Hospital standardised mortality ratio not fit for purpose

After growing interest in assessing Australian hospital performance, the HSMR has emerged as a potentially universal system-level indicator for comparing death rates between hospitals both within and across different jurisdictions. Australian Health Ministers have endorsed the HSMR as a key indicator of quality and safety, and efforts are currently underway towards its national implementation.

However, Dr Ian Scott, Director of Internal Medicine and Clinical Epidemiology at the Princess Alexandra Hospital in Brisbane, and co-authors said the HSMR’s value was not yet proven.

“The validity and reliability of the HSMR as a screening tool for distinguishing low-quality from high-quality hospitals remains in doubt, and it has not yet been proven that HSMR reporting necessarily leads to worthwhile improvement in quality of care and patient outcomes,” Dr Scott said.

“Despite its apparent low cost and ease of measurement, the HSMR is currently not ‘fit for purpose’ as a screening tool for detecting low-quality hospitals and should not be used in making interhospital comparisons. It may be better suited to monitoring changes over time within individual institutions.”

In an accompanying article, Dr Martin Gallagher, Head of Renal Policy at The George Institute for Global Health in Sydney, said public reporting in Australia had lagged behind many other countries, and learning from the international experience may smooth the development of an Australian reporting program.

“Public reporting of patient outcomes following hospitalisation in Australia has lagged behind that of other countries, but there is now clear commitment to its implementation,” Dr Gallagher said.

“There remain numerous challenges in the design and implementation of such a program, including strategic decisions, statistical methods, and the prevention of risk aversion and perverse behaviour.

“While the international experience of public reporting can provide invaluable lessons, the solutions to these challenges and the shape of the Australian program will need to suit the local context.”

In an accompanying editorial, Professor David Ben-Tovim from Flinders University, said the technical challenges of HSMRs must be balanced against the potential for public reporting to effectively improve care processes in Australia.

The Medical Journal of Australia is a publication of the Australian Medical Association.

The statements or opinions that are expressed in the MJA  reflect the views of the authors and do not represent the official policy of the AMA unless that is so stated.

CONTACT:            Dr Ian Scott                                                     0412 668 472

                           Ms Susan Murray                                              0401 771 457

                           George Institute for Global Health on behalf of Dr Martin Gallagher

                           Professor David Ben-Tovim                                 0414 730 991

                           Ross Verschoor,                                                 0407 187 907

                           Manager Media Unit, Flinders Medical Centre