Brian Jarman

Identification of underprivileged areas

risk of contracting rubella in pregnancy and giving birth to a handicapped child. If these observations are confirmed by an extension of our own experience and that of other laboratories, there are clear indications for health education since there may be groups of women needing vaccination programmes specifically directed at them. This might well necessitate special programmes in areas where the Asian population is concentrated. We would like to know whether other laboratories carrying out antenatal screening for rubella antibodies have made similar observations.

Explaining differences in English hospital death rates using routinely collected data

Objectives: To ascertain hospital inpatient mortality in England and to determine which factors best explain variation in standardised hospital death ratios. Design: Weighted linear regression analysis of routinely collected data over four years, with hospital standardised mortality ratios as the dependent variable. Setting: England. Subjects:Eight million discharges from NHS hospitals when the primary diagnosis was one of the diagnoses accounting for 80% of inpatient deaths. Main outcome measures: Hospital standardised mortality ratios and predictors of variations in these ratios. Results: The four year crude death rates varied across hospitals from 3.4% to 13.6% (average for England 8.5%), and standardised hospital mortality ratios ranged from 53 to 137 (average for England 100). The percentage of cases that were emergency admissions (60% of total hospital admissions) was the best predictor of this variation in mortality, with the ratio of hospital doctors to beds and general practitioners to head of population the next best predictors. When analyses were restricted to emergency admissions (which covered 93% of all patient deaths analysed) number of doctors per bed was the best predictor. Conclusion: Analysis of hospital episode statistics reveals wide variation in standardised hospital mortality ratios in England. The percentage of total admissions classified as emergencies is the most powerful predictor of variation in mortality. The ratios of doctors to head of population served, both in hospital and in general practice, seem to be critical determinants of standardised hospital death rates; the higher these ratios, the lower the death rates in both cases.

Ethnic differences in consultation rates in urban general practice.

OBJECTIVE--To determine the patterns of consultations with the general practitioner among different ethnic groups and the outcome of these consultations. DESIGN--Retrospective analysis of data from one urban group general practice collected during 1979-81 as part of a research project in seven practices. SETTING--Group general practice in the London borough of Brent with a list size of 10,877 patients in July 1980. SUBJECTS--Patients registered with the practice during the 23 months to April 1981 who accounted for 67,197 consultations. MAIN OUTCOME MEASURES--Ethnic state, sex and social class distribution, and diagnosis of patients consulting and frequency of consultations analysed as standardised consultation ratios and standardised patient consultation ratios. RESULTS--Compared with other ethnic groups male Asians (that is, including those born in Britain and those originating from the Indian subcontinent and east Africa) had a substantially increased standardised patient consultation ratio. Consultation rates for mental disorders--in particular, anxiety and depression--were reduced in all groups of immigrant descent. West Indians consulted more frequently for hypertension and asthma, and their children less frequently with otitis media. Asians consulted more frequently with upper respiratory tract infections and non-specific symptoms. Native British patients were more likely to leave the surgery with a follow up appointment, prescription, or certificate. CONCLUSION--Notwithstanding the limitations of this study, ethnic differences in consultation rates were apparent. These differences require further investigation if the needs of minority ethnic groups are not to be overlooked.

Predicting psychiatric admission rates.

OBJECTIVE--To determine the numbers of actual and expected psychiatric admissions for the residents of the district health authorities of England and to develop a model to indicate which social, health status, and service provision factors best explain the variation of the actual from the expected psychiatric admissions; to use this model to predict psychiatric admission for district health authorities as an aid to resource allocation. DESIGN--The actual psychiatric admission for district health authority residents were extracted from data of the 1986 Mental Health Enquiry. Expected admissions were calculated using the age, sex, and marital status structure of each district health authority and the national psychiatric admission rates related to age, sex, and marital status. Standardised psychiatric admission ratios were calculated as the ratios of the numbers of actual to expected psychiatric admissions. A wide range of social, health status, and service provision data were used as the explanatory variables in regression analyses to determine which combination of factors best explained the variation between districts of standardised psychiatric admission ratios. SETTING--The 168,652 psychiatric admissions recorded for the 1986 Mental Health Enquiry, after exclusion of mental handicap and psychogeriatric admissions. RESULTS--The actual number of psychiatric admissions varied from 79% above to 54% below the expected number of admissions from age, sex, and marital status for the districts of England. The most powerful variables to explain this variation were the rate of notification of drug misusers, standardised mortality ratios, and levels of illegitimacy in each district. A complex model was developed which could be used to predict district psychiatric admissions as an aid to resource allocation. A simpler model was also developed (which was less powerful than the more complex model) based on the underprivileged area score. One advantage of this model was that it could be used at the level of electoral wards as well as district health authorities.

Using care bundles to reduce in-hospital mortality: quantitative survey

Problem To reduce hospital inpatient mortality and thus increase public confidence in the quality of patient care in an urban acute hospital trust after adverse media coverage. Design Eight care bundles of treatments known to be effective in reducing in-hospital mortality were used in the intervention year; adjusted mortality (from hospital episode statistics) was compared to the preceding year for the 13 diagnoses targeted by the intervention care bundles, 43 non-targeted diagnoses, and overall mortality for the 56 hospital standardised mortality ratio (HSMR) diagnoses covering 80% of hospital deaths. Setting Acute hospital trust in north west London. Strategies for change Use of clinical guidelines in care bundles in eight targeted clinical areas. Interventions Use of care bundles in treatment areas for the diagnoses leading to most deaths in the trust in 2006-7. Key measures for improvement Change in adjusted mortality in targeted and non-targeted diagnostic groups; hospital standardised mortality ratio (HSMR) during the intervention year compared with the preceding year. Effect of the change The standardised mortality ratio (SMR) of the targeted diagnoses and the HSMR both showed significant reductions, and the non-targeted diagnoses showed a slight reduction. Cumulative sum charts showed significant reductions of SMRs in 11 of the 13 diagnoses targeted in the year of the quality improvements, compared with the preceding year The HSMR of the trust fell from 89.6 in 2006-7 to 71.1 in 2007-8 to become the lowest among acute trusts in England. 255 fewer deaths occurred in the trust (174 of these in the targeted diagnoses) in 2007-8 for the HSMR diagnoses than if the 2006-7 HSMR had been applicable. From 2006-7 to 2007-8 there was a 5.7% increase in admissions, 7.9% increase in expected deaths, and 14.5% decrease in actual deaths. Lessons learnt Implementing care bundles can lead to reductions in death rates in the clinical diagnostic areas targeted and in the overall hospital mortality rate.

