| Are some hospitals better than others at, well, keeping folks alive? That's what the Cambridge-based Institute for Health Improvement has tried to quantify with its Hospital Standardized Mortality Rate metric, which measures life-or-death outcomes in the most common diagnoses -- those that account for 80% of all deaths. It's intended to be a stark and powerful marker of the quality of care at a hospital -- and to spur hospitals to act to improve quality of care. Health care quality and cost are closely related issues, and are likely to get more attention as the cost of care continues to spiral out of control. And with the financing of our new health care law on a knife-edge, it's an especially keen issue in Massachusetts. I went to a talk yesterday on the possibility of using this metric in hospitals across Massachusetts, and even making the numbers public. It was organized by Health Care for All, with Mass. Coalition for the Prevention of Medical Errors. The discussion dealt with the questions: - Is it a good metric?
- What does it tell you, and what doesn't it tell you?
- Is it useful to have such information be public, or is it likely to be misinterpreted by the press and the general public -- with negative consequences for all concerned?
The answers may be "yes" to both parts of that last question. Sir Brian Jarman, former President of British Medical Association and developer of the HSMR metric, claims that just such a metric has helped improve practices across the UK, by spotlighting potential problem areas. And yet, as a global measure of care at a hospital, it might well be publicly misinterpreted or over-emphasized, due to various confounding variables. |
| 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. |
