When DRG based reimbursement was introduced in the USA within a few
years 'DRG creep' was found to be a problem as administrators influenced
the diagnosis and severity, and complications of reasons for admission.
This did not stop other countries, including Australia, from blindly
following. The problem with assessing hospitals is always the biases
introduced by management response to the alteration to their 'performance'
criteria, this will occur if SMR's are used as 'quality measures'.
SMR's are useful if and only if they are used in relation to a fixed
geographhical catchment area - they can be validly used to assess health
services that have responsibility for health outcomes in a defined
geographical area. This particularly useful as the catchment population
morbidity associated measures such as unemployment, education, disposable
income are also available for analysis on a geographical basis - so the
variability of input (patient risk measures) can also be used when
We are left with process measures as the only reliable measure for the
quality of service provided by a single service entity, but many of these
remain to be validated and those being applied are more often selected by
their cost and simplicity. AS usual more research is needed.
Competing interests: No competing interests