Medicinska resultat i hälso- och sjukvården – några

Calculation of adjusted death rates, HSMR Experience in Sweden Hans Rutberg, Senior medical adviser Swedish National Board of Health and Welfare

Sweden Inhabitants ~ 9 million County Councils: 21 Hospitals ~ 70

ÖSTERGÖTLANDS LÄN Linköping

Age, sex, admission method, los, diagnosis, HSMRs - hospital standardised mortality ratios 1995-2001 (99% CIs) HSMRs (95% CIs) 1995/6 to 2000/1

140 120 100 80 60 40 20

Source: Sir Brian Jarman

TP R VL R NH R DE R EX R E7

R

JH R

H 2 R

D3 Q Q R NQ R

R

JS R

AJ R CC R TK R RK R DZ R VW

R

LZ M F R CD R

R

EF R

CF R BD

R

R

T3

0

Walsall change of HSMR Observed – expected deaths (for top 80% all deaths) by 19 March 2005 = a reduction of 303 deaths (379 death if scaled to 100% deaths, 0.147/bed/year reduction)

HSMR (with 95% confidence intervals)

150

First publication of HSMRs Jan 2001 Start of improvement interventions

140 130 120 110 100 90 80 70 60 50

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Source: Sir Brian Jarman

Walsall Hospital Standardised Mortality Ratio, HSMR, England 2000-01distribution and Walsall 19/3/2005 Walsall 2000/1

120 100 80 60 40

Source: Sir Brian Jarman

RMC

RAS

RBN

RFW

RDU

RM4

RWD

RAP

RC9

RWP

RTG

RE9

RJ2

RVW

RWF

RJN

RM3

REM

RA9

RCD

RCC

RR2

RXC

RLQ

RJ7

RGT

RPR

RH8

0

RWG

20 RNJ

HSMRs 2000-01 English acute Trusts

Walsall 19 March 2005, but with wide CIs 140

Evaluation of HSMR in Sweden • A project initiated by the National Board of Health and Welfare, the Federation of County Councils and the Southeast health care region. • A national interest to use HSMR to compare hospitals and county councils

• A possible indicator for comparison of the Nordic countries?

Swedish Hospital Discharge Register started in the 1960:s. Since 1987 it covers all public, in-patient care in Sweden • Data on patient: Personal id-number, sex, age, place of residence • Data on hospital: •

County council, hospital, department Administrative data Date of admission/discharge, LoS, acute/planned admissions, admitted from, discharged to

•

Medical data Main and secondary diagnoses, surgical procedures, external cause of injury and poisoning

HSMR in Sweden Variables: • Sex • • • • •

Age Length of stay Way of admission, transfer from other hospital Acute/planned admission Main diagnosis

HSMR in Sweden Main diagnosis • The main diagnoses accounting for 80 % of hospital mortality • 58 diagnoses • 370 000 admissions yearly, ~ 25 % of all admissions • 27 000 deaths annually

HSMR in Sweden Discharged as dead

• Good quality • 27 000 registrations per year

• 30 days mortality ??

Swedish deaths 2001 by CCS* group (*Clinical Classification System. Elixhauser A, Andrews RM, Fox, S. Clinical classifications for health policy research: Discharge statistics by principal diagnosis and procedure. Provider Studies Research Note 17. Rockville, MD: Agency for Health Care Policy and Research; 1993. AHCPR Pub. No. 93-0043. www.ahrq.org )

Acute cerebrovascular disease Acute myocardial infarction Congestive heart failure, nonhypertensive Pneumonia (except that caused by tuberculosis or sexually transmitted disease) Cancer of bronchus, lung Septicemia (except in labor) Cancer of prostate Cancer of colon Cancer of pancreas Aortic, peripheral, and visceral artery aneurysms Cancer of breast Secondary malignancies Respiratory failure, insufficiency, arrest (adult) Peripheral and visceral atherosclerosis Cardiac arrest and ventricular fibrillation Chronic obstructive pulmonary disease and bronchiectasis Leukemias Pulmonary heart disease Non-Hodgkin's lymphoma Coronary atherosclerosis and other heart disease 0

Source: Sir Brian Jarman

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

HSMR in Sweden Length of stay,1998-2004

0-7 days 8-14 days 15-28 days 29-365 days

OR 0.52 0.48 0.71 1.00

95 % CI 0.51 0.53 0.47 0.49 0.70 0.72 --

HSMR in Sweden 1998-2004

• Transfer from other hospital

OR 95 % Ci 1,26 1,24-1,28

• Not planned

2,53 2,50-2,56

HSMR in Sweden Admission data Transfer from other clinic, same hospital

Transfer from an other hospital

Total number of admissions 2003-2004

Sahlgrenska

1,2%

2,8%

212 706

Ryhov

4,4%

4,8%

56 700

Norrlands universitetssj

5,6%

7,6%

65 865

Linköping

5,4%

10,6%

83 700

Huddinge sjukhus

8,5%

6,2%

96 000

MAS

8,4%

2,2%

98 900

10,1%

43,5%

105 600

4,1%

8,0%

2 819 000

Example:

