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

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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)

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100110120130140150

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

HSM

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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

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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 SwedenVariables:

• 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 diseaseNon-Hodgkin's lymphoma

Pulmonary heart diseaseLeukemias

Chronic obstructive pulmonary disease and bronchiectasis

Cardiac arrest and ventricular fibrillationPeripheral and visceral atherosclerosis

Respiratory failure , insufficiency, arrest (adult)Secondary malignancies

Cancer of breastAortic, peripheral, and visceral artery aneurysms

Cancer of pancreasCancer of colon

Cancer of prostateSepticemia (except in labor)

Cancer of bronchus, lung

Pneumonia (except that caused by tuberculosis or sexuallytransmitted disease)

Congestive heart failure, nonhypertensiveAcute myocardial infarction

Acute cerebrovascular disease

Source: Sir Brian Jarman

HSMR in SwedenHSMR in SwedenLength of stayLength of stay,,1998-20041998-2004

OR 95 % CI0-7 days 0.52 0.51 0.538-14 days 0.48 0.47 0.4915-28 days 0.71 0.70 0.7229-365 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 706Ryhov 4,4% 4,8% 56 700Norrlands universitetssj 5,6% 7,6% 65 865Linköping 5,4% 10,6% 83 700Huddinge sjukhus 8,5% 6,2% 96 000MAS 8,4% 2,2% 98 900Akademiska 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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Swedish preliminary county HSMRs 1998-Swedish preliminary county HSMRs 1998-2004 (some exclusions will be necessary)2004 (some exclusions will be necessary)

50

60

70

80

90

100

110

120

130

HSM

R (w

ith 9

5% c

onfid

ence

inte

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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