The Hospital Standardized Mortality Ratio Fallacy

Gestel, Yvette R.B.M. van; Lemmens, Valery; Lingsma, Hester F.; Hingh, Ignace H. J. T. de; Rutten, H.J.T.; Coebergh, Jan Willem

doi:10.1097/mlr.0b013e31824ebd9f

Cited by 55 publications

(43 citation statements)

References 48 publications

(62 reference statements)

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“…Na discussão sobre vantagens e problemas do uso da mortalidade hospitalar global ou específica por condição, é importante ter em conta que análises por condições específicas utilizando dados administrativos brasileiros vinham apresentando capacidade discriminativa dos modelos de risco inadequadas (estatística C inferior a 0,70) 3,29 do que a obtida na base inglesa, na qual 15 causas formavam esse grupo 21 . Apesar da sua atratividade em função da característica global e boa capacidade preditiva, a seleção de causas baseada na proposta de Jarman et al 21 é considerada mais imprecisa, já que a inclusão de muitos e variados motivos implica maior heterogeneidade do risco, sendo o tratamento do diagnóstico principal no modelo de risco mais complexo, o que pode levantar questionamentos quanto à validade atribuível 17,18 . Entretanto, essa ferramenta pode auxiliar o monitoramento temporal e assinalar problemas ou melhorias em ações voltadas para garantir a qualidade do cuidado hospitalar, tanto para os gestores das unidades quanto para gestores da rede.…”

Section: Discussionunclassified

“…Merecem destaque ainda as questões relacionadas à validade da mortalidade hospitalar associadas à adequação do ajuste de risco, particularmente quando se trabalha com uma gama de causas de morte agrupadas e com informação sobre gravidade do paciente extremamente limitada 17,18 . Nesse sentido, não foi possível identificar as comorbidades ou doenças presentes na admissão, que afetam a condição do paciente e seu prognóstico 14 .…”

Section: Limitesunclassified

“…Outro ponto de destaque, refere-se à análise da mortalidade hospitalar global ou segundo problemas específicos, escolha marcada por controvérsias na literatura quanto à validade, utilidade para a tomada de decisão e finalidade da avaliação 15,16,17,18 . Apoiados no incremento dos méto-dos e técnicas estatísticas para o ajuste de risco, na disponibilidade de grandes bases de dados administrativos e, sobretudo, no conhecimento disponível sobre a validade causal entre processo e resultado do cuidado, as análises da mortalidade hospitalar específica por doenças ou procedimentos cirúrgicos foram sendo mais exploradas 6,15,19 .…”

Section: Introductionunclassified

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Variação do desempenho hospitalar segundo fontes de pagamento nos estados de São Paulo e Rio Grande do Sul, Brasil

Machado¹,

Martins

Leite

2016

Cad. Saúde Pública

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Resumo: No Brasil, a convivência público-privado no financiamento e na prestação do cuidado ganha nítidos contornos na assistência hospitalar. Os arranjos de financiamento adotados pelos hospitais (Sistema Único de Saúde - SUS e/ou planos de saúde e/ou pagamento particular) podem afetar a qualidade do cuidado. Alguns estudos buscam associar a razão de mortalidade hospitalar padronizada (RMHP) a melhorias na qualidade. O objetivo foi analisar a RMHP segundo fonte de pagamento da internação e arranjo de financiamento do hospital. Analisaram-se dados secundários e causas responsáveis por 80% dos óbitos hospitalares. A RMHP foi calculada para cada hospital e fonte de pagamento. Hospitais com desempenho pior que o esperado (RMHP > 1) foram majoritariamente públicos de maior porte. A RMHP nas internações SUS foi superior, inclusive entre internações no mesmo hospital. Apesar dos limites, os achados indicam iniquidades no resultado do cuidado. Esforços voltados para a melhoria da qualidade de serviços hospitalares, independentemente das fontes de pagamento, são prementes.

