Ranking the performance of a public hospital has always been fraught with danger. Hospitals have much at stake with the release of performance data, including everything from funding allocations to the bonuses received by top executives.
Let’s say there is much incentive to get creative in the public reporting of such metrics.
In recent years the media have made much about hospital standardized mortality ratios (HSMR), a measure imported from UK that looks at the number of unexpected deaths that take place in a hospital.
Now a study funded by Oshawa’s Lakeridge Health suggests that the HSMR may be subject to considerable gaming to improve the image of certain hospitals.
While the study acknowledges some hospitals may have done considerable work to improve patient outcomes, much of the improved HSMR may be in fact the result of how deaths are coded.
The proof – a dramatic rise in the number of deaths coded as “palliative,” which don’t count in the HSMR score.
“Because calculating the expected number of deaths is dependent on how patients have been coded, an opportunity exists for a hospital to alter how sick their patients appear to be,” states the new report written by Christopher AKY Chong, Geoffrey C. Nguyen and M. Elizabeth Wilcox.
Between 2008 and 2010 palliative deaths recorded in hospital rose by close to 50 per cent – paralleling what happened in the UK when HSMRs were introduced there.
When HSMRs were first calculated and made public in 2007, many hospitals suggested that their poor ratings were “due to misunderstandings in palliative coding” despite the fact that the Canadian Institute for Health Information had sent out specific coding guidelines the previous year.
While the coding issue may be responsible for much of this sudden change in HSMR scores, the study did not look at other gaming options, including sending patients home to die. Evidently the English Department of Health must have had their suspicions that this was also taking place in the UK. They adopted a new mortality measure that includes not just palliative care patients, but also deaths that took place within 30 days of discharge.
Dr. Chong, one of the authors, told the National Post “just on the surface, if you looked at some hospitals, the performance is a Lance Armstrong performance – it’s a bit hard to believe.”