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Hospitals' star ratings and clinical outcomes: ecological study

BMJ 2004; 328 doi: (Published 15 April 2004) Cite this as: BMJ 2004;328:924
  1. Kathy Rowan, director1,
  2. David Harrison, statistician1,
  3. Anthony Brady, senior statistician1,
  4. Nick Black (, professor of health services research2
  1. 1Intensive Care National Audit and Research Centre, London WC1H 9HR, 2 London School of Hygiene and Tropical Medicine, London WC1E 7HT
  2. 2London School of Hygiene and Tropical Medicine, London WC1E 7HT
  1. Correspondence to: N Black
  • Accepted 12 November 2003


The English Department of Health is developing global measures of the performance of all NHS bodies, including 166 acute hospital trusts. Since 2000-1, the trusts get zero, one, two, or three stars to indicate performance.1 This rating may not reflect the effectiveness of clinical care measured in patient outcomes because of the lack of accurate routine data.2 One exception is in adult critical care3; we checked whether a hospital's rating provided an indication of its clinical outcomes.

Methods and results

We compared the 2001-2 rating of 102 acute hospital trusts for which we had validated data for that year. We calculated each patient's predicted risk of death before discharge from hospital4 and compared it with actual mortality for all admissions in 2001-2 for each unit.

We compared rating with crude mortality at the patient level rather than aggregated by hospital; our sample …

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