The hospital standardised mortality ratio: a powerful tool for Dutch hospitals to assess their quality of care?

Aim of the study To use the hospital standardised mortality ratio (HSMR), as a tool for Dutch hospitals to analyse their death rates by comparing their risk-adjusted mortality with the national average. Method The method uses routine administrative databases that are available nationally in The Netherlands—the National Medical Registration dataset for the years 2005–2007. Diagnostic groups that led to 80% of hospital deaths were included in the analysis. The method adjusts for a number of case-mix factors per diagnostic group determined through a logistic regression modelling process. Results In The Netherlands, the case-mix factors are primary diagnosis, age, sex, urgency of admission, length of stay, comorbidity (Charlson Index), social deprivation, source of referral and month of admission. The Dutch HSMR model performs well at predicting a patients risk of death as measured by a c statistic of the receiver operating characteristic curve of 0.91. The ratio of the HSMR of the Dutch hospital with the highest value in 2005–2007 is 2.3 times the HSMR of the hospital with the lowest value. Discussion Overall hospital HSMRs and mortality at individual diagnostic group level can be monitored using statistical process control charts to give an early warning of possible problems with quality of care. The use of routine data in a standardised and robust model can be of value as a starting point for improvement of Dutch hospital outcomes. HSMRs have been calculated for several other countries.

Paediatric cardiac surgical mortality in England after Bristol: descriptive analysis of hospital episode statistics 1991-2002

Abstract Objective To describe trends in mortality of open cardiac surgery in children in Bristol and England since 1991. Design Retrospective analysis of hospital episode statistics data. Setting All open cardiac surgery of children in England. Population Patients younger than 16 undergoing open cardiac surgical procedures in England between April 1991 and March 2002. Three time periods were defined: epoch 3 (April 1991 to March 1995), epoch 5 (April 1996 to March 1999), epoch 6 (April 1999 to March 2002). Main outcome measure Mortality in hospital within 30 days of a cardiac procedure. Results We identified 5221 open operations between April 1996 and March 2002 in children under 1 year and 6385 in children aged 1-15 years. Mortality for all centres combined fell from 12% in epoch 3 to 4% in epoch 6. Mortality in children under 1 year at Bristol fell from 29% (95% confidence interval 21% to 37%) in epoch 3 to 3% (1% to 6%) in epoch 6, below the national average. The reduction in mortality did not seem to be due to fewer high risk procedures or an increase in the numbers of low risk cases. Oxford had a significantly higher mortality than the national average in all three epochs (11% (5% to 18%) in epoch 6), which was not affected by adjusting for procedure or the inclusion of cases with missing outcomes. Conclusions At Bristol, mortality for open operations in children aged under 1 year has fallen markedly, to below the national average. Nationwide mortality has also fallen. Improved quality of care may account for the drop in mortality, through new technologies or improved perioperative and postoperative care, or both.

Strengths and weaknesses of hospital standardised mortality ratios

Hospital standardised mortality ratios are fairly easy to produce and, as the example of Mid Staffordshire shows, can help identify hospitals with poor performance. However, they are not without problems

Measuring disadvantage: changes in the underprivileged area, Townsend, and Carstairs scores 1981-91.

OBJECTIVE--To compare the intercensal change for each of the underprivileged area (UPA), Townsend, and Carstairs scores calculated from 1981 and 1991 census data. SETTING--England and Wales. METHODS--The method described enables comparison of change in composite scores such as the UPA, Townsend, and Carstairs scores which are derived from normalised variables. The national values of equivalent variables derived from the censuses are calculated and normalised on the same baseline of the 1981 electoral ward mean and SD values. The resultant change in composite scores for different censuses can then be compared directly. MAIN OUTCOME MEASURE--Change in the composite score values for the 1991 census when compared with the 1981 census. RESULTS--For England and Wales, the UPA score increased by 5.62 units (0.35 of the SD) but the Townsend and Carstairs scores fell by 2.39 and 1.13 units respectively (0.71 and 0.33 of the SDs). CONCLUSION--The Townsend and Carstairs scores are good measures of material deprivation and show a general improvement as such between 1981 and 1991. The UPA score, however, includes additional factors relating to family structure, social deprivation, and health need and shows a decline in the overall situation.

“HRG drift” and payment by results

In April 2004 the NHS introduced its new “payment by results” system, starting with foundation hospitals. Under this system, providers will no longer be paid by block contracts, but by case mix adjusted activity.w1> This new system uses healthcare resource groups (HRGs) as a measure of care based on diagnosis and complexity of treatment. HRGs are analogous to diagnosis related groups (DRGs) used in other countries. This new system has already run into problems: evidence shows disproportionate rises in the numbers of short stay inpatients admitted through accident and emergency departments. As a consequence, the planned implementation of payment by results across all NHS trusts for April 2005 has been restricted to elective admissions only.w2> In addition, there is concern that “gaming” may result, whereby providers reclassify patients into more complex and therefore more …