Hospital Mortality Monitoring of... · 2020-05-21 · NEQOS Hospital Mortality Monitoring report 20: October 2012 to September 2013 June 2014 (FINAL) North East Quality Observatory

Hospital Mortality Monitoring

Report 20: Oct 2012 to Sept 2013

June 2014

undertaken by

North East Quality Observatory System

on behalf of

All North East Subscribers to NEQOS Services

NEQOS is jointly operated by Northumberland, Tyne and Wear

and South Tees Hospitals NHS Foundation Trusts

NEQOS Hospital Mortality Monitoring report 20: October 2012 to September 2013 June 2014 (FINAL)

North East Quality Observatory is jointly operated by Northumberland Tyne & Wear NHS Foundation Trust and South Tees Hospitals NHS Foundation Trusts Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ – 0191 245 6708 Page 2

Confidential

Contains commercially sensitive information

© North East Quality Observatory System (NEQOS)

The Hospital Mortality Monitoring report and all associated tools and materials are Copyright © NEQOS for the purpose

of assurance within subscribing organisations and may not be used for any other purposes or distributed further without

the express permission of NEQOS.


Contents

Contents .................................................................................................................................................................................... 3

Executive Summary ................................................................................................................................................................... 4

1 Context and background ............................................................................................................................................ 5

2 Methods and measures .............................................................................................................................................. 6

3 Comparisons of hospital mortality between Trusts ................................................................................................... 7

Figure 1: SHMI funnel plot by acute trust using 95% Control Limits and adjustment for over-dispersion for Oct 12

to Sept 13 ................................................................................................................................................................... 7

Table 1: SHMI, total discharges, observed and expected deaths, % aged 75+ and banding by acute trust for Oct 12

to Sept 13 ................................................................................................................................................................... 7

4 Hospital mortality through time for Trusts in the North East .................................................................................... 8

Table 2: HSMR, observed and expected deaths, for 2012 and 2013 .......................................................................... 8

Figure 2: HSMR for October 2012 to September 2013 ............................................................................................... 9

Figure 3: SHMI and unadjusted mortality rate April 2010 – Sep 2013, by Acute Trust ............................................ 10

Figure 4: HSMR and palliative care discharges April 2010 - Dec 2013 by Acute Trust.............................................. 11

Figure 5: Average SHMI and HSMR by Acute Trust, Q1 2010/11 to Q2 2013/14 ..................................................... 12

Figure 6: Proportion of deaths with palliative care coding, Oct 12 to Sept 13 ......................................................... 12

Figure 7: Monthly HSMR by Acute Trust for DDT area, January 2012 to December 2013 ....................................... 13

Figure 8: Monthly HSMR by Acute Trust for CNTW area, January 2012 to December 2013 .................................... 13

5 SHMI by CCS group ................................................................................................................................................... 14

Figure 9: SHMI by CCS bundle for North East Trusts, October 2012 to September 2013 ......................................... 14

Table 3: SHMI summary of funnel plots of CCS bundles for NE Trusts, October 2012 to September 2013 ............. 14

6 SHMI for selected cancer CCS Groups ...................................................................................................................... 15

Figure 10: SHMI for lung cancer, colo-rectal cancer and other secondary cancers .................................................. 15

7 Comparison of SHMI by Clinical Commissioning Group ........................................................................................... 16

Figure 11: SHMI by North East CCGs, October 2012 to September 2013 ................................................................. 16

Table 4: SHMI for North East CCGs, October 2012 to September 2013 ................................................................... 16

8 Comorbidity coding .................................................................................................................................................. 17

Figure 12: Number of comorbidities per spell, by Acute Trust for April 2010 to December 2013 ........................... 17

9 Conclusions .............................................................................................................................................................. 17

10 Abbreviations and glossary ...................................................................................................................................... 18

11 Appendix .................................................................................................................................................................. 19



Executive Summary

This is the twentieth report for NHS organisations in the North East (NE) reviewing hospital mortality in the region. The objective is to give both providers and commissioners hospital mortality monitoring and benchmarking data to assist with assurance across the NE. The report is provided to organisations subscribing to the North East Quality Observatory System (NEQOS).

