The death of death rates? Academics question using mortality rates as a quality indicator for hospitals

Credit: Andy G

Writing in The BMJ, the academics claim that however carefully they are adjusted, death rates do not account for recording errors, variation in risk across hospitals, variation in performance within hospitals, and the availability of alternative places where patients can die.

The three academics at York’s Department of Health Sciences, Professor Tim Doran, Professor Karen Bloor and Emeritus Professor Alan Maynard, were commenting on a piece of research which argues that standardised mortality ratios (SMRs) for hospitals do not provide an accurate picture of how many deaths could have been avoided.

The study was led by researchers at the London School of Hygiene & Tropical Medicine and Imperial College London and is also published in The BMJ.

Hospital-wide SMRs compare the number of deaths in a hospital with the expected number (based on a statistical probability derived from routine administrative data). These measures have been widely used in many countries for more than 20 years and are often used to identify ‘problem’ hospitals.

 The study was commissioned by Professor Sir Bruce Keogh (Medical Director of NHS England) following his review of 14 Trusts in 2013 which questioned whether SMRs for hospitals provide an accurate indication of the number of avoidable deaths occurring. It was funded by the National Institute for Health Researchand the Department of Health.

 The researchers found that the proportion of avoidable hospital deaths was 3.6%. There was no significant association between hospital-wide SMRs and the proportion of avoidable deaths in a trust.

 The three academics from York argue that alternative approaches should be considered, including “indoctrinating trainees in the medical professions with the principles of quality and compassion.”

 They argue that once these trainees emerge into practice there should be continuing and career-long support, with protected time for effective audit and reflection.

Clinicians, administrators, and policy makers also need to be statistically literate and able to understand the reasons for variations in patient outcomes between hospitals, they argue.

They say: “Many within the NHS will find it difficult to accept that SMRs – a tool that identified Mid-Staffordshire NHS Foundation Trust – could fail to identify other sinners, and faith in SMRs is likely to remain strong.

 “Even apostates may find it difficult to let go in the absence of more cost effective alternatives. It will, after all, take a brave administrator to ignore an outlier.”

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