Effects of admission rates may have been understated

EDITOR—Unlike Jarman et al, I do not yet think that we can state with confidence that “more doctors means fewer deaths.”1 As the authors make clear, there has been a lively discussion on comparative hospital death rates in the United States. From this debate two points emerge clearly: for any given population the standardised admissions rate is positively correlated with the standardised death rate but is inversely correlated with the standardised hospital death rate (defined as any death within 30 days of a hospital admission).2 3 Where a population is admitted to hospital fairly frequently a higher proportion of admissions will not be associated with subsequent death; hence there will be a lower apparent hospital mortality. A study in Ohio found African-Americans to have consistently higher admissions and lower severity-adjusted hospital mortality than white patients treated at the same hospitals.4

It was therefore informative that the authors included with …