CMAJ • November 4, 2008; 179 (10). doi:10.1503/cmaj.1080102.
© 2008 Canadian Medical Association or its licensors
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
This Article
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Shojania, K. G.
Right arrow Articles by Forster, A. J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Shojania, K. G., MD
Right arrow Articles by Forster, A. J., MD MSc
Related Collections
Right arrow Quality improvement

Letters

Hospital standardized mortality ratios

Kaveh G. Shojania, MD* and Alan J. Forster, MD MSc{dagger}

*Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ont.; {dagger}Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ont.

[The authors respond:]

The finding of higher rates of preventable deaths in hospitals with high mortality in the study by Dubois and colleagues1 applied only to the analysis of deaths from pneumonia, for which the physician reviewers exhibited very poor agreement (kappa = 0.11). Moreover, in citing Dubois and colleagues in our commentary,2 we did not presuppose that process problems constitute the gold standard for quality indicators. However, process change represents the major aspect of health care delivery under providers' control. If hospital standardized mortality ratios correlate poorly with the need for process changes (as in the study by Dubois and colleagues and a recent study from Ontario3), it remains unclear how hospital standardized mortality ratios can serve as a useful screen for quality problems.

Few would argue there are quality problems in the Canadian health care system. The Canadian Adverse Event Study found preventable events in every hospital studied.4 Ideally, all hospitals would accept these results as fact and undertake vigorous efforts to look for quality problems rather than wait for the results of their hospital standardized mortality ratios analysis. Given that this does not occur, one might argue for the use of a screening test, to engage hospitals.

However, as we outlined in our commentary, the hospital standardized mortality ratio has both low sensitivity and poor specificity for quality problems.2 This is not unheard of among screening tests. Despite terrible performance characteristics, the fecal occult blood test improves detection of colon cancer, presumably because the results of annual application of this test randomly scare sufficient numbers of patients into undergoing the test they should have agreed to undergo in the first place, namely colonoscopy.

Unfortunately, whereas colon cancer really does reside in the colon, most quality problems do not manifest themselves in the charts of deceased patients.5 Thus, rather than engaging hospitals in vigorous and effective detection of quality problems, promotion of hospital standardized mortality ratios focuses hospitals' attention on chart reviews of in-hospital deaths, which has all the inconvenience of colonoscopy but not comparable benefits.

Footnotes

Competing interests: None declared.


REFERENCES

  1. Dubois RW, Rogers WH, Moxley JHD, et al. Hospital inpatient mortality. Is it a predictor of quality? N Engl J Med 1987;317:1674-80.[Abstract]
  2. Shojania KG, Forster AJ. Hospital mortality: when failure is not a good measure of success. CMAJ 2008;179:153-7.[Free Full Text]
  3. Guru V, Tu JV, Etchells E, et al. Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates. Circulation 2008;117:2969-76.[Abstract/Free Full Text]
  4. Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004;170:1678-86.[Abstract/Free Full Text]
  5. Bates DW, O'Neil AC, Petersen LA, et al. Evaluation of screening criteria for adverse events in medical patients. Med Care 1995;33:452-62.[CrossRef][Medline]




This Article
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Shojania, K. G.
Right arrow Articles by Forster, A. J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Shojania, K. G., MD
Right arrow Articles by Forster, A. J., MD MSc
Related Collections
Right arrow Quality improvement