Using care bundles to reduce in-hospital mortality: quantitative survey
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1234 (Published 01 April 2010) Cite this as: BMJ 2010;340:c1234
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Sir,
We question the cause and effect inferences in the above report [1]
for the following reasons:
1. This is only one report from a large population of potential
reports and hence should be considered at high-risk of publication bias.
Negative single-centre quality improvement reports are notable by their
absence.
2. The study was uncontrolled – controlled multi-centre studies
provide much more modest results.[2;3] A controlled before and after multi
-centre evaluation of an intervention that included IHI bundles will be
reported in due course.
3. The intervention effect is implausible for two related reasons:
a. The size of the observed effect greatly exceeds the total
preventable death rate of 0.3%, which can be calculated from the figures
cited by the authors in the introduction.
b. It seems implausible for an intervention so simple that it could
be introduced across a whole hospital within one month, to have had such a
massive effect.[4]
4. Reported death rates for certain diseases started to improve in
January 2007 (well before the intervention date in April 2007), suggesting
that other (confounding) factors were at work.
5. The topics were chosen for intervention on the grounds that they
had “led to the largest number of deaths” in the previous year and the
findings may therefore have been subject to regression to the mean.
6. We do not accept that differences in use of bundles by the
hospitals within the trust generates valid internal controls for the
following related reasons:
a. This was not an intention-to-treat analysis;
b. There are many potential confounding differences between the
hospitals;
c. The method by which use of the bundles was measured was not itself
audited and is likely to have been subject to measurement error.
There is a fashion for giving credence to single-centre studies that
would not normally be regarded as likely to be valid, provided they can be
described as ‘quality improvement’.[5] Yet the risks of bias are not
contingent on how a study is labelled.
References:
[1] Robb E, Jarman B, Suntharalingam G, Higgens C, Tennant R, Elcock
K. Using care bundles to reduce in-hospital mortality: quantitative
survey. BMJ 2010;340:c1234.
[2] Landon BE, Hicks LS, O'Malley AJ, Lieu TA, Keegan T, McNeil BJ et
al. Improving the Management of Chronic Disease at Community Health
Centers. N Engl J Med. 2007;356(9):921-34.
[3] Landon BE, WIlson IB, McInnes K, Landrum MB, Hirschhorn L,
Marsden PV et al. Effects of a Quality Improvement Collaborative on the
Outcome of Care of Patients with HIV Infection: The EQHIV Study. Ann
Intern Med. 2004;140(11):887-96.
[4] Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ. Reality check
for checklists. Lancet. 2009;374:444-5.
[5] Berwick DM. The Science of Improvement. JAMA. 2008;299(10):1182-
4.
Competing interests:
RL is senior author on controlled before and after multi-centre evaluation mentioned in response.
Competing interests: No competing interests
The results shown in this report clearly present a very
important and positive finding on the effect of these care
bundles. The authors' main outcome metric is a comparison
between mortality rates in 2006/7 and 2007/8 based on HES
data.
However, 2008/9 HES data has now been available for a few
months and the Trust should have access to even more recent
data. The key question is: have these reductions been
sustained?
Competing interests:
None declared
Competing interests: No competing interests
The mortality reductions have been maintained
In reply to the first Rapid Response from Robert Shaw, I have checked the HSMRs over the years from 2006/07 (using year 2007/08 as the fixed reference baseline for the calculations) - year followed by HSMR:
2006/07 102.3;
2007/08 80.0;
2008/09 89.2;
2009/10 76.5;
2010/11 83.1.
The mortality reduction initiative started on 01 April 2007. Year 2010/11 is only part of the financial year. These are the values (to 2009/10) that will be published later this year unless hospitals refresh their 2009/10 data in the next couple of months.
Competing interests:
One of the authors of the article
Competing interests: No competing interests