The Dr Foster Unit at Imperial College is making four methodological upgrades to the Hospital Standardised Mortality Ratio (HSMR) risk models to improve case-mix adjustment and make the methodology more statistically robust. The four changes are:
1. Only use data from 2000/2001 onwards
As we now have 15 years of data, and the early years are of lesser quality, and perhaps reflect different patterns of care, we are only going to use the most recent years of better quality data from 2000/01 onwards.
2. Remove ethnicity from the case-mix model
Although coding is improving, ethnicity is variably recorded across trusts. In some cases, up to 50% of admissions record ethnicity as unknown and this unequal recording may be very slightly biasing some of our indicators. We are therefore going to remove it from the case-mix model (although you will still be able to analyse by ethnicity in our quality solution, Real Time Monitoring).
3. Improved Charlson weightings for interaction
The effect of comorbidity differs by age. We are now taking this into account in our case-mix model. The inclusion of interaction terms is widely used in the literature.
4. Better adjustment for age
Where previously the HSMR model required at least 20 deaths per age group we now only need 10 deaths per group. This better adjustment for age will give us a better prediction of death for each patient.
What does this mean?
The improvements to the methodology mean greater power in the modelling for most diagnoses within Dr Foster’s Real Time Monitoring tool, strengthening the insight that can be gleaned by users from the drill-down capabilities. These upgrades are fundamentally about improving the underlying models that compose the HSMR.
This also means that all English HSMR’s will change slightly to reflect the impact of the new risk model. Early estimates show that For 2010/11, three trusts will improve banding, one trust will go from ‘as expected’ to ‘higher than expected’ and that all other acute hospital trusts will stay within the same band. Your regional Customer Support Managers will be in touch directly if you are affected by a change in band.
Differences in HSMR’s are likely to range from – 4.3 points to + 2.7 points. However, for 65% of trusts the difference will be ± 1 point or lower, for 84% of trusts the difference will be ± 1.5 points or lower and for 95% of trusts the difference will be ± 2 points or lower. Therefore only 5% of trusts will have a difference in their HSMR of greater than ± 2 points.
The data extract will be published in early September and will be used to calculate 2010/2011 HSMRs and other indicators for the 2011 Hospital Guide.
Contact Us
Should you have any questions please contact your regional Customer Support Manager (CSM) for more information. If you do not know who your CSM is please call 0800 288 9810.
I have a few issues with the way our hospital is running its Emergency rota.
Patients are admitted under one consultant & are then transferrred under another consultant only to be operated by a third consultant.If in this process a patient dies it skews the figures of the operating surgeon, which is mostly a ? Locum Surgeon!
One major issue with the current HSMR is the way that allowance is made for patients under “palliative care”.
The rules set down in the NHS Classifications Service Coding Clinic Volume 7 Issue of June 2010. state that patients shoudl only be assigned to the ICD code Z51.5 if they are under the care of a palliative care team i.e. a consultant with specialty code 315 (Palliative Medicine).
Other patients receiving palliative care towards the end of life should be coded Z51.8 “Other specified medical Care”.
Your current algorithm only includes the Z51.5 code and not the Z51.8 code even though both groups of patients have an inherent higher risk of mortality.
In spite of most paitents classed as “palliative care” NOT being under the care of a specialist palliative care team but managed by Elderly Medicine consultants, most hospitals are still using the Z51.5 code – mainly to satsify your crterion and hence not to have an excessive HSMR.
I have apprroached a few hosptials who openly admit they their current coding is incorrect, but they do not wish to change as it will have an adverse effect on their HSMR. This is thus a classic case of “tail wagging dog”.
Can I request that you thus include BOTH the Z51.5 and the Z51.8 codes when calculating the HSMR.
This will both give a more accurate picture of true excess mortatity and enable trusts to correclty code their patients.
Until this happens, those trusts that are coding correclty are having to expalin to both their SHA and the DoH why they apparently have excess mortality.
Happy to porvide more detail if required.
Dr Adrian Lambourne
Assistant Director of Information and Perforamnce
NHS Luton