west hertfordshire hospitals nhs trust analysing mortality data derived from secondary user services
TRANSCRIPT
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
Analysing mortality data derived from Secondary User Services
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st Purpose Of Mortality Indicators
•Highlight unexpected variation and areas of concern for further investigation
•Enable the Trust to make more informed decisions to drive change and improvement
•Demonstrate progress towards a reduction in avoidable deaths
•Understanding variation in mortality rates leads to the spread of best practice
A suite of indicators should always be used when analysing and interpreting mortality data
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st National Benchmarking
•Enables the Trust to compare itself against peers and provides expected rates
•Uses data from a full financial year
•Currently based on 2012/13 Secondary User Services (SUS) data
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
Hospital Standardised Mortality Ratio (HSMR)
•Is the ratio of observed deaths to expected deaths for 56 diagnosis groups, often expressed as a percentage - if greater than 100% then mortality has exceeded the expected level
•These groups represent 80% of inpatient deaths
•Expected deaths are calculated using crude mortality data adjusted for the profile of a hospital’s patients
•Factors influencing that adjustment include primary diagnosis, age, sex co-morbidity, deprivation and method of admission
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
Hospital Standardised Mortality Ratio (HSMR)
It is important not to use HSMRs in isolation and confidence intervals are vital
HSMRs can be distorted by changes in coding practice i.e coding of:
•Primary diagnosis•Inclusion or exclusion of palliative care codes•Depth of coding (co-morbidities)•Place of death (more patients may die in hospital if community alternatives are limited)
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st HSMR December 2013 – November 2014
•For the rolling 12 month period HSMR is 86.45 (significantly lower than expected)
•Shows a reducing trend
•WHHT is one of 9 Trusts (out of 17) across the region with lower than expected HSMR
•Significant difference between the weekday and weekend HSMR for emergency admissions (84.99 and 91.86), but neither is higher than expected
•However the HSMR for septicaemia (except in labour) is 137.74 and is significantly higher than expected (75 deaths vs 54.45 expected), but analysis has shown this is due to coding mistakes
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
HSMR Trend December 2010 – November 2014
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
HSMR Trend December 2013 – November 2014
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st Standardised Mortality Rate (SMR)
•Ratio of observed to expected deaths
•Expected deaths are calculated for a typical area with the same case mix adjustment
•May be quoted as a percentage
•If higher than 100%, then observed deaths are higher than expected
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st SMR December 2013 – November 2014
Division SMR Statistical Status
Medical 86.18 Lower than expected
Surgical 90.82 As expected
Women’s and children’s
64.14 Lower than expected
All diagnosis SMR is 83.63 which is lower than expectedThere are however two diagnosis groups with a higher than expected SMR:•Septicaemia (except in labour)•Rehabilitation care, fitting of prostheses and adjustment of devices
SMR by Division
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st SMR Divisional Diagnosis Group Outliers
Diagnosis Group
Division Observed Expected SMR
Respiratory failure, insufficiency, arrest (adult)
Medical 49 36.01 136.06
Acute myocardial infarction
Surgical (once again coding as these are ITU)
5 0.68 733.57
Septicaemia (except in labour)
Surgical ( reviewed and due to coding)
10 3.93 254.71
Pneumonia Women’s and children’s
2 0.18 1106.15
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
All Diagnosis SMR Trend December 2010 – November 14
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
All Diagnosis SMR Trend December 2013 – November 2014
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
All Diagnosis SMR Peer Comparison December 2010- November 2011
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
All Diagnosis SMR Peer Comparison December 2011 to November 2012
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
All Diagnosis SMR December 2012 to November 2013
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
All Diagnosis SMR Peer Comparison December 2013 – November 2014
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
Summary Hospital Level Mortality Indicator (SHMI)
•Mortality at Trust level across NHS England
•Published quarterly by the Health & Social Care Information Centre (HSCIC) since October 2011
•It is the ratio between the number of patients who die following hospitalisation at the Trust and the number of patients expected to die
•All deaths in hospital or within 30 days post discharge are counted
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
Summary Hospital Level Mortality Indicator
•Expected deaths are based on the England average given the characteristics of the patients
•SHMI may also be expressed as a percentage and if greater than 100% then mortality has exceeded the expected level