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Section: Discussionunclassified

Section: Limitesunclassified

Section: Introductionunclassified

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Variação do desempenho hospitalar segundo fontes de pagamento nos estados de São Paulo e Rio Grande do Sul, Brasil

Machado¹,

Martins

Leite

2016

Cad. Saúde Pública

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“…Overall progress cannot be measured by SMRs alone, given that they are by nature cross-sectional and, when used to make comparison rankings, centered at specific values (such as 1.0 or 100) [35]. SMRs are not particularly informative when care is likely to be improving across a population as a whole.…”

Section: Monitoring Progress In Kidney Disease: Elements Of An Effectmentioning

confidence: 99%

Global challenges posed by the growth of end-stage renal disease

Wetmore

Collins

2016

Ren Replace Ther

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Profound challenges confront societies worldwide due to the growth of end-stage renal disease (ESRD). Meeting these challenges requires a sober assessment of how overall global health trends affect ESRD, coupled with an understanding of how progress in the care of ESRD patients is most appropriately measured and monitored. For many affluent countries, incident ESRD rates have stabilized since about the middle of the last decade. For example, the number of new cases in the USA has remained stable at approximately 110,000 per year during this period, while in Japan, growth in annual incident counts appears to have stabilized as of 2012. However, incidence rates rose for many developing countries. An immense "renal replacement therapy (RRT) gap," the difference between the number of people receiving RRT and the number needing it, was recently described, highlighting the magnitude of the difficulties these countries face as they continue to develop. To guide efforts to improve care, broad goals should be established by the worldwide renal health care community. For countries without universal dialysis access, expansion of RRT accessibility should be the first target in order to reduce the RRT gap; for countries that have moved beyond this stage, the goals should include reductions in ESRD incidence rates; all-cause, cardiovascular, and infection-related death rates; and cardiovascular-and infection-related hospitalizations. To inform judgements about progress in this area, measures beyond the traditional standardized mortality ratio are needed. Carefully determining trends over time within a given country, such as is done by the World Health Organization, might prove to be a more useful way to determine progress in combating ESRD and its complications.

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“…This suggests that use of SMRs may be suboptimal when small units of measure, such as individual outpatient dialysis facilities, are being compared. Additionally, and perhaps more profoundly for public health, overall societal progress cannot be adequately measured by SMRs because it is by nature cross-sectional and by definition centered (e.g., at 1.0 or 100) (43). SMRs are not especially informative when care is likely to be improving across a population as a whole, as in the case of United States dialysis patients since the turn of the millennium.…”

Section: Monitoring Progress: What Is the Most Appropriate Framework?mentioning

confidence: 99%

Improving Outcomes in Patients Receiving Dialysis: The Peer Kidney Care Initiative

Wetmore

Gilbertson

Liu

et al. 2016

CJASN

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The past decade has witnessed a marked reduction in mortality rates among patients receiving maintenance dialysis. However, the reasons for this welcome development are uncertain, and greater understanding is needed to translate advances in care into additional survival gains. To fill important knowledge gaps and to enable dialysis provider organizations to learn from one another, with the aim of advancing patient care, the Peer Kidney Care Initiative (Peer) was created in 2014 by the chief medical officers of 14 United States dialysis provider organizations and the Chronic Disease Research Group. Areas of particular clinical importance were targeted to help shape the public health agenda in CKD and ESRD. Peer focuses on the effect of geographic variation on outcomes, the implications of seasonality for morbidity and mortality, the clinical significance of understudied disorders affecting dialysis patients, and the debate about how best to monitor and evaluate progress in care. In the realm of geovariation, Peer has provided key observations on regional variation in the rates of ESRD incidence, hospitalization, and pre-ESRD care. Regarding seasonality, Peer has reported on variation in both infectionrelated and non-infection-related hospitalizations, suggesting that ambient environmental conditions may affect a range of health outcomes in dialysis patients. Specific medical conditions that Peer highlights include Clostridium difficile infection, which has become strikingly more common in patients in the year after dialysis initiation, and chronic obstructive pulmonary disease, the treatments for which have the potential to contribute to sudden cardiac death. Finally, Peer challenges the nephrology community to consider alternatives to standardized mortality ratios in assessing progress in care, positing that close scrutiny of trends over time may be the most effective way to drive improvements in patient care.

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The Hospital Standardized Mortality Ratio Fallacy

Abstract: Given the several shortcomings, use of the HSMR as an indicator of quality of care can be considered as a fallacy. Publication of the HSMR is not likely to lead to improvement of quality of care and might harm both hospitals and patients.

Cited by 55 publications

References 48 publications

Variação do desempenho hospitalar segundo fontes de pagamento nos estados de São Paulo e Rio Grande do Sul, Brasil

Variação do desempenho hospitalar segundo fontes de pagamento nos estados de São Paulo e Rio Grande do Sul, Brasil

Global challenges posed by the growth of end-stage renal disease

Improving Outcomes in Patients Receiving Dialysis: The Peer Kidney Care Initiative

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