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It was to be expected at this hospital, or at any other hospital,
that sooner or later there would be an increase in the death rate for some
form of surgery, and that failure to detect this increase in a timely
fashion could cost lives. An increase in the death rate can be purely
random, and not indicative of a problem. Any death in a series of patients
with less than 100% death rate increases the death rate, just as any
patient surviving to whichever length of follow-up is being used will
cause a decrease in the death rate. A non-random increase will have a
cause which could be correctable. It could be poor surgical technique or
even homicidal behaviour, but there is a vast range of other
possibilities, particularly in intensive care. The cause may not be
correctable. A change in the type of patient might be responsible.
Whether a death rate is acceptable is a second question, which is
separate from the issue of whether it has increased. Since the death rate
translates into a level of risk for prospective patients, a third question
concerns the information to be given to patients, particularly if there
has been a recent increase in the death rate.
All three questions require continuous appraisal of the death rate.
In the absence of risk-adjustment, the "death rate" is the number of
deaths as a percentage of the number of patients treated. All patients die
eventually, and so the death rate is 100%, provided the period of follow-
up is long enough. It is innumerate to refer to a death rate, unless it is
clear from the context what period of follow-up is intended. An
understanding of which type of patient, such as heart only or heart and
lung, is also helpful. Another point concerning death rate is how far back
in time to go when counting up the total number of deaths.
The heart transplant programme at St. George's did not keep a watch
dog. Instead the alarm was raised by the clinicians themselves at the
hospital. The sounds of alarm were eventually heard by a loose network of
organisations supported by public money but with poorly defined activity.
It took time for the alarm to reach them because they were some distance
away, in a different valley so to speak. They did not have day-to-day
contact with the hospital and knowledge of the death rate there. When the
alarm did reach them, they were not able to contribute much more than some
extra sounds of consternation. One such external organisation, CHI, has
made more noise than most. However the CHI report 1 did not address any of
the relevant three questions with authority. A professionally qualified
statistician should have been involved.
Rather than rely on a off-site organisation, it would be better to
have a competent watchdog on the premises.
"The dog that did not bark" - comment on a report by the Commission for Health Improvement
It was to be expected at this hospital, or at any other hospital,
that sooner or later there would be an increase in the death rate for some
form of surgery, and that failure to detect this increase in a timely
fashion could cost lives. An increase in the death rate can be purely
random, and not indicative of a problem. Any death in a series of patients
with less than 100% death rate increases the death rate, just as any
patient surviving to whichever length of follow-up is being used will
cause a decrease in the death rate. A non-random increase will have a
cause which could be correctable. It could be poor surgical technique or
even homicidal behaviour, but there is a vast range of other
possibilities, particularly in intensive care. The cause may not be
correctable. A change in the type of patient might be responsible.
Whether a death rate is acceptable is a second question, which is
separate from the issue of whether it has increased. Since the death rate
translates into a level of risk for prospective patients, a third question
concerns the information to be given to patients, particularly if there
has been a recent increase in the death rate.
All three questions require continuous appraisal of the death rate.
In the absence of risk-adjustment, the "death rate" is the number of
deaths as a percentage of the number of patients treated. All patients die
eventually, and so the death rate is 100%, provided the period of follow-
up is long enough. It is innumerate to refer to a death rate, unless it is
clear from the context what period of follow-up is intended. An
understanding of which type of patient, such as heart only or heart and
lung, is also helpful. Another point concerning death rate is how far back
in time to go when counting up the total number of deaths.
The heart transplant programme at St. George's did not keep a watch
dog. Instead the alarm was raised by the clinicians themselves at the
hospital. The sounds of alarm were eventually heard by a loose network of
organisations supported by public money but with poorly defined activity.
It took time for the alarm to reach them because they were some distance
away, in a different valley so to speak. They did not have day-to-day
contact with the hospital and knowledge of the death rate there. When the
alarm did reach them, they were not able to contribute much more than some
extra sounds of consternation. One such external organisation, CHI, has
made more noise than most. However the CHI report 1 did not address any of
the relevant three questions with authority. A professionally qualified
statistician should have been involved.
Rather than rely on a off-site organisation, it would be better to
have a competent watchdog on the premises.
Acknowledgement
This letter is an extract from a longer report, which is available at
http://www.sghms.ac.uk/depts/phs/staff/jdp/txreview.htm
Competing interests: No competing interests