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Patient safety

CIHI publishes mortality rates in hospitals

OTTAWA – For the first time in Canada, hospital standardized mortality ratio (HSMR) results for eligible acute care hospitals and health regions outside Quebec are being published in a new report by the Canadian Institute for Health Information (CIHI). The measure compares the actual number of deaths in a hospital or region with the average Canadian experience, after adjusting for several factors that may affect in-hospital mortality rates, such as the age, sex, diagnoses and admission status of patients.

“Hospitals and health care providers are continuously looking for ways to improve quality of care for their patients,” says Graham W. S. Scott, Chair of the Board of Directors of CIHI. “The HSMR builds on this good work by providing another important tool to better understand in-hospital mortality and identify areas for improvement.”

First used in the United Kingdom, the HSMR measure was adapted by CIHI for use in Canada at the request of hospitals and patient safety experts. The HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada report includes HSMR results for 85 larger acute care facilities/corporations and 42 health regions outside Quebec over the last three fiscal years (2004–2005 to 2006–2007). During this period, just over 254,000 patients died in Canadian hospitals outside of Quebec. (Quebec results are not available due to historical differences in hospital data collection.)

Today’s report builds on earlier efforts to develop information about quality of care and patient safety in Canada. A landmark study in 2004 funded by CIHI and the Canadian Institutes of Health Research found that 7.5% of adult medical or surgical patients had adverse events in hospital, about one-third of which were deemed preventable by expert reviewers. Most patients recover within six months, but each year, between 9,250 and 23,750 Canadian adults experience a “preventable” adverse event in hospital and later die, according to the study led by Ross Baker and Peter Norton.

“The HSMR is one tool for measuring and monitoring progress in patient safety. It’s a tool that can motivate change and make health care safer,” says Dr. Michael Baker, Physician-in-Chief at Toronto’s University Health Network. “HSMR numbers can be used as one measure of the quality of care, but the ratio is best used as an indicator of trends, not as a target.”

In-hospital mortality rates vary by patient group

The overall average HSMR fell by 6% over the study period (excludes patients identified by hospitals as having received palliative care), but trends vary by patient group. For example, death rates for patients with heart attacks fell faster than those for patients with pneumonia. The HSMR measure focuses on 65 diagnosis groups that account for 80% of in-hospital deaths, excluding palliative care. The five diagnoses that had the highest numbers of deaths were heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease and septicemia.

Age, sex and other factors related to risk of in-hospital mortality

CIHI’s analysis found that older patients, those with certain health problems in addition to their main diagnosis (such as kidney disease or AIDS), urgent/emergent admissions and men had higher odds of dying than other patients. These factors, plus the patients’ length of stay in hospital and whether or not they were transferred between hospitals, were taken into account in calculating hospital and regional HSMR results.

“Some hospital patients are older or have more health problems than others,” says Glenda Yeates, CIHI’s President and CEO. “The HSMR calculation adjusts for these and other variables wherever possible, but each hospital and community is unique. No measure can take into account all possible factors that may influence the risk of dying in hospital, and as a result, HSMR results are most helpful when used by individual hospitals and health regions to track their progress over time.”

HSMR: from measurement to action in Canada and abroad

Hospitals in the U.K. and the United States have been using HSMR results to track in-hospital mortality and target areas for improvement in the delivery of care for several years. For example, the Bradford Teaching Hospitals Trust in the U.K. reported on its experiences in the Journal of the Royal Society of Medicine last year. Its HSMR fell from 95 to 78 over four years, an improvement that the hospital estimates translates into 905 fewer deaths. Work with HSMR is also under way in several other countries, such as the Netherlands and Sweden.

In Canada, hospitals and regions have begun to track their HSMR results as part of efforts to improve care. For example:

The Saskatoon Health Region has committed to transforming the care and service experience in the region, including reduced hospital mortality. In support of this goal, the Region is introducing rapid response teams to prevent deaths in patients who are failing outside of intensive care settings, and adopting practices to prevent ventilator-associated pneumonia, to reduce medication problems and infections and to standardize wound and skin care. The Region considers this work a key plank in its efforts to improve patient safety.

Pneumonitis due to inhaling solids and liquids is on the top-20 list of diagnoses related to in-hospital death. Because of data it was able to obtain from the HSMR, New Brunswick is able to focus on opportunities to improve feeding practices for patients with dementia who have trouble swallowing.

“In recent years, many hospitals, health regions and clinical teams have implemented strategies to reduce the harm and deaths related to adverse events, such as infections and medication incidents, and to improve quality of care overall,” says Phil Hassen, CEO of the Canadian Patient Safety Institute and Chair of the Safer Healthcare Now! campaign. “It’s promising to see that these efforts are paying off, and to be able to measure this progress in a tangible way.”


About CIHI
The Canadian Institute for Health Information (CIHI) collects and analyzes information on health and health care in Canada and makes it publicly available. Canada’s federal, provincial and territorial governments created CIHI as a not-for-profit, independent organization dedicated to forging a common approach to Canadian health information. CIHI’s goal: to provide timely, accurate and comparable information. CIHI’s data and reports inform health policies, support the effective delivery of health services and raise awareness among Canadians of the factors that contribute to good health.