Is avoidable mortality a good
measure of the quality of
healthcare?
Dr Helen Hogan
Clinical Senior Lecturer in Public Health
London 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
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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 death
Stage of patient Types of problem identified
journey
Preadmission
Poor monitoring of warfarin
Delays in admission for hospital procedure
Contraindicated drug prescribed in outpatients
Early in
admission
Failure to diagnose
Delayed diagnosis
Wrong diagnosis
Failure 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 environment
Technical 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 infection
Unsafe mobilisation leading to serious falls
Hospital acquired infection
Prescription of contraindicated drug
Delay 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
• Local Mortality Review
The future
– Standardised self-assessment will ensure robust process
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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