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

3. ÖSTERGÖTLANDS LÄN Linköping Sweden Inhabitants ~ 9 million County Councils: 21 Hospitals ~ 70

4. Age, sex, admission method, los, diagnosis, HSMRs - hospital standardised mortality ratios 1995-2001 (99% CIs) Source: Sir Brian Jarman

5. 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) First publication of HSMRs Jan 2001 Start of improvement interventions Source: Sir Brian Jarman

6. Walsall Hospital Standardised Mortality Ratio, HSMR, England 2000-01distribution and Walsall 19/3/2005 Walsall 2000/1 Walsall 19 March 2005, but with wide CIs Source: Sir Brian Jarman

7. 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?

8. 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

9. HSMR in Sweden Variables: Sex Age Length of stay Way of admission, transfer from other hospital Acute/planned admission Main diagnosis

10. 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

11. HSMR in Sweden Discharged as dead Good quality 27 000 registrations per year 30 days mortality ??

12. 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 ) Source: Sir Brian Jarman

13. HSMR in Sweden Length of stay, 1998-2004 OR 95 % CI 0-7 days 0.52 0.51 0.53 8-14 days 0.48 0.47 0.49 15-28 days 0.71 0.70 0.72 29-365 days 1.00 --

14. HSMR in Sweden 1998-2004 OR 95 % Ci Transfer from other hospital1,261,24-1,28 Not planned2,532,50-2,56

15. HSMR in Sweden Admission data

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

17. Swedish preliminary county HSMRs 1998- 2004 (some exclusions will be necessary)

18. HSMR, County Council, The Swedish Hospital Discharge Register,1998-2004. HSMR, County Council, The Swedish Hospital Discharge Register,1998-2004. OR95 % CI Stockholm0,850,840,86 Uppsala0,870,840,89 Dalarna0,910,890,94 Jönköping0,930,900,95 Västerbotten0,960,940,99 Östergötland0,980,951,00 Halland0,980,951,01 Västra Götaland0,980,971,00 Kronoberg1,000,971,04 Jämtland1,020,981,05 Kalmar1,041,011,06 Gotland1,051,001,12 Västernorrland1,061,031,08 Skåne1,061,041,07 Blekinge1,091,051,13 Norrbotten1,091,061,12 Gävleborg1,141,111,17 Värmland1,151,121,18 Örebro1,181,151,21 Södermanland1,181,151,21 Västmanland1,211,181,25

19. OR 95 % CI Stockholm0,850,840,86 Dalarna0,900,880,93 Östergötland0,950,920,98 Kronoberg0,950,920,99 Halland0,960,930,98 Västra Götaland0,980,960,99 Jämtland0,980,951,02 Västerbotten0,990,961,02 Jönköping1,000,971,03 Gotland1,020,961,08 Västernorrland1,041,011,06 Skåne1,041,021,05 Uppsala1,041,011,07 Norrbotten1,051,021,08 Kalmar1,061,031,09 Gävleborg1,081,061,11 Värmland1,091,061,12 Blekinge1,091,051,13 Västmanland1,171,141,21 Örebro1,201,171,23 Södermanland1,201,171,24 HSMR, County Council, compensated for transfer within hospital

20. 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?

21. 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