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. 2012 Nov 5;2(6):e001729.
doi: 10.1136/bmjopen-2012-001729. Print 2012.

Trends in Canadian hospital standardised mortality ratios and palliative care coding 2004-2010: a retrospective database analysis

Christopher Aky Chong  1 , Geoffrey C Nguyen, M Elizabeth Wilcox
Affiliations

Trends in Canadian hospital standardised mortality ratios and palliative care coding 2004-2010: a retrospective database analysis

Christopher Aky Chong et al. BMJ Open. .

Abstract

Background: The hospital standardised mortality ratio (HSMR), anchored at an average score of 100, is a controversial macromeasure of hospital quality. The measure may be dependent on differences in patient coding, particularly since cases labelled as palliative are typically excluded.

Objective: To determine whether palliative coding in Canada has changed since the 2007 national introduction of publicly released HSMRs, and how such changes may have affected results.

Design: Retrospective database analysis.

Setting: Inpatients in Canadian hospitals from April 2004 to March 2010.

Patients: 12 593 329 hospital discharges recorded in the Canadian Institute for Health Information (CIHI) Discharge Abstract Database from April 2004 to March 2010.

Measurements: Crude mortality and palliative care coding rates. HSMRs calculated with the same methodology as CIHI. A derived hospital standardised palliative ratio (HSPR) adjusted to a baseline average of 100 in 2004-2005. Recalculated HSMRs that included palliative cases under varying scenarios.

Results: Crude mortality and palliative care coding rates have been increasing over time (p<0.001), in keeping with the nation's advancing overall morbidity. HSMRs in 2008-2010 were significantly lower than in 2004-2006 by 8.55 points (p<0.001). The corresponding HSPR rises dramatically between these two time periods by 48.83 points (p<0.001). Under various HSMR scenarios that included palliative cases, the HSMR would have at most decreased by 6.35 points, and may have even increased slightly.

Limitations: Inability to calculate a definitively comparable HSMR that include palliative cases and to account for closely timed changes in national palliative care coding guidelines.

Conclusions: Palliative coding rates in Canadian hospitals have increased dramatically since the public release of HSMR results. This change may have partially contributed to the observed national decline in HSMR.

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Figures

Figure 1
Figure 1
Crude monthly percentage of deaths and percentage of cases with palliative care as any diagnosis of Canadian inpatients, April 2004 to March 2010 (n=12 593 329).
Figure 2
Figure 2
Crude monthly percentage of cases with palliative care as any diagnosis, grouped by inpatients in hospitals that do (n patients=4 791 714) and do not (n patients=7 801 635) have publicly released Canadian HSMR results, April 2004 to March 2012.
Figure 3
Figure 3
Seasonally adjusted HSMR (n=3 816 181) and HSPR (n=12 593 172) rates for Canadian inpatients, April 2004 to March 2010.
See this image and copyright information in PMC

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