Case-mix adjusted hospital mortality is a poor proxy for preventable mortality: a modelling study
- Alan J Girling1,
- Timothy P Hofer2,
- Jianhua Wu3,
- Peter J Chilton1,
- Jonathan P Nicholl4,
- Mohammed A Mohammed1,
- Richard J Lilford1
- 1Department of Public Health, Epidemiology and Biostatistics, University of Birmingham, Birmingham, UK
- 2Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- 3Centre for Environmental and Preventive Medicine, Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- 4Medical Care Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
- Correspondence to Prof Richard J Lilford, Department of Public Health, Epidemiology and Biostatistics, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK; r.j.lilford{at}bham.ac.uk
- Accepted 17 September 2012
- Published Online First 15 October 2012
Abstract
Risk-adjustment schemes are used to monitor hospital performance, on the assumption that excess mortality not explained by case mix is largely attributable to suboptimal care. We have developed a model to estimate the proportion of the variation in standardised mortality ratios (SMRs) that can be accounted for by variation in preventable mortality. The model was populated with values from the literature to estimate a predictive value of the SMR in this context—specifically the proportion of those hospitals with SMRs among the highest 2.5% that fall among the worst 2.5% for preventable mortality. The extent to which SMRs reflect preventable mortality rates is highly sensitive to the proportion of deaths that are preventable. If 6% of hospital deaths are preventable (as suggested by the literature), the predictive value of the SMR can be no greater than 9%. This value could rise to 30%, if 15% of deaths are preventable. The model offers a ‘reality check’ for case mix adjustment schemes designed to isolate the preventable component of any outcome rate.
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