Hospital mortality rates: fact or fiction?

A report out today discusses the issues in using mortality to measure the quality of hospital care. On the face of it, overall mortality rates for hospitals might seem to be a good measure of the quality of care given to patients – but are they?

Using mortality rates to assess the quality of health care is complex because hospitals provide a wide range of services for a wide range of conditions, to patients with very different risks of dying.

About 60 per cent of all deaths take place in hospital. Most of these deaths are inevitable and beyond the control of hospitals. A reliable comparison between hospitals therefore requires the mortality data to be fully adjusted for factors such as age, sex, deprivation and co-morbidities, which do not reflect the quality of care. This may not always be possible. Furthermore, most organisations perform well in some areas and less well in others, adding to the limitations of a single, overall indicator as a measure of quality.

The publication of the Dr Foster Hospital Guide in 2009, which appeared to contradict the findings of other quality assessments, including those of the Care Quality Commission, led to considerable confusion in the NHS and amongst the public.

A heated debate ensued among health care professionals and academics on how reliable and useful hospital-wide mortality rates are as a measure of quality, and the virtues of alternative approaches to measuring quality.

It was against this background that the Department of Health (DH) commissioned a review, of hospital-wide mortality measures. The group, of which I was a member, publishes its report today.

So what's the verdict?

The report, National Quality Board advice and recommendations concludes that mortality rates can be used but with caution and only alongside other indicators of quality. It recommends that a standardised NHS-wide methodology – to be developed during 2011 – is used for calculating the new indicator, the Summary Hospital-level Mortality Indicator (SHMI).

But the report carries its own significant health warnings. In particular, it states that alongside the SHMI, there has to be guidance as to the publication, presentation and use of such data to prevent the level of confusion the publication of hospital-wide mortality rates have caused in the past.

Information can be a powerful tool, both to inform patients about the quality of care provided by different hospitals, and to enable clinicians to drive improvements in quality within their organisations or practice. For example, where mortality rates look high – whether at a service or whole organisation level – they can act as a useful starting point for further investigation. But if used inappropriately, information has the potential to mislead patients and the public, and erode confidence in NHS staff and the organisations they work in.

Despite the solution offered by the DH, it's clear that mortality rates generate, and will continue to generate, significant public interest and professional debate. In the US an expert group has concluded against public reporting of hospital-wide mortality rates because of their inherent unreliability. However, with the Freedom of Information Act, the scandal of Mid-Staffordshire, the move to more open government and the 'information revolution' in health promised by the coalition government, the publication of this indicator (in one guise or another) for English hospitals is unavoidable. Those of us interested in ensuring data serves to improve care and empower patients have an interest in ensuring that its publication is done in the most responsible way possible.

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Comments

#261 Jan Poloniecki
Reader in Medical Statistics

I agree with you pretty much totally.

At St.George's we have been monitoring monthly since 2002
every single death: by separate specialties, some diagnostic
groups, some surgical procedures and for the whole hospital
together. As far as I know the Steering group working on
devising a single number to chacterise the death rate at a
hospital did not talk to anyone at our hospital. They may
of course have talked to folk at other hospitals where there
is mortality monitoring. For the 38 members of the Steering
Group one hospital affiliation is in fact named, University
Hospitals Birmingham.

#263 Ann
consultant

When measuring statistics or monitoring 
every single death are you monitoring the amount of diamorpine use when these patients die and in particularly the elderly.. Are we and will we all be in fear of a culture in the NHS when we go into hospital after the age of 60years.. doctors and nurses are administering morphine with out consent from the patient or the family?
There is evidence that there is a culture to rid the elderly who are putting too much pressure on the NHS?
There are no laws in place to protect us on the abuse of diamorpine in this country…yet no one wants to discuss the subject. WE should not have to fight for life after we die it should be there in place to protect us before death.

#609 Norboo
hospital administrator
S.N.M Hospital,Leh,Ladakh

I agree with you, about hospital mortality rates, but is it possible to have a permissible level of Hospital mortality percentage. like my hospital had 5928 indoor admissions in 2010-11 financial year and mortality of only 70 patients that year, so it comes to around only 1.8 %. I may consider it a safe level of mortality of the hospital

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