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Death and the Infirmary

Death and the Infirmary. Standardised Mortality at Hull & East Yorkshire Hospitals NHS Trust. Comparing mortality. Measuring and comparing hospitals Crude and standardised mortality Trust/regional factors affecting standardised mortality Past and current position Ongoing action.

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Death and the Infirmary

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  1. Death and the Infirmary Standardised Mortality at Hull & East Yorkshire Hospitals NHS Trust

  2. Comparing mortality • Measuring and comparing hospitals • Crude and standardised mortality • Trust/regional factors affecting standardised mortality • Past and current position • Ongoing action

  3. Comparing mortality • Crude mortality • deaths in hospital as a proportion of total patients • admissions? • discharges? • consultant episodes? • just in hospital, or for a period after discharge?

  4. Standardised mortality • Allows comparison across hospitals • formulae to calculate “expected” death • only models • actual deaths:expected deaths • allows for local variation • based on routinely collected data • potential inaccuracies • ‘gaming’

  5. Standardised mortality • Three widely used formulae: • Hospital standardised mortality ratio (HSMR) • Risk adjusted mortality index (RAMI) • Summary hospital-level mortality indicator (SHMI)

  6. Standardised mortality: HSMR • Subset of diagnoses • 80% of inpatient deaths • In hospital deaths only • Adjusts for case mix • deprivation • age • diagnosis, etc • Adjusts for Charlson comorbidity index • Based on 1st Consultant Episode (FCE)

  7. Standardised mortality: RAMI • Includes all patients/diagnoses • except for palliative care • In hospital deaths only • Adjusts for case mix • Alternative comorbidity weighting system • Based on primary Health Resource Group (HRG), not 1st FCE

  8. Standardised mortality: SHMI • All inpatient deaths • All deaths within 30 days of discharge • regardless of cause • Adjusts for case mix • age • primary diagnosis • Charlson comorbidity index • No weighting for deprivation index

  9. Standardised mortality • “A high SHMI on its own is not an indicator of poor standards of care” Ian Dalton • “All models are wrong but some are useful” Brian Jarman, quoting George Box

  10. Historic standardised mortality at HEY

  11. Standardised mortality • Causes of high SMR: • low expected mortality • high actual mortality

  12. HEY: high actual mortality • Tertiary centre • cardiothoracic • neurosurgery • renal replacement • Cancer centre • palliative care ward • Poor clinical care/avoidable death • not a major contributory factor

  13. HEY: high actual mortality • Case mix • confounded by demographics • SHMI does not include deprivation weighting

  14. Kingston upon Hull • 11th most deprived LA in England • 6th highest concentration of deprived LSOAs • High all-age all-cause mortality • 732/100 000 (England 582/100 000) • cancer SMR 128m 131 f • CHD SMR 139m 167f • 3rd highest teenage pregnancy rate • 6.87% of 15-17 year olds cf 4% for England • High rate of smoking • m 32%, f 33% (cf 24% and 20%)

  15. East Riding of Yorkshire • 151st highest concentration of deprived LSOAs • Goole one of most deprived areas in England • Third most elderly population • high proportion residential care • Overall near national average SMR • Goole similar to Hull • Very limited residential palliative care

  16. HEY: high actual mortality • Case selection • high risk surgery • Shortage of community palliative care beds • Low percentage of home deaths • High proportion of nursing home patients

  17. HEY: Low expected mortality • Demographics/socio-economic factors • ‘bipolar population’ • Primary diagnostic coding at first FCE • non-specific diagnosis • signs/symptoms as diagnosis • Imprecise coding • Incomplete recording of comorbidities • Inaccurate procedure documentation • Insufficient recognition of end of life care

  18. Alert on perinatal mortality

  19. Alert on perinatal mortality

  20. Alert on perinatal mortality

  21. Alert on perinatal mortality

  22. Mortality Alerts • Liver biopsy • all deaths in patients having biopsy to diagnose metastatic cancer • Breast cancer • all deaths in patients admitted for terminal care • none coded as ‘palliative care’ • half had no medical intervention

  23. Mortality Alerts • Urinary tract infection • elderly patients; some end of life • correct diagnosis in only 50% (1st FCE) • even when correct, this was rarely cause of death • comorbidity poorly recorded • Cardiothoracic surgery • procedures coded inaccurately • some operations on extremely high risk patients

  24. Mortality Reduction Committee • Improve recording and coding • More acknowledgement of comorbidity • Avoidance of inappropriate admission • Increase support for home deaths • work with partner organisations • funding community palliative care consultant • Clearer decisions on high risk surgery • Continue to investigate alerts • some patient safety gains

  25. SHMI: Oct 2011-Aug 2013

  26. HSMR: Nov 2011-Sep 2013

  27. Crude death rate

  28. Mortality: conclusions • Mortality rates are used to compare quality of care in hospitals • Standardised mortality rates are designed to balance local variations • All standardising models have limitations • High mortality rates are a ‘smoke alarm’ • HEYHT had the highest HSMR in the country in 2010-11 • HEYHT now has relatively low mortality

  29. Questions?

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