Improving the mortality index among gynecologic oncology patients

Background: The mortality index is a quality metric that measures the ratio of observed mortality to expected mortality among inpatients. Expected mortality is a probability calculation based on documentation of patient risks and comorbidities. A mortality index of <1.0 represents fewer patients dying while admitted to the hospital than expected. We aimed to decrease the mortality index in our department by 10% in 6 months. Methods: We formed a multidisciplinary team from Gynecologic Oncology, Health Information Management, Office of Performance Improvement, Revenue Operations, Coding and Institutional Compliance. We educated providers on documentation of patient comorbidities, standardized documentation templates, focused coder analysis and in-depth review and discussion as a department of all inpatient deaths. Pre-intervention 8/2017–7/2018 and post-intervention 11/2018–2/2020 outcomes were compared using the Mann Whitney U test. Results: The median mortality index decreased by 44% from 0.84 to 0.47 (p = 0.03). The median expected mortality increased by 37% from 2.94 to 4.02 (p = 0.002). The median number of inpatient deaths, or observed mortalities, was unchanged though there was a non-significant decreasing trend. Conclusions: Inpatient mortality index is an important quality metric that can be improved through education, standardized documentation, focused review and discussion of all inpatient mortalities.

Mortality index; Mortality review; Inpatient mortality

[1] Hibbard JH, Stockard J, Tusler M. Does publicizing hospital performance stimulate quality improvement efforts? Health Affairs. 2003; 22: 84–94.

[2] Marshall MN, Shekelle PG, Leatherman S, Brook RH. The Public Release of Performance Data: what do we expect to gain? A review of the evidence. The Journal of the American Medical Association. 2000; 283: 1866.

[3] Longo DR. Consumer reports in health care: do they make a difference in patient care? The Journal of the American Medical Association. 1997; 278: 1579.

[4] Orlander JD, Fincke BG. Morbidity and mortality conference. Journal of General Internal Medicine. 2003; 18: 656–658.

[5] Dholakia CA, Reavis KM. Morbidity and Mortality Conference. The SAGES Manual of Quality, Outcomes and Patient Safety (pp. 161–164). Boston, MA: Springer. 2012.

[6] Harbison SP, Regehr G. Faculty and resident opinions regarding the role of morbidity and mortality conference. The American Journal of Surgery. 1999; 177: 136–139.

[7] Hutter MM, Rowell KS, Devaney LA, Sokal SM, Warshaw AL, Abbott WM, et al. Identification of Surgical Complications and Deaths: an Assessment of the Traditional Surgical Morbidity and Mortality Conference Compared with the American College of Surgeons-National Surgical Quality Improvement Program. Journal of the American College of Surgeons. 2006; 203: 618–624.

[8] Horwood CR, Latimer T, Powers CJ, Moffatt-Bruce SD, Rushing GD, Eiferman DS. Improving the mortality index by capturing patient acuity through interprofessional real-time documentation improvement in a single hospital system. Surgery. 2018; 164: 687–693.

[9] Ferris TG, Torchiana DF. Public Release of Clinical Outcomes Data —Online CABG Report Cards. New England Journal of Medicine. 2010; 363: 1593–1595.

[10] Barbieri JS, Fuchs BD, Fishman N, Cutilli CC, Umscheid CA, Kean C, et al. The Mortality Review Committee: a Novel and Scalable Approach to Reducing Inpatient Mortality. The Joint Commission Journal on Quality and Patient Safety. 2013; 39: 387–AP9.

[11] Dharmarajan K, Hsieh AF, Lin Z, Bueno H, Ross JS, Horwitz LI, et al. Diagnoses and Timing of 30-Day Readmissions after Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia. The Journal of the American Medical Association. 2013; 309: 355.

[12] Martin G, Majumder A, Adams Z, Binger T, Harder B. Methodology U.S. News & World Report 2019-2020 Best Hospitals Procedures & Conditions Ratings. 2019.

[13] Pope DG. Reacting to rankings: Evidence from “America’s Best Hospitals” Journal of Health Economics. 2009; 28: 1154–1165.

[14] Jin GZ, Sorensen AT. Information and consumer choice: the value of publicized health plan ratings. Journal of Health Economics. 2006; 25: 248–275.

[15] Scanlon DP, Chernew M, McLaughlin C, Solon G. The impact of health plan report cards on managed care enrollment. Journal of Health Economics. 2002; 21: 19–41.

[16] Wedig GJ, Tai-Seale M. The effect of report cards on consumer choice in the health insurance market. Journal of Health Economics. 2002; 21: 1031–1048.

[17] DesHarnais SI, Chesney JD, Wroblewski RT, Fleming ST, McMahon LF. The Risk-Adjusted Mortality Index: a new measure of hospital performance. Medical Care. 1988; 26: 1129–1148.

[18] Arquiette JM, Moss HA, Truong T, Pieper CF, Havrilesky LJ. Impact of a documentation intervention on health-assessment metrics on an inpatient gynecologic oncology service. Gynecologic Oncology. 2019; 153: 385–390.

[19] Pinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ, et al. Standards for Reporting Implementation Studies (StaRI): explanation and elaboration document. BMJ Open. 2017; 7: e013318.

[20] Hui D, Kim SH, Roquemore J, Dev R, Chisholm G, Bruera E. Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer. 2014; 120: 1743–1749.

[21] Lloyd SS. Physician and coding errors in patient records. The Journal of the American Medical Association. 1985; 254: 1330–1336.

[22] Shahian DM, Wolf RE, Iezzoni LI, Kirle L, Normand ST. Variability in the Measurement of Hospital-wide Mortality Rates. New England Journal of Medicine. 2010; 363: 2530–2539.

[23] Kipnis P, Liu V, Escobar GJ. Accuracy of hospital standardized mortality rates: Effects of model calibration. Medical Care. 2014; 52: 378–384.

[24] Pitches DW, Mohammed MA, Lilford RJ. What is the empirical evidence that hospitals with higher-risk adjusted mortality rates provide poorer quality care? A systematic review of the literature. BMC Health Services Research. 2007; 7: 91.

[25] Dubois RW, Rogers WH, Moxley JH, Draper D, Brook RH. Hospital Inpatient Mortality. New England Journal of Medicine. 1987; 317: 1674–1680.

[26] Thomas JW, Hofer TP. Accuracy of Risk-Adjusted Mortality Rate as a Measure of Hospital Quality of Care. Medical Care. 1999; 37: 83–92.