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Feature Statistics Behind the Headlines

Are you 45% more likely to die in a UK hospital rather than a US hospital?

BMJ 2013; 347 doi: (Published 24 September 2013) Cite this as: BMJ 2013;347:f5775

Rapid Response:

Re: Are you 45% more likely to die in a UK hospital rather than a US hospital?

The authors of a 2012 JAMA paper analysed coding data from the 2003-2009 period and damningly suggest that the fall in hospital mortality in pneumonia patients in USA was due to trends in diagnostic coding. (1).

This is not surprising considering that an army of professional coders exist to maximise revenue for hospitals in USA. Mis-coding and up-coding is widespread in USA and billions are estimated to be lost to healthcare fraud. (2)(3).

By contrast, coders in UK have been pretty much invisible and only recently, the payment-by-results and damnation by HSMR has brought visibility to coders in hospital hierarchy.

A cursory glance at patient discharge summaries, from UK and USA hospitals, would reveal the huge gulf in coding practices between the two healthcare systems.

Hence, the exploratory, pneumonia mortality data by Brian Jarman, while deserving of careful scrutiny by policy makers, should not be accepted at face value.(4).

The editorial accompanying the JAMA paper by Lindenauer et al prophetically warns about 'naïve analysis of administrative data' and ''lack of appreciation of the nuances in diagnostic coding'. (5).

Brian Jarman is clearly passionate about improving patient outcomes and NHS is certainly very far from being perfect. But bold claims about NHS deficiencies without robust data needlessly undermines patient's trust in NHS and denigrates NHS staff.(4).


1. Lindenauer P, Lagu T, Shieh M, Pekow P, Rothberg M. Association of Diagnostic Coding With Trends in Hospitalizations and Mortality of Patients With Pneumonia, 2003-2009. JAMA. 2012;307(13):1405-1413. doi:10.1001/jama.2012.384.

2. Pitts SR. Higher-complexity ED billing codes--sicker patients, more intensive practice, or improper payments? N Engl J Med. 2012 Dec 27;367(26):2465-7. doi: 10.1056/NEJMp1211315

3. Center for Public Integrity : How doctors and hospitals have collected billions in questionable Medicare fees. (accessed 26 sept 2013).

4. Spiegelhalter D. Statistics Behind the Headlines. Are you 45% more likely to die in a UK hospital rather than a US hospital?. BMJ 2013; 347 doi:

5. Sarrazin M, Rosenthal G. Finding Pure and Simple Truths With Administrative Data. JAMA. 2012;307(13):1433-1435. doi:10.1001/jama.2012.404.

Competing interests: No competing interests

28 September 2013
Santhanam Sundar
Consultant Oncologist
Nottingham University Hospitals NHS Trust
Nottingham. NG5 1PB