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Description
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The ratio of the actual number of in-hospital deaths in a region or hospital to the number that would have been expected, based on the types of patients a region or hospital treats.

For further details, please see the General Methodology Notes.

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Calculation: Description
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The ratio of the actual number of in-hospital deaths to the expected number of in-hospital deaths, for conditions accounting for about 80% of inpatient mortality

Unit of Analysis: Hospitalization

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Calculation: Geographic Assignment
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Place of service

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Calculation: Type of Measurement
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Ratio

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Calculation: Adjustment Applied
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The following covariates are used in risk adjustment:
For each HSMR diagnosis group, the HSMR logistic regression models are fitted with age, sex, length-of-stay (LOS) group, admission category (urgent and elective), comorbidity (Charlson Index Score) group and transfers as independent variables.

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Calculation: Method of Adjustment
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Logistic regression

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Denominator
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Description:
Expected deaths, or number of deaths that would have occurred in a hospital or region had the mortality of these patients been the same as the mortality of similar patients across the country, based on the reference year years (2012–20132015–2016 to 2017–2018)
Inclusions:
1. Discharge between April 1 of a given year and March 31 of the following year 2. Admission to an acute care institution (Facility Type Code = 1)

32. Discharge with diagnosis group of interest (i.e., one of the diagnosis groups that account for about 80% of in-hospital deaths, after excluding patients receiving palliative care)

43. Age at admission between 29 days and 120 years

54. Sex recorded as male or female

65. Length of stay of up to 365 consecutive days

76. Admission category recorded as urgent/emergent or elective (Admission Category Code = U or L)
Exclusions:
1. Cadavers or stillborns (Discharge Disposition Code = 08 or 09)

2. Self sign-outs or did not return from a pass (Discharge Disposition Code = 06, 12, 61,* 62,* 65,* 66,* 67*)

3. Records with brain death as most responsible diagnosis code (ICD-10-CA: G93.81)

4. Records with most responsible diagnosis (, or Admission Category Code = R or S)

2. Records with most responsible diagnosis (MRDx) of palliative care (ICD-10-CA: Z51.5). For Quebec data: records where Z51.5 coded as MRDx, or cancer (C00–C97) coded as MRDx and Z51.5 coded in any secondary diagnosis field

53. Medical assistance in dying (MAID):
• 2016–2017 to 2017–2018 data only:
Discharge Disposition Code = 07 (in-hospital death) AND either 1 of the following 2:
– Prefix = J in any field; OR
– 3 CCI codes: 1.ZZ.35.HA-P7, 1.ZZ.35.HA-P1, 1.ZZ.35.HA-N3 (all present on the same abstract)
• 2018–2019 data onward: Discharge Disposition Code = 73

Note
*2018–2019 data onward

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Numerator
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Description:
Observed deaths, or actual number of in-hospital deaths that occurred in a hospital or region
Inclusions:
Death (Discharge Disposition Code = 07, 72*, * 74*)

Note
*2018–2019 data onward

Exclusions:
Same as for the denominator

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Data Sources
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DAD, HMDB

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Available Data Years
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Type of Year:
Fiscal
First Available Year:
2013 2014
Last Available Year:
2017 2018

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Geographic Coverage
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All provinces

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Reporting Level/Disaggregation
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National, Province/Territory, Region, Facility

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Update Frequency
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Twice a Every year

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Indicator Results
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Web Tool:
Your Health System: In Depth
URL:
Accessing Indicator Results on Your Health System: In Depth

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Updates
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Changes to the HSMR methodology , implemented in February 2015, November 2019 include the following:

1. Developed an updated top 80 list of diagnosis groups using 2015–2016 to 2017–2018 data; diagnosis groups C85, E86 and I24 were replaced with J10, A49 and I33.

2. HSMR results are calculated with an updated baseline using 2012–2013 2015–2016 to 2017–2018 data. The previous baseline was calculated using 2009–2010 2012–2013 data.

23. The statistical test of significance is based on comparing results with the national average peer group averages (as opposed to 100the national average).

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Caveats and Limitations
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Medical assistance in dying (MAID) was decriminalized in Canada with the enactment of Bill C-14 in June 2016. MAID cases are excluded from HSMR calculations for all DAD-submitting provinces and territories. It is In 2016–2017 and 2017–2018, it was not possible to exclude MAID cases from Quebec results due to differences in data collection. The impact of the differences of MAID exclusion is not fully known but is estimated to have a small effect on interprovincial comparability.

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Trending Issues
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Not applicable

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Comments
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The average experience of Canadian hospitals is set at 100 and is based on data collected in 2012–2013. HSMR results are compared against the current national average. An HSMR above the national average indicates that the hospital's mortality rate is higher than the average HSMR. An HSMR below the national average indicates that the hospital's mortality rate is lower than the average HSMR.

Further information is available in the Technical Notes and other HSMR resources: https://www.cihi.ca/en/health-system-performance/quality-of-care-and-outcomes/hsmr

Indicator results are also available in

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