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st Differences Between SHMI and HSMR
SHMI includes deaths occurring outside of hospitalHSMR only includes in hospital deaths
SHMI includes deaths from all Clinical Classification System (CCS) GroupsHSMR Includes deaths from 56 CCS Groups
Variables used in the statistical model to calculate estimated deaths differ eg
SHMI does not include adjustment for palliative care codes or deprivation
HSMR does include adjustment for palliative care codes and deprivation
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st SHMI June 2013 – June 2014
SHMI 90.33 - within expected range
SHMI (in hospital) 88.75 - significantly lower than expected
SHMI (adjusted for palliative care) 90.51 significantly lower than expected
3 diagnosis groups with a significantly higher than expected SHMI:
Septicaemia 178.59Cancer of breast 193.32Leukaemias 194.67
Hence all deaths now coded by a consultant
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st SHMI Trend July 2010 – June 2014
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
SHMI Trend Quarter 2 2011 – Quarter 1 2014
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
July 2010 – June 2011
SHMI and HSMR By Peers For All Admissions
July 2011 – June 2012
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
SHMI AND HSMR By Peers For All
Admissions
July 2013 – June 2014
July 2012 – June 2013
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st Cumulative Sum Analysis (CUSUM)
•The CUSUM chart provides an early warning system for changing mortality rates
•Plots patients’ actual outcomes against their expected outcomes sequentially over time. The chart has upper and lower thresholds and breaching these threshold triggers an alert
•Can reveal when a change occurred
•Is used by the CQC to monitor Trust performance
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st CUSUM December 2013 – November 2014
Diagnosis / Procedure Group
CUSUM Alert
Observed Expected Relative Risk
Diagnosis group 5 80 57.7 139
HSMR basket of 56 diagnosis group
6 4 1241 1433.8 87
Septicaemia (except in labour) 4 79 57.7 137
Sprains and strains 1 1 0.1 1828
Procedure Group 6 72 46.7 154
Chemotherapy 1 4 0.8 491
Compensation for renal failure 1 14 6.8 206
Coronary angioplasty 1 8 6.4 124
Rest of arteries and veins 1 43 30.7 140
Rest of joint 1 1 1 96
Rest of lower GI 1 2 0.9 211
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st Patient Safety Indicators
Currently two metrics are available through Dr Foster
•Death in low risk diagnosis groups which is as expected
•Death after surgery which is also as expected
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st Septicaemia Tracking
Relative risk remains significantly higher than expected for the rolling 12 month period at 136.93
But
Relative risk is reducing month on month and the latest rolling 6 month picture shows that relative risk is as expected at 71.59
Correction of a coding error during the last 6 months has led to an improvement on the previous 6 months indicators
Amongst peers the Trust is improving its position
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
Septicaemia Trend December 2013 – November 2014
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
Septicaemia Trend December 2010 – November 2014
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
Septicaemia vs. Peers December 2010 – November 2011
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
Septicaemia vs. Peers December 2011 – November 2012
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
Septicaemia vs. Peers December 2012 – November 2013
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
June 2014 – November 2014
December 2013 – May 2014
Septicaemia vs. Peers – Current 6 months vs. Previous
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st Fractured Of Neck Of Femur Tracking
•#NOF relative risk is statistically as expected at 108.62
•An improvement from 2 months earlier when relative risk was higher than expected at 118.57
•6 month data shows relative risk within the expected range at 90.16
•Significantly higher than expected number of deaths on a Sunday and for those admitted on a Sunday, though this is not reflected across the 6 month data
•Amongst peers the Trust is improving its position
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
#NOF Trend December 2010 – November 2014
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
#NOF Trend December 2013 – November 2014
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
#NOF vs. Peers December 2010 – November 2011
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
#NOF vs. Peers December 2011 – November 2012
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
#NOF vs. Peers December 2012 – November 2013
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st
December 2013 – May 2014
June 2014 – November 2014
#NOF vs. Peers – Current 6 Months vs. Previous
We
s t H
ert
ford
sh
ire
Ho
sp
ita
ls N
HS
Tr u
st In Summary
• The picture is one of general improvement
• The Trust is performing well within its peer group
• Several areas for further focus have been highlighted, including the difference between mortality on weekdays and weekend days
• Data highlights the importance of correct coding and demonstrates the impact of coding errors on performance analysis (scepticaemia)