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Hospital mortality: What we don’t know

September 25, 2007 By Charley on the MTA

True to pattern, Paul Levy of Beth Israel Deaconess thinks it's a good idea for hospitals to make their HSMR scores public, and wonders why insurers don't require that. He frames it as a matter of keeping good faith with the public. Now, his protestations notwithstanding, that's difficult to disentangle from the fact that BIDMC has always performed quite well on HSMR — considerably below the national average. Now, you'd think that with all of our totally fabulous health care in Massachusetts, we'd be doing pretty well, right? Well, no: Massachusetts hospitals as a whole have tracked about ten points worse than the national rate since the 2000 data. And there are a few hospitals in MA that continue to be far, far worse in this metric than the national average (i.e. 140, vs. 100). At the very least, should they not know internally that this is the case? As BIDMC's Ken Sands posits, knowing the HSMR is useful for generating hypotheses within the hospital about how to improve care.

Followers of the standardized-testing debate in schools will recognize this pattern: Some people don't like being evaluated on the basis of a single numerical score, like Mass. General CEO Gregg Meyer. (To his credit, Meyer was a good enough sport to show up and make his case.) Meyer notes that “transparency” is the “mom and apple pie” virtue of business these days, but worries about popular misinterpretation of medical statistics. And indeed, much like their college rankings, hospital “rankings” of the US News and World Report kind are probably worth a bucket of warm spit.

But it strikes me that the answer is better statistics — and better, more sophisticated public interpretation — not to bury them altogether. Meyer himself mentioned a quality-improvement effort in Pittsburgh, wherein the local media were pro-actively briefed on how to interpret data. Such trust-building efforts would be most welcome — especially as opposed to silence.

We commonly see statistics used to bewilder and obfuscate rather than enlighten: For instance, baseball fans have long put too much emphasis on a batter's batting average, at the expense of say, on-base percentage. That being said, is batting average completely irrelevant? Moreover, should it be hidden from the public? If a hospital has higher mortality rate than it ought, that should be public; otherwise, we're going on the “trust-me” model of public accountability. The age of revered, unquestioned institutions — the courts, medicine, churches —
is over. Particularly in an era of increased public involvement and dollar-investment in our health care system, it's not too much to ask that our medical providers earn their credibility.

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Filed Under: User Tagged With: bidmc, health-care, hospitals, hsmr, mgh, paul-levy

Comments

  1. zadig says

    September 25, 2007 at 12:19 pm

    There are some basic problems with using mortality rate as a measure. Consider these situations:

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    1) Suppose Hospital A has an international reputation for cancer care. All of the truly desperate cases will come from around the world to get their care. Being desperate cases, they’ll often die getting that care. Does that mean Hospital A is worse than the county hospital down the street that only gets “normal” cases and therefore saves them at a higher rate?

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    2) Population demographics — a hospital with a very old or poor population will have a higher mortality rate than one with a young, affluent population, right?

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    The stats shouldn’t be hidden from the public (I can’t think of very much data that should be hidden from the public, to be honest), but they need to be released with a whole lot of caveats. The raw numbers won’t help people choose a good hospital — they need explanation, too.

    • charley-on-the-mta says

      September 25, 2007 at 12:27 pm

      that HSMR actually does calculate those factors — or at least it can.

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      It was agreed by all concerned that there is only so much value for this as a comparative consumer tool — should I go to hospital A or B — but it is useful to the hospital, at least to know whether care is getting better or worse.

    • hrs-kevin says

      September 25, 2007 at 12:29 pm

      The HSMR score represents the ratio of actual deaths to expected deaths, were the latter takes into account diagnosis and demographic factors.

      • zadig says

        September 25, 2007 at 2:47 pm

        That makes a lot more sense. I’m sorry if that was somewhere in the links and I missed it — I did look around before posting, but didn’t see that.

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        Doesn’t change my ultimate opinion that the information should be available to all concerned (i.e., the public, too) along with clarifying warnings and information.

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        Thanks for clearing up my misconceptions.

        • charley-on-the-mta says

          September 25, 2007 at 4:23 pm

          I don’t know if this will make sense to you, but Sir Brian Jarman’s PowerPoint from the event is here. In it he explains a little bit how the metric is put together.

  2. goldsteingonewild says

    September 25, 2007 at 9:08 pm

    I agree: the answer to incomplete information is more information, in every public sector.  Paul Levy is a hero! 

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    Status quo protectors — ie, people who work in the sector, who usually are well-financed and tend to contribute heavily to politics — try to prevent us (public) from getting add’l information by setting up an impossible-to-reach standard that says “Unless all information is somehow perfect, none can be released.” 

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    For example, there was a Globe story 2 weeks ago that the cops weren’t providing requested info on the race of drivers they stopped.  Ah, here it is. 

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    An ambitious state program launched two years ago to explore the disproportionate number of minority drivers pulled over on state roads has failed to produce any comprehensive results because nearly half of the targeted police departments did not follow the recommended guidelines and the state never received or reviewed any data, according to documents obtained by the Globe.

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    Why?

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    Police chiefs, many of whom have opposed the program since its inception, said the lack of results was predictable. Many chiefs have long contended that there is no widespread racial profiling in Massachusetts and that asking officers to fill out detailed reports on every traffic stop wastes police resources.

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    I don’t do a lot of citizen traffic stops, but I’m not clearn on how checking off  race and gender can take more than a couple seconds. 

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    And even if the chiefs were RIGHT, the data could serve a valuable purpose, which is to assauge a significant chunk of citizens who think otherwise. 

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    Data should need to pass the “reasonable-ness” test, not the “perfection” test, in order to be shared.  And the gatekeepers shouldn’t be the self-interested. 

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