The Intelligent Monitoring Reports (IMRs) produced by the Care Quality Commission have not yet been refreshed and are expected in June 2014. This report details the mortality indicators which will be included in the next IMR for the period October 2012 to September 2013.

The analysis contained in Table 2 of the report shows that for most of the trusts in the NE there has been an increase in HSMR however this generally does not arise from an increase in observed deaths. The SHMI and HSMR differ in their construction around the palliative care coding which is included within the HSMR model but is not part of the SHMI model. Whilst levels of palliative care coding have increased nationally, in the NE levels have remained the same or fallen, and this relative change is a factor in the rising HSMR.

A number of reports relevant to hospital mortality monitoring have been published this quarter. Two by the Royal College of Physicians on asthma deaths and care of the dying and one by Dr Foster on the impact of the changing use of specialist palliative care coding in the NHS. The Faculty of Public Health (FPH) have released a position statement on the use of the HSMR, emphasising the methodological controversies.

Nationally, preparations for the introduction of the Outcomes Framework indicator ‘hospital deaths attributable to problems in care’ continue and trusts will be expected to implement this indicator (which is based on a case note review process in which clinicians judge whether a death could have been prevented) during 2014-15. PRISM2 (led by Professor Black as recommended in the Keogh Review) will be the basis for the new indicator and the methods employed are being replicated by NE Trusts in order to prepare for the new indicator.

The report includes the following conclusions:

The Summary Hospital-level Mortality Indicator (SHMI) is the main measure used to monitor hospital mortality rate. All NE Trusts continue to be as expected for SHMI with the exception of North Tees with a SHMI of 113.1 which is above the upper limit of the funnel plot.

As the mortality indicators being reported here include the hard winter of 2012/13, the high level of respiratory deaths discussed in previous reports continues to be an important factor.

The SHMI for North Tees is slightly higher than for the last release of data when the Trust was also an outlier. Whilst this is of concern and the trust will want to examine its mortality, the SHMI has not been persistently high and so does not yet require the level of external scrutiny applied to Trusts reviewed by Keogh. The highest priority is clinical review of deaths and examining pathways for pneumonia care.

HSMR remains important and is included along with the unadjusted mortality rate (all deaths divided by all spells in SHMI). The CQC use HSMR as part of their Intelligent Monitoring Reports.

The HSMR continues to be high for a number of trusts in the North East and the fall in specialist palliative care coding seen at several trusts in the region, contributes to this.



1 Context and background

1.1 This is the twentieth report for NHS organisations in the North East (NE) reviewing hospital mortality in the region. The objective is to give providers and commissioners hospital mortality monitoring and benchmarking data to assist with assurance across the NE. The report is provided to organisations subscribing to the North East Quality Observatory System (NEQOS).

1.2 The Care Quality Commission (CQC) published the first hospital Intelligent Monitoring Reports (IMR) in October 2013 (www.cqc.org.uk/public/hospital-intelligent-monitoring) and the second iteration in March 2014. The IMRs are constructed from more than 150 indicators. Mortality indicators include SHMI, HSMR from Dr Foster (four HSMR indicators: overall HSMR, HSMR for emergency admissions split for weekday/weekend and deaths in low risk conditions) and the composite indicators used in the CuSum based Mortality Alert system operated by Dr Foster for the CQC.

1.3 Dr Foster has announced that they are publishing the four HSMR indicators used in the IMRs independently on a quarterly basis. This report uses the HSMR calculated by HED and the IMR is due to be published again in June 2014 with the HSMR from Dr Foster.

1.4 In March 2014 Dr Foster signalled their intention to adapt their adjustment models in relation to the use of specialist palliative care codes, publishing a report examining the changing use of these codes and the negative impact this has had on the reliability of the HSMR. The report is available from http://drfosterintelligence.co.uk/wp-content/uploads/2014/03/Palliative-report-final-260314.pdf.

1.5 Health and Social Care Information Centre (HSCIC) has continued to provide SHMI data at patient level and has released Variable Life Adjusted Display (VLAD) charts for 11 SHMI Diagnosis Groups. All NE acute trusts providing data to NEQOS receive an analysis of their VLADs with help in interpretation and links to clinical process measurement and clinical review of case notes. NEQOS analysis includes break-down to hospital site.

