Q&A: An interdepartmental approach to hospital mortality reviews
Q: What is the purpose of hospital mortality reviews, and how are they calculated?
A: In simple terms, mortality reviews are a review of encounters where patients have expired while in the hospital. These reviews are done for anything related to risk factors, quality indicators, risk adjustment scoring, or financial purposes. Some of the benefits of doing these reviews are that they can most accurately reflect the acuity of patients and the care they are provided, which in turn will impact risk adjustment diagnoses, including mortality risk variables, reimbursement through the acute inpatient prospective payment system, and publicly related data such as CMS star ratings.
There are many types of data that can be reported from mortality reviews. For example, mortality reviews can start with mostly reporting on changes to the severity of illnesses and risks of mortality that were seen in reported diagnosis-related groups (DRG), but then be built out to also calculate risk adjustment changes. Additional information on observed-to-expected mortality rates can be provided as well, helping to identify the DRGs that are most commonly related to mortalities.
Diving more deeply into some of the calculators and methodologies used for mortality reviews and reporting, the mortality index is a standardized way of reporting inpatient mortality and is calculated by dividing the observed mortality by the expected mortality. The observed mortality is the actual number of mortalities within a specific time frame: the goal is to decrease the observed mortality, which is done by increasing the number of patients that are discharged alive. The expected mortality—sometimes referred to as relative expected mortality—is a predicted number of deaths based on patients’ level of illness, age, gender, diagnoses, and various other factors. The goal for expected mortality is to appropriately document and code all of the conditions that are contributing to a patient's severity of illness and their risk of mortality. In terms of the score itself, an optimal mortality index score would be less than one, indicating that the actual mortality rate is lower than the expected mortality rate.
The general goal is to decrease observed deaths and then appropriately document the acuity, the severity of illness, and the risk of mortality for all patients in order to improve the expected mortality. It is helpful to understand that the expected mortality is determined by both the patients who expire and the patients who are discharged alive. It’s a really important point to remember that the entire population helps determine the expected mortality.
The mortality index can also be utilized to help hospitals understand how their actual mortality rate stacks up against what is statistically expected. Many mortality index methodologies highlight mortality predictors, and those are factors that can increase the expected mortality. Examples of these factors include fluid and electrolyte imbalances, acute and chronic kidney disease, organ failures, malnutrition, cachexia, and neoplasms. Most of those variables have to be present on admission to count towards that relative expected mortality. Generally, inpatient hospice deaths get excluded from the mortality index.
Many mortality cases do have a short length of stay, so it is important to ensure that all of the diagnoses are being documented with supporting clinical indicators, as the principal diagnosis will impact the DRG that is assigned for a particular admission. The DRG can then determine the risk model in which a patient falls into while the risk model is used for the expected mortality within that mortality index. The principal diagnosis selection and DRG really play a large role in the calculation of the mortality index.
Mortality reviews are best approached as a team effort that involves quality review specialists, coders, CDI professionals, providers, and additional stakeholders. To impact the mortality index, there needs to be a collaborative approach, and it has to be a balance between retrospective analysis and proactive improvement.
Editor’s note: Sydni Johnson, BSN, RN, CCDS, director of education for clinical documentation and denials at Banner Health in Arizona, and Beth Simms, BSN, RN, CCDS, CDI and acute care coding program manager at Banner Health, answered this question on the ACDIS Podcast. This Q&A originally appeared on JustCoding.