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Mortality rate indicator reveals seven acute trust outliers

Seven acute trusts have emerged as consistent outliers against the controversial mortality rate measure, with significantly more patient deaths than expected, analysis of the latest data reveals.

The third summary hospital level mortality indicator (SHMI) data set was published by the NHS Information Centre last week, showing mortality rates for the year from October 2010 to September 2011.

Just nine trusts had higher than expected mortality rates in April’s data, compared to 14 in the first release last October and 11 in January.

Seven trusts – East and North Hertfordshire Trust, Basildon and Thurrock University Hospitals Foundation Trust, Colchester Hospital University Foundation Trust, Hull and East Yorkshire Hospitals Trust, Blackpool Teaching Hospitals Foundation Trust, George Eliot Hospital Trust and Tameside Hospital Foundation Trust – had higher than expected death rates in each of the first three publications of SHMI data.

Only Hull and East Yorkshire did not have a significantly higher than average proportion of admissions for palliative care.

Basildon, Colchester and East and North Hertfordshire had significantly more deaths than average coded as palliative. These are also the only three trusts found to be within the expected mortality range under the alternative hospital standardised mortality ratio measure produced by Dr Foster.

Unlike the SHMI, the Dr Foster measure adjusts for the proportion of patients coded as palliative on admission and at death.

The variation suggests that although palliative care may be a factor in some of the outliers it is not the only cause.

All the outlier trusts said they had examined in detail the reasons for their inclusion on the SHMI outlier list since the figures were first published last year. East and North Herts and Basildon highlighted palliative care as the main issue.

The DH-commissioned steering group set up to develop the SHMI and bring consensus to the contested area of mortality rates decided against adjusting for palliative care due to the huge variation in how the coding is used.

According to supporting data published alongside the latest SHMI, the percentage of admissions coded as palliative ranged from 0-3.2 per cent across trusts while the percentage of deaths classified as palliative ranged from 0 to 41.6 per cent. However, experts have questioned whether that variation can reflect reality or the coding practice.

King’s Fund senior fellow Veena Raleigh, a member of the steering group, told HSJ the methodology could be altered to take into account palliative care in future if guidance was produced on how the code should be used which reduced variation.

Readers' comments (3)

  • The HSJ has pointed out rightly that SHMI ratings are influenced by a range of factors, including palliative care. In the Trust’s case, Dr Foster has verified independently that if deaths taking place in our NHS hospice at the Mount Vernon Cancer Centre are removed from the calculation, the Trust’s resulting SHMI score would be at the average expected for an organisation of our size and complexity.

    On behalf of Jane McCue
    Medical Director, East and North Hertfordshire NHS Trust

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  • "Just nine trusts had higher than expected mortality rates". These are not "higher than expected" I think, but are those trusts lying outside the confidence limits of the data distribution. Whilst it is clearly not desirable to be an outlier at the top end, it is important not to confuse a statistical effect with poor performance. Its like the old journalistic saw about "half the schools performing worse than average"!

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  • Despite the fact that this indicator was hailed as "experimental" and a "smoke alarm" rather than a "fire alarm", it was only a matter of time before those trusts with the higher SHMI figures would be highlighted with the suggestion of poor performance. Even this report highlights that 3 of the trusts were as expected under HSMR. I am all for transparency but in an environment that wants to judge performance, indicators will always end up as performance management tools rather than improvement tools. It may well be that those with high palliative deaths are as a result of poor hospice provision locally or even that because they care so compassionately for the dying that people choose to die in that environment.

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