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Standardised Mortality Ratios& their monitoring
Paul Hawgood
Everything that you wanted to know about SHMI but were too afraid to ask!
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Housekeeping
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Join the conversation..
#SaferNHS
@AQUA_Inform
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Agenda (Pre Coffee)Item TimeWelcome, introductions, housekeeping
9:30
Planned outcomes for the workshop 9:45Quiz 9:50An introduction to SMRsHow SHMI is calculatedDifferences between SMRs What to look for in the dataMyth busters
10:00-
11:30
Break
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Agenda (Post Coffee)
Item TimeQ&A Session 11:30Quiz – yes, again! 11:45How do I engage with AQuA? 12:00How do I engage with my local trust / health economy/ social services?
12:15
Lunch 12:30
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Outcomes• Increase your understanding of SMRs in
general and, specifically, SHMI and HSMR so that you can:– work with local acute Trusts on an informed basis– look to reduce mortality rates as a whole health economy
• Provide you with the knowledge to ask the right questions of providers.
• Place SMR in context/relation to other indicators of the quality of care.
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It’s not about the data!“It’s true that cancer care has come on in leaps and bounds but we can’t look at our comparative survival rates and think anything other than we need to do more.”
Professor Sir Bruce Keogh, National Medical Director 24/3/2014
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Content• My approach / house rules• Crude rate• Standardised Mortality Ratios [SMRs]• Different methodologies• SHMI in detail • Interpretation• Myth busters• Questions
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Crude [mortality] rate x 100 x 100
• Population-based rates– CCG mortality rates– GP Practice-based disease prevalence
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Problem?
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Standardised Mortality Ratios• Standardising means “making adjustments”
– age, sex, severity of condition– admission type, deprivation, palliative care
• Indirect and direct standardisation• Calculates a new, standardised mortality
rate
• ‘Rate’, ‘Ratio’ or ‘Index’?
x 100
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Damned lies“Essentially, all models are wrong but some are useful.”
George E.P. Box 1951
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SHMI Oct 2011 to Oct 2012 (NW Trusts)
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Methodologies
• 3 main methodologies in NHS• SHMI, HSMR & RAMI
– Describe – Similarities– Differences– Pros & Cons
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Summary Hospital-Level Mortality Indicator
• SHMI• Published by NHS [HSCIC]• Published quarterly
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Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Oct-12 n n n n n n n n n n n nJan-13 n n n n n n n n n n n nApr-13 n n n n n n n n n n n nJul-13 n n n n n n n n n n n nOct-13 n n n n n n n n n n n nJan-14 n n n n n n n n n n n nApr-14 n n n n n n n n n n n nJul-14 n n n n n n n n n n n n
2011 2012SHMI issue date
Data used in the SHMI calculations
2013
Ja n
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Summary Hospital-Level Mortality Indicator
• SHMI• Published by NHS [HSCIC]• Published quarterly• Key Differences
– 137 Trusts– Out-of-hospital deaths (30 days post
discharge)– Agnostic to Palliative Care
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Hospital Standardised Mortality Ratio• HSMR• Published by Dr Foster Intelligence
– Hospital Guide
• Fore-runner to SHMI• Published annually / quarterly• Key differences
– All trusts– Explicit adjustment for deprivation– Palliative Care
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Risk Adjusted Mortality Indicator
• RAMI• Published by CHKS• Published ??• Key differences
– HRG not first episode– Excludes spells with Palliative Care
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Key DifferencesAttribute SHMI HSMR
Hospitals included Excludes specialist, MH & independent
All providers (SUS)
Basket of conditions No exclusions Basket of 56 diagnostic groups which relate to c. 80% of activity
Death attributed to… Trust that patient died in or was discharged from (30 days)
All trusts involved in the patient’s care during the ‘super-spell’
Out-of -hospital Includes deaths up to 30 days post discharge
Not included
Palliative Care No adjustment made Relative-risk weighting applied
Deprivation Proxy via co-morbidity [?] Relative-risk weighting applied
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How SHMI is calculated
• SHMI Specification 1.14• Observed deaths• Expected deaths• Outliers
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Observed deaths• HES data [from CDS; from the Trust]• Patients dying in hospital
– Discharge method = 4 (therefore, not Stillbirths)
– Excluding daycases, regular day attenders, regular night attenders [Classpat = 2,3 or 4]
• Patients that died within 30 days of discharge– ONS data; linked to HES data
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How SHMI is calculated• SHMI Specification 1.14• Observed deaths• Expected deaths
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Expected Deaths (1)• All discharges (apart from noted exclusions)• Split them up into all possible combinations
of risk factors (i.e. stratify)– How many groups?
