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

6. 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?

8. 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’

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

10. 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 1 st Consultant Episode (FCE)

11. 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 1 st FCE

12. 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

13. 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

15. Historic standardised mortality at HEY

16. Standardised mortality Causes of high SMR: –low expected mortality –high actual mortality

17. 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

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

19. Kingston upon Hull 11 th most deprived LA in England –6 th highest concentration of deprived LSOAs High all-age all-cause mortality –732/100 000 (England 582/100 000) –cancer SMR128m 131 f –CHD SMR139m 167f 3 rd 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%)

20. East Riding of Yorkshire 151 st 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

21. 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

22. 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

23. Alert on perinatal mortality

27. 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

28. Mortality Alerts Urinary tract infection –elderly patients; some end of life –correct diagnosis in only 50% (1 st 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

29. 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

30. SHMI: Oct 2011-Aug 2013

31. HSMR: Nov 2011-Sep 2013

32. Crude death rate

33. 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

34. Questions?