Akademiska sjukhuset ( Uppsala ) All hospitals

50 Universitetssjukhuset Huddinge sjukhus Danderyds sjukhus Norrlands Akademiska Karolinska sjukhuset Falu lasarett Universitetssjukhuset S:t Görans sjukhus Södersjukhuset Sundsvalls sjukhus Kristianstads sjukhus Ryhov, länssjukhus SÄ-sjukvården Sahlgrenska Växjö lasarett Sunderbyns sjukhus Enköpings lasarett Hässleholms sjukhus Landskrona lasarett NU-sjukvården Östersunds sjukhus Ljungby lasarett Simrishamns sjukhus Skaraborgs sjukhus Värnamo sjukhus Ludvika lasarett Länssjukhuset Kungälvs sjukhus Örebro regionsjukhus Mora lasarett Blekingesjukhuset Ängelholms sjukhus Varbergs sjukhus Västerviks sjukhus Sala lasarett Halmstads sjukhus Arvika sjukhus Gävle sjukhus Visby lasarett Säffle sjukhus Bollnäs sjukhus Vrinnevisjukhuset Hudiksvalls sjukhus Örnsköldsviks Lindesbergs lasarett Kalix lasarett Karlstads sjukhus Lycksele lasarett Piteå Älvdals sjukhus Avesta lasarett Köpings lasarett Trelleborgs lasarett Norrtälje sjukhus Södertälje sjukhus Härnösands sjukhus Universitetssjukhuset Västerås lasarett Mälarsjukhuset Nyköpings sjukhus Helsingborgs lasarett Hälsinglands sjukhus Ystads lasarett Alingsås lasarett Oskarshamns sjukhus Kullbergska sjukhuset Kristinehamns Torsby sjukhus Kiruna lasarett Skellefteå lasarett Sollefteå sjukhus Gällivare lasarett Motala lasarett Nacka sjukhus Höglandssjukhuset Karlskoga lasarett Fagersta lasarett

HSMR (with 95% confidence intervals)

Swedish preliminary HSMRs 1998-2004 (some exclusions will be necessary) 190

170

150

130

110

90

70

Swedish preliminary county HSMRs 19982004 (some exclusions will be necessary)

HSMR, County Council, The Swedish Hospital Discharge Register,1998-2004. OR

95 % CI

Stockholm

0,85

0,84

0,86

Uppsala

0,87

0,84

0,89

Dalarna

0,91

0,89

0,94

Jönköping

0,93

0,90

0,95

Västerbotten

0,96

0,94

0,99

Östergötland

0,98

0,95

1,00

Halland

0,98

0,95

1,01

Västra Götaland

0,98

0,97

1,00

Kronoberg

1,00

0,97

1,04

Jämtland

1,02

0,98

1,05

Kalmar

1,04

1,01

1,06

Gotland

1,05

1,00

1,12

Västernorrland

1,06

1,03

1,08

Skåne

1,06

1,04

1,07

Blekinge

1,09

1,05

1,13

Norrbotten

1,09

1,06

1,12

Gävleborg

1,14

1,11

1,17

Värmland

1,15

1,12

1,18

Örebro

1,18

1,15

1,21

Södermanland

1,18

1,15

1,21

Västmanland

1,21

1,18

1,25

OR

95 % CI

Stockholm

0,85

0,84

0,86

Dalarna

0,90

0,88

0,93

Östergötland

0,95

0,92

0,98

Kronoberg

0,95

0,92

0,99

Halland

0,96

0,93

0,98

Västra Götaland

0,98

0,96

0,99

Jämtland

0,98

0,95

1,02

Västerbotten

0,99

0,96

1,02

Jönköping

1,00

0,97

1,03

Gotland

1,02

0,96

1,08

Västernorrland

1,04

1,01

1,06

Skåne

1,04

1,02

1,05

Uppsala

1,04

1,01

1,07

Norrbotten

1,05

1,02

1,08

Kalmar

1,06

1,03

1,09

Gävleborg

1,08

1,06

1,11

Värmland

1,09

1,06

1,12

Blekinge

1,09

1,05

1,13

Västmanland

1,17

1,14

1,21

Örebro

1,20

1,17

1,23

HSMR, County Council, compensated for transfer within hospital

HSMR in Sweden Data quality problem:

• Transfer within hospital (1,2 - 10,1%) • Transfer between hospitals (2,2 - 43,5%) • Underreporting planned/not planned • Large vs. small hospitals?

HSMR in Sweden Future steps: • Present the method and publish preliminary results on county council level in the Swedish Medical Journal

• Discuss data quality with those responible on county council level • Consider to use HSMR as a national indicator • Pilot project in the South-east healthcare region on structured patient record review on hospital deaths with IHIs Trigger Tool