title: A simple insightful approach to investigating a hospital standardised mortality ratio: an illustrative case-study.
abstract: BACKGROUND
  Despite methodological concerns Hospital Standardised Mortality Ratios (HSMRs) are promoted as measures of performance. Hospitals that experience an increase in their HSMR are presented with a serious challenge but with little guidance on how to investigate this complex phenomenon. We illustrate a simple penetrating approach.
  
  
  METHODS
  Retrospective analysis of routinely collected hospital admissions data comparing observed and expected deaths predicted by the Dr Foster Unit case mix adjustment method over three years (n = 74,860 admissions) in Shropshire and Telford NHS Trust Hospital (SaTH) constituting PRH (Princess Royal Hospital) and RSH (Royal Shrewsbury Hospital); whose HSMR increased from 99 in the year 2008/09 to 118 in the year 2009/10.
  
  
  RESULTS
  The step up in HSMR was primarily located in PRH (109 to 130 vs. 105 to 118 RSH). Disentangling the HSMR by plotting run charts of observed and expected deaths showed that observed deaths were stable in RSH and PRH but expected deaths, especially at PRH, had fallen. The fall in expected deaths has two possible explanations-genuinely lower risk admissions or that the case-mix adjustment model is underestimating the risk of admissions perhaps because of inadequate clinical coding. There was no evidence that the case-mix profile of admissions had changed but there was considerable evidence that clinical coding process at PRH was producing a lower depth of coding resulting in lower expected mortality.
  
  
  CONCLUSIONS
  Knowing whether the change (increase/decrease) in HSMR is driven by the numerator or the denominator is a crucial pivotal first step in understanding a given HSMR and so such information should be an integral part of the HSMR reporting methodology.
authors.affiliation: Primary Care Clinical Sciences, University of Birmingham, Birmingham, United Kingdom. m.a.mohammed@bham.ac.uk
authors.forename: Mohammed A
authors.initials: MA
authors.lastname: Mohammed
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Stevens
mesh_terms: D003953:Diagnosis-Related Groups; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D010343:Patient Admission / Q000706:statistics & numerical data*; D010351:Patient Discharge; D011785:Quality Assurance, Health Care; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D020379:Risk Adjustment; D006113:United Kingdom