Tag Archives: Preventable deaths

On Standardised Mortality Ratios and Preventable Deaths

Helen Hogan has summarised the problems with both Standardised Mortality Ratios (SMRs) and preventable deaths, and News Blog readers might like to read her report.[1] The signal to noise ratio with SMRs is lousy so they don’t even qualify as a screening test and would not pass the NHS screening committee – not by a wide margin.[2] Case-note review of deaths to determine preventability is fraught with difficulties relating to measurement error.[3] Neither is a good option, but if I had to choose I would go for case-note review every time. Why? Because at least it provides learning about quality of care issues. For example, we found problems with failure to use non-invasive ventilation and excessively rapid lowering of high potassium levels in our reviews of case-notes.[4] These provide real learning opportunities akin to the excellent clinical review meetings we would conduct when I was a young doctor on the medical wards.

— Richard Lilford, CLAHRC WM Director

References:

  1. Hogan H. The problem with preventable deaths. BMJ Qual Saf. 2016; 25: 320-3.
  2. Girling AJ, Hofer TP, Wu J, et al. Case-mix adjusted hospital mortality is a poor proxy for preventable mortality: a modelling study. BMJ Qual Saf. 2012; 21(12): 1052-6.
  3. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA. 2001;286(4): 415-20.
  4. Benning A, Dixon-Woods M, Nwulu U, et al. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ. 2011; 342:d199.
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A Good Summary on Preventable Death

Identifying preventable deaths is an obvious target for quality improvement. But how to do it – case-note review, routine data, or proxy measures. For a summary of problems see a recent succinct summary by Helen Hogan.[1] Case note review suffers from poor reliability and summary statistics from poor signal to noise ratios. The CLAHRC WM Director has long argued for proxy measures in the form of adherence to evidence-based tenets of good care – that is to say, clinical process measures.[2]

— Richard Lilford, CLAHRC WM Director

References:

  1. Hogan H. The problem with preventable deaths. BMJ Qual Saf. 2016; 25: 320-3.
  2. Brown C, Hofer T, Johal A, Thomson R, Nicholl J, Franklin BD, Lilford RJ. An epistemology of patient safety research: a framework for study design and interpretation. Part 3. End points and measurement. Qual Saf Health Care. 2008. 17;170-7.

Preventable hospital deaths and other measures of safety

Readers of this blog may well know the views of the CLAHRC WM Director on using hospital mortality to compare hospital safety.[1] [2] Following the recommendations in the Keogh review, published in 2013, there was greater interest in looking at preventable hospital deaths in order to improve the NHS.

Helen Hogan and colleagues have recently published findings of a retrospective case record review that looked for relationships between preventable hospital deaths and eight other measures of safety in ten English acute hospital trusts.[3] Of the eight measures of safety they looked at, only MRSA bacteraemia rate had a significant association with proportion of preventable deaths (P<0.02). Hospital Standardised Mortality Ratios (HSMRs), widely used in the UK to measure safety, was not significantly associated (P=0.97). Additionally, the difference in the proportion of preventable deaths between hospitals was not statistically significant (P=0.94), varying from 3–8%. The authors are planning a larger study in order to establish these findings, with 24 additional UK hospitals.

— Richard Lilford, Director CLAHRC WM

References:

  1. Girling AJ, Hofer TP, Wu J, Chilton PJ, Nicholl JP, Mohammed MA, Lilford RJ. Case-mix adjusted hospital mortality is a poor proxy for preventable mortality: a modelling study. BMJ Qual Saf. 2012; 21(12): 1052-6.
  2. Lilford RJ, Pronovost P. Using hospital mortality rates to judge hospital performance: a bad idea that just won’t go away. BMJ. 2010; 340: c2016.
  3. Hogan H, Healey F, Neale G, Thomson R, Vincent C, Black N. Relationship between preventable hospital deaths and other measures of safety: an exploratory study. Int J Qual Health Care. 2014; 26(3): 298-307.