Associations between hospital deaths (HSMR), readmission and length of stay (LOS): A longitudinal assessment of performance results and facility characteristics of teaching and large-sized hospitals in Canada between 2013-2014 and 2017-2018

Objectives To examine the association between hospital deaths (hospital standardised mortality ratio, HSMR), readmission, length of stay (LOS) and eight hospital characteristics. Design Longitudinal observational study. Setting A total of 119 teaching and large-sized hospitals in Canada between fiscal years 2013-2014 and 2017-2018. Participants Analysis focused on indicator results and characteristics of individual Canadian hospitals. Primary and secondary outcomes Hospital deaths (HSMR); all patients readmitted to hospital; average LOS and a series of eight hospital characteristic summary measures: number of acute care hospital stays; number of acute care beds; number of emergency department visits; average acute care resource intensity weight; total acute care resource intensity weight; hospital occupancy rate; patients admitted through the emergency department (%); patient days in alternate level of care (%). Results Comparing 2013-2014 to 2017-2018, hospital deaths (HSMR) largely declined, while readmissions increased; 69% of hospitals decreased their hospital deaths (HSMR), while 65% of hospitals increased their readmissions rates. A greater proportion of community-large hospitals (31%, n=14) improved on both hospital deaths (HSMR) and readmission compared to Teaching hospitals (13.9%, n=5). Hospital deaths (HSMR), readmission and LOS largely showed very weak and non-significant correlations. LOS was largely positively and statistically significantly correlated with the suite of eight hospital characteristics. Hospital deaths (HSMR) was largely negatively (not statistically significantly) correlated with the hospital characteristics. Readmission was largely not statistically significantly correlated and showed no clear pattern of correlation (direction) with hospital characteristics. Conclusions Examining publicly reported hospital performance results can reveal meaningful insights into the association among outcome indicators and hospital characteristics. Good or bad hospital performance in one care domain does not necessarily reflect similar performance in other care domains. Thus, caution is warranted in a narrow use of outcome indicators in the design and operationalisation of hospital performance measurement and governance models (namely pay-for-performance schemes). Analysis such as this can also inform quality improvement strategies and targeted efforts to address domains of care experiencing declining performance over time; further granular subdivision of the analyses, for example, by hospital peer-groups, can reveal notable differences in performance.