Editorials

Mortality indicators used to rank hospital performance

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5952 (Published 25 October 2013) Cite this as: BMJ 2013;347:f5952
  1. J Nicholl, professor of health services research,
  2. R Jacques, research fellow,
  3. M J Campbell, professor of medical statistics
  1. 1School of Health and Related Research (ScHARR), University of Sheffield, Sheffield S1 4DA, UK
  1. j.nicholl{at}sheffield.ac.uk

Should include deaths that occur after discharge

There is considerable debate about the value of using hospital mortality rates adjusted for case mix as an indicator of the quality and safety of care provided by hospitals. A linked paper by Pouw and colleagues (doi:10.1136/bmj.f5913) investigates the inclusion of post-discharge deaths in these mortality indicators.1 The main doubts about their value are that standardisation for differences between hospitals in the characteristics of their patients (the case mix) doesn’t work, and that these indicators do not measure performance because they are not related to avoidable mortality. There is no doubt that the case mix adjustment is problematic. We know that different adjustment models lead to different results,2 and that important measures of case mix are missing from models based on routine data.3 We also know that these measures are at best weakly related to avoidable mortality—models show that they would begin to be useful for identifying poor quality of care only when at least 16% of hospital deaths are avoidable.4 Recent studies have shown that in the United Kingdom this figure is closer …

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