Group Number
Admission Method 3
Age 21
Charlson Index 3
Gender 3
Year 3
CCS Group 140
Total 238,140
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Expected deaths (2)
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Bottom 10 and top 10 Intercept Values
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Groups of Codes ICD10 Codes16,000
CCS Categories260
CCS Groups
140
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Groups of Codes in practice
• Primary diagnosis of first episode [FFCE]• Unless primary diagnosis is an ‘R’ code; in
which case use primary diagnosis of 2nd FCE• Unless this is also an ‘R’ code; in which case
revert to the primary diagnosis of the FFCE !!!!
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Charlson Co-morbidity Index
• All Secondary diagnoses of first episode [FFCE]
• Unless primary diagnosis is an ‘R’ code; in which case use secondary diagnoses of 2nd FCE
• Unless this is also an ‘R’ code; in which case revert to the secondary diagnoses of the FFCE !!!!
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Outliers• Data are put into a funnel plot
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Outliers• Data are put into a funnel plot• Poisson distribution• Over-dispersion [page 16]• 3 bands
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Interpretation (SHMI)• 3 bandings (when compared to England
average)– Higher than expected– As expected– Lower than expected
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Interpretation (SHMI)• 3 bandings (when compared to England
average)– Higher than expected– As expected– Lower than expected
• Trends
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Interpretation (SHMI)• 3 bandings (when compared to England
average)– Higher than expected– As expected– Lower than expected
• Trends• What is driving a change?
– Observed or Expected– CCS Groups, week-end and the rest…
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Observed or Expected?
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Interpretation (SHMI)• 3 bandings (when compared to England
average)– Higher than expected– As expected– Lower than expected
• Trends• What is driving a change?
– Observed or Expected– CCS Groups, week-end and the rest…
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Myth-busters• We’re in a highly deprived area• We have some data recording issues, that’s all• We provide high levels of Palliative Care• We have audited every death and found no
issues• We have a high proportion of [SHMI] deaths
that are out of hospital• CCS Groups are useful• The London effect
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Deprivation (1)
• SHMI makes no adjustment for social deprivation– It might create the impression that a higher
death rate for those who are more deprived is acceptable and has the potential to remove from the SHMI some of the differences that it is designed to measure
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Deprivation (2)
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Deprivation (3)
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Deprivation (4)
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Data/coding issues (1)
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Data/coding issues (2)
• R codes
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Palliative Care (1)• SHMI: not adjusted for
– Included in published “Contextual” Data
• HSMR: adjusted for• RAMI: Spells discounted
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Palliative Care (2)
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Audit of deaths• Why do it?
– Learn lessons– Check coding
• Expected deaths based upon all discharges• CCS Group analysis
• PRISM2– Nick Black et al.– 2,000 case-note reviews, nationally
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Out of hospital deaths (1)
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Out of hospital deaths (2)• It is desirable to have fewer deaths
– It is desirable to have fewer deaths in hospital– It is desirable to have fewer deaths <30 days
of discharge
• Does the ratio of the 2 figures matter?
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Out of hospital deaths (3)
Baseline Scenario 1 Scenario 2 Scenario 30
200
400
600
800
1,000
1,200
In-hosp Out hosp
25%
44% 9%
9%
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Out of hospital deaths (4)• Factors causing a higher rate
– Patient discharged too early– Poor care in the community– Good hospice care / support to die at home
• Factors causing a lower rate– The opposite of the above– Good systems to prevent unnecessary
admissions, especially in those likely to die
• Desirable things could cause a higher rate or a lower rate – so, it doesn’t matter.
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Out of hospital deaths (5)
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CCS Groups• 140 Groups• Alerts• Relies on accurate coding• Identifies clinical areas to look at…• …or does it? • Congruence with death certificate
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The London effect
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Any questions?
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Pack• Quiz – with answers• SHMI Specification• Latest quarterly mortality report• PRISM2 review form• Palliative Care coding – first 2 pages • ccvol7issue4 Palliative Care Coding.pdf
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Portal• Avoidable mortality
– Amenable to healthcare– Preventable deaths
• Lessons Learned + checklist
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Next time…• CUSUM alerts• VLADs• GP/CCG SHMI !!!• Severe Winter!!!
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Next Steps …• What do you want from AQuA?• CCG co-design session 16th July (29th
July)• ? other masterclasses• Handouts & Links post session