BMJ 1999;318:1515-1520 ( 5 June )

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Explaining differences in English hospital death rates using routinely collected data

Brian Jarman, emeritus professor of primary health care, a Simon Gault, research analyst, a Bernadette Alves, research analyst, a Amy Hider, statistician, b Susan Dolan, research analyst, a Adrian Cook, research analyst, a Brian Hurwitz, senior lecturer, a Lisa I Iezzoni, professor of medicine. c

a Department of Primary Health Care and General Practice, Imperial College School of Medicine, London W2 1PG, b Department of Medical Statistics and Evaluation, Imperial College School of Medicine, Hammersmith Hospital, London W12 0NN, c Harvard Medical School, Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue LY-326, Boston, MA 02215, USA

Correspondence to: B Jarman

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.


Key messages

  • Between 1991-2 and 1994-5 average standardised hospital mortality ratios in English hospitals reduced by 2.6% annually, but the ratios varied more than twofold among the hospitals

  • After adjustment for the percentage of emergency cases and for age, sex, and primary diagnosis, the best predictors of standardised hospital death rates were the numbers of hospital doctors per bed and of general practitioners per head of population in the localities from which hospital admissions were drawn

  • England has one of the lowest number of physicians per head of population of the OECD countries, being only 59% of the OECD average

  • It is now possible to control for factors outside the direct influence of hospital policy and thereby produce a more valid measure of hospital quality of care




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Rapid Responses:

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Admission rate effects may have been under-stated
Tom Hennell
bmj.com, 8 Jun 1999 [Full text]
Data won't support authors' conclusions
John P Bunker
bmj.com, 15 Jul 1999 [Full text]
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