Is avoidable mortality a good measure of the quality of

healthcare?

Dr Helen Hogan Clinical Senior Lecturer in Public HealthLondon School of Hygiene and Tropical

Medicine

Outline

• What drives interest in avoidable mortality

• Problems with use as a measure of hospital quality

• Approaches to measurement and what we have learned

• Local and national developments

• The future

Why it matters?

Limitations of avoidable deaths a measure of quality

Measuring avoidable death using population-level data

• HSMR/ SHMI/ RAMI• Coded adverse events linked to death• Known avoidable harms linked to death• Patient Safety Indicators• Prospective surveillance systems

Measuring avoidable deaths at patient level

What have we learnt so far

• Preventable Incidents Survival and Mortality studies (PRISM) 1 and 2

(co-applicants Nick Black, Frances Healy, Graham Neale, Richard Thomson, Charles Vincent, Ara Darzi)

• Association between avoidable deaths (RCRR) and excess deaths (hospital-wide mortality ratios)

PRISM 1 Study

• 2010/2011• Aims: – estimate proportion of avoidable hospital deaths– identify ‘problems in care’ and contributory factors – estimate years of life lost

• Method:– RCRR (1000 adult deaths across 10 acute Trusts in

England)– Trained, retired doctors with standard form

Findings• 75% good or excellent care• 11.3% ‘problem in care’ contributing to

death• 5.2% deaths probably avoidable– range 3% - 8% (low variation between Trusts)– estimate 11,859 avoidable adult deaths/year in

England NHS

• Life expectancy of avoidable death patients– 60% patients had life expectancy less than 12 months

• Inter-rater reliability Kappa 0.49

Problems in care identified in cases of preventable deathStage of patient journey

Types of problem identified

Preadmission Poor monitoring of warfarinDelays in admission for hospital procedureContraindicated drug prescribed in outpatients

Early in admission

Failure to diagnoseDelayed diagnosisWrong diagnosisFailure to identify the severity of underlying conditions and risks posed by the chosen therapeutic approach Failure to optimise preoperative state

Care during a procedure

Procedure conducted in inappropriate environmentTechnical error

Post procedure Inadequate monitoring (fluid balance, infection)Poor assessment

Ward care Inadequate monitoring of overall condition, fluid balance, laboratory tests, side effects of medications (especially warfarin), pressure areas and infectionUnsafe mobilisation leading to serious fallsHospital acquired infectionPrescription of contraindicated drugDelay in undertaking required procedure

PRISM 2 Study• Based on recommendations emerging from the

Keogh review

• Relationship between ‘excess mortality rates’ and actual ‘avoidable deaths’

• Findings to support introduction of a new national outcome framework “hospital deaths attributable to problems in care” and systematic approach to local mortality review

PRISM 2 Study• 2014/2015• Extend PRISM 1 to further 24 Trusts• Similar method to permit analyses of combined

data from both studies (n=3,400 records)• Random sample of Trusts across 4 strata of HSMR• Trained reviewers (70% current consultants, 30%

retired)• Linear regression to determine the percentage

increase in avoidable death proportion for a 10 point increase in HSMR/SHMI

Findings• 78% good or excellent care• 9.4% ‘problem in care’ contributing to

death• 3.0% deaths probably avoidable– range 0% - 9% (low variation between Trusts

persists)

• Inter-rater reliability Kappa 0.35

Combined Findings

• 3.6% probably avoidable• no statistical significant association between

hospital SMRs and the proportion of avoidable deaths

The future

• Local Mortality Review– Standardised self-assessment will ensure robust process

• National approach to training and materials• Electronic database/ NRLS• All deaths screened, high risk cases selected for in-depth• Multidisciplinary process

• National Tracking of Outcome Indicator• Random sample of NHS deaths • National panel of trained reviewers (multi-disciplinary)• Multiple reviewers per record

• Timetable: Invitation to tender via HQIP– http://hqip.org.uk/tenders/rcrr%20tender%202015/

The future• Direct comparison of Trusts based on avoidable X

deaths

• Develop notional avoidable death proportions ??• Use a coherent set of indicators known to be

associated with quality e.g. hospital acquired infections and measure as robustly as possible

• Develop indicators that reflect integrated care/ quality of care across health systems

Thank you

helen.hogan@lshtm.ac.uk