VANCOUVER, B.C. - To improve hospital mortality scores, clinicians should include all possible diagnoses in patient charts, according to oncologist and palliative care specialist Dr. Thomas J. Smith.

U.S. News & World Report’s "Best Hospitals," the Centers for Medicaid and Medicare Services’ Hospital Compare, and other hospital rating programs compare hospital outcomes to national averages based on how sick patients are, said Dr. Smith, medical director of palliative care at Virginia Commonwealth University Massey Cancer Center in Richmond.

"You get counted on your observed mortality rate. They compare that to how many people are expected to die" according to the averages, he said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine. Deaths in excess of the averages are considered unexpected and are assumed to be caused by poor quality care, which lowers hospitals in the mortality rankings.

By listing all possible diagnoses – especially at the end of life – "[you increase] your expected mortality, so that your observed-to-expected ratio improves. Even if you ignore improving mortality, if you change [how many people are expected to die] you’ll improve your ratio" and hospital standing, he said.

The reason is that hospital coders pull the diagnoses off patient charts and include them in claims submissions, the data upon which the rankings are based.

The approach is not about "gaming the system," Dr. Smith said. "You are adequately documenting the severity of the patients that you take care of" to ensure accurate mortality scores.

The key is to list diagnoses, not "medical thoughts," he said.

For example, " ‘lytic lesion of vertebra on spine films’ does not count. Write ‘bone mets’ [because] your coders can count that. Don’t write ‘neutrophils’ with an arrow going down. It doesn’t count. You have to write ‘neutropenia.’ If you write ‘admit for chemo,’ you can write ‘admit for chemo, dehydration, chronic blood loss anemia’ [as appropriate] and your severity index will go up a lot," said Dr. Smith, adding that each site of metastases should be listed because "you get points for each one."

Similarly, " ‘chest x-ray with pneumonitis status post radiation therapy’ does not count. You have to write ‘radiation pneumonitis.’ [And] don’t put ‘total protein and albumin low.’ Put ‘cachexia or malnutrition, moderate or severe.’ Don’t write ‘admit for pain control.’ Write ‘intractable pain form malignancy,’ and you have to say ‘lung cancer, breast cancer, bone cancer, liver cancer’ [accordingly]," he said.

Such diagnoses only have to be written once during the admission to count, he noted.

The approach worked for Massey Cancer Center’s palliative care unit.

"In about an 18- to 24-month period, we paid a lot attention to having most of the attendings and the fellows write out diagnostic statements, rather than medical thoughts," Dr. Smith said.

"When we started, our actual-vs.-expected mortality ratio was 150% higher than what it was supposed to be. We didn’t change the mortality rate one bit, but we changed the expected mortality. It came down to 55%, which is still high, but, heck, it’s a palliative care unit. A lot of people are sick and they’re going to die," he said.

"The APR-DRG [All Patient Refined Diagnosis Related Groups] severity of illness doubled just by paying attention to having those diagnostic statements put in," he said.

Dr. Smith gave an example of how the strategy also increases payments: An elderly person was admitted upon diagnosis of urosepsis, dehydration, and chronic obstructive pulmonary disease, but the patient’s condition allowed for more, including urinary tract infection; malnutrition; preexisting decubitus ulcer; and shock because the patient was a bit hypotensive.

With the additional diagnoses, the patient’s severity of illness (SOI) weighting increased from 0.5973 to 3.3739, resulting in a $5,613 payment increase.

"That’s a huge difference," Dr. Smith said.

He had a final tip for improving Hospital Compare mortality scores.

The CMS counts 30-day mortality, but the 30-day clock doesn’t start until 24 hours after admission. "So if you can enroll a Medicare patient in hospice within 24 hours of them hitting your emergency room door, then they don’t count towards your 30 day mortality," Dr. Smith said.

To help, "you can post somebody in the ER and make the ER aware that this is important, so that you can see those patients in the ER. Let your social workers know that the 24 shot-clock is ticking," Dr. Smith said.

The goal is to "accelerate the process of patients and families making choices. You can push that a little bit," he said.

Dr. Smith said he has no relevant disclosures.

Chart All Possible Diagnoses to Improve Hospital Mortality Scores