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Death rates should not be used to judge hospital performance

Death rates should not be used to judge hospital performance because they are too blunt an instrument for a truly effective measure of the quality of hospital care, a new report from Britain argues.

04 Jul 2010

Death rates should not be used to judge hospital performance because they are too blunt an instrument for a truly effective measure of the quality of hospital care, a new report from Britain argues.

The British Medical Journal article comes after a public inquiry was ordered into the Mid Staffordshire hospital, based on high mortality rates.

Richard Lilford from the University of Birmingham and Peter Pronovost from Johns Hopkins University School of Medicine, say that hospital mortality rates are a poor diagnostic test for quality.

“They should not be used to calculate excess deaths resulting from poor care,” they say.

The hospital standardised mortality ratio is used to measure the quality and safety of hospital care in the United Kingdom and around the world. The ratio identifies hospitals where more patients die than would be expected (‘bad’ hospitals) and hospitals with fewer deaths than expected (‘good’ hospitals).

Lilford and Pronovost argue that the validity of this ratio has been criticised because it may not adequately adjust for the type of patients treated at a particular hospital (case mix) or account for measurement errors between hospitals. Yet it continues to be used as a measure of quality.

“The practice is kept alive by well-meaning decision makers who want the idea that mortality reflects quality to be true,” they say.

According to Lilford and Pronovost, there is an argument for use of hospital mortality rates as an initial signal for scientific study. But they warn that public inquiries can lead to hospitals being unjustly singled out and may undermine improvements in other areas.

They argue for increasing use of direct measures of the quality of care by checking hospital case notes.

“Examining selected case notes to ensure that the correct treatment has been given and errors avoided is much more informative than trying to pick out ‘bad apples’ using the blunt instrument of hospital wide mortality rates,” they say.

“If we really want to improve care, than managers are going to have to learn more statistics and statisticians more management. In the meantime, performance management of medical care by hospital mortality is not the answer.”


Published: 04 Jul 2010