Hospital standardized mortality ratio: consequences of adjusting hospital mortality with indirect standardization

PLoS One. 2013 Apr 9;8(4):e59160. doi: 10.1371/journal.pone.0059160. Print 2013.


Background: The hospital standardized mortality ratio (HSMR) is developed to evaluate and improve hospital quality. Different methods can be used to standardize the hospital mortality ratio. Our aim was to assess the validity and applicability of directly and indirectly standardized hospital mortality ratios.

Methods: Retrospective scenario analysis using routinely collected hospital data to compare deaths predicted by the indirectly standardized case-mix adjustment method with observed deaths. Discharges from Dutch hospitals in the period 2003-2009 were used to estimate the underlying prediction models. We analysed variation in indirectly standardized hospital mortality ratios (HSMRs) when changing the case-mix distributions using different scenarios. Sixty-one Dutch hospitals were included in our scenario analysis.

Results: A numerical example showed that when interaction between hospital and case-mix is present and case-mix differs between hospitals, indirectly standardized HSMRs vary between hospitals providing the same quality of care. In empirical data analysis, the differences between directly and indirectly standardized HSMRs for individual hospitals were limited.

Conclusion: Direct standardization is not affected by the presence of interaction between hospital and case-mix and is therefore theoretically preferable over indirect standardization. Since direct standardization is practically impossible when multiple predictors are included in the case-mix adjustment model, indirect standardization is the only available method to compute the HSMR. Before interpreting such indirectly standardized HSMRs the case-mix distributions of individual hospitals and the presence of interactions between hospital and case-mix should be assessed.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Hospital Mortality*
  • Hospitals
  • Humans
  • Netherlands
  • Patient Admission
  • Quality Indicators, Health Care* / standards
  • Retrospective Studies
  • Risk Adjustment

Grants and funding

The study was part of a study commissioned by the Dutch Ministry of Health, Welfare and Sport. They had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.