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Reducing the number of avoidable deaths in hospital is the focus of many quality improvement initiatives worldwide.1 Comparing indicators of avoidable mortality between different hospitals could help to target improvement efforts, but optimally defining and measuring hospital deaths that could be deemed preventable remains a challenge.2 Unlike performance comparisons based on hospital standardised mortality ratio (HSMR), a new policy initiative announced by the UK Government will rank hospitals for avoidable mortality based on case reviews of 2000 deaths in English hospitals each year. Although this initiative aims to overcome limitations of current policies, two statistical properties of the proposed approach mean that it is unsuitable for classifying hospital performance.
The first issue relates to the ability to identify whether any one death really was avoidable on a case-by-case basis. It would appear3 that the planned process is based on work by Hogan et al4 using retrospective case record review (RCRR). In line with previous studies using RCRR, these investigators asked experienced clinicians to rate whether a death was preventable on a 6-point Likert scale.4 ,5 Their study recognised that the use of a semicontinuous scale better reflects ‘the probabilistic nature of reviewers’ decision making more closely than requiring a simple “yes” or “no” response’.4 ,5 However, in operationally defining an avoidable death, the probabilistic component of the instrument is lost because a fixed cut-off is used such that deaths where it is judged that there is more than a 50% chance that the death was preventable are classified as avoidable, and those below 50% are not. (It should be noted that the somewhat arbitrary choice of a 50% cut-off value is not the real issue here, but rather the dichotomisation itself is. However, hereafter, we assume a 50% cut-off value is used …
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