermanland 1,201,1
7 1,24
HSMR, County Council, compensated for transfer within hospital
HSMR in SwedenHSMR in SwedenData quality problem:
• Transfer within hospital (1,2 - 10,1%)
• Transfer between hospitals (2,2 - 43,5%)
• Underreporting planned/not planned
• Large vs. small hospitals?
HSMR in SwedenHSMR in SwedenFuture steps:• Present the method and publish preliminary results on county council
level in the Swedish Medical Journal
• Discuss data quality with those responible on county council level
• Consider to use HSMR as a national indicator
• Pilot project in the South-east healthcare region on structured patient
record review on hospital deaths with IHIs Trigger Tool