1.6 The Royal College of Physicians have published two reports relevant to hospital mortality. The first is the National Review of Asthma Deaths (NRAD), which is run by a consortium of asthma professional and patient bodies, which looked into the circumstances surrounding deaths from asthma from 1 February 2012 to 30 January 2013. The report can be found at: http://www.rcplondon.ac.uk/projects/national-review-asthma-deaths. The second was the National Care of the Dying Audit for Hospitals, England, which found significant variations in care across hospitals in England. The audit shows that major improvements need to be made to ensure better care for dying people, and better support for their families, carers, friends and those important to them. The report can be found at: http://www.rcplondon.ac.uk/resources/national-care-dying-audit-hospitals.

1.7 The Faculty of Public Health (FPH) released a position statement on Hospital Standardised Mortality Ratios (HSMR) at: http://www.fph.org.uk/uploads/Position%20statement%20-%20hospital%20mortality%20rates.pdf, emphasising the methodological controversies. FPH recommends an evidence-based, rigorous and questioning approach to inspecting hospitals with more attention to staffing levels, to community health and social care factors. This approach would help ensure adequate means of caring for terminally ill patients, relieve pressure on A&E ‘pinch points’, elderly care wards and prevent unnecessary admission.

1.8 Nationally, preparations for the introduction of the Outcomes Framework indicator ‘hospital

deaths attributable to problems in care’ continue and trusts will be expected to implement

http://www.cqc.org.uk/public/hospital-intelligent-monitoring

http://drfosterintelligence.co.uk/wp-content/uploads/2014/03/Palliative-report-final-260314.pdf

http://drfosterintelligence.co.uk/wp-content/uploads/2014/03/Palliative-report-final-260314.pdf

http://www.rcplondon.ac.uk/projects/national-review-asthma-deaths

http://www.rcplondon.ac.uk/resources/national-care-dying-audit-hospitals

http://www.fph.org.uk/uploads/Position%20statement%20-%20hospital%20mortality%20rates.pdf

http://www.fph.org.uk/uploads/Position%20statement%20-%20hospital%20mortality%20rates.pdf



this indicator (which is based on a case note review process in which clinicians judge whether

a death could have been prevented) during 2014-15. A number of trusts in the region are sites

for PRISM2, the study that aims to demonstrate whether avoidable mortality, as measured by

this case note review process, shows any association with HSMR or SHMI and which will be

the basis for the new indicator. The steering group for the development of the new indicator

has been established and recommendations are expected towards the end of 2014.

2 Methods and measures

2.1 SHMI is the hospital-level indicator which reports all deaths in hospital and all deaths that occur within 30 days of discharge from hospital across the NHS in England1. It compares the observed number of deaths for each acute trust with the number expected calculated from a statistical model that takes account of patients’ age, sex, method of admission to hospital, diagnosis and comorbidities.

2.2 The primary diagnosis and comorbidities are taken from the first consultant episode within the provider spell; the exception to this is where the primary diagnosis is an R-code (i.e. from within the ICD-10 Signs and Symptoms chapter). If the primary diagnosis is an R-code the primary diagnosis from the second episode is used. Where the primary diagnosis for the second episode is also an R-code then the first episode is used. This methodology applies to the derivation of the Dr Foster HSMR as well as to the HSCIC’s SHMI.

2.3 The latest tranche of data, published 30th April 2014 covers October 2012 to September 2013. Patient level SHMI data is released allowing the calculation of VLADs by diagnosis group.

2.4 The SHMI and HSMR are extracted from the Healthcare Evaluation Data (HED) system supplied by University Hospitals Birmingham NHS Foundation Trust (UHB). The HSCIC has undertaken a comprehensive review of their processes for handling the release of data (http://www.hscic.gov.uk/article/4743/Review-of-Processes-for-Release-of-Data). This resulted in a delay in providing HES data to HED however HED are able to reproduce the mortality indicators to a high degree of accuracy and NEQOS have used these for this report.

2.5 This report presents the latest data using funnel plots for the cross sectional analysis of Trusts in the period October 2012 to September 2013. The SHMI is the ratio of observed over expected deaths, where 100 indicates that both the observed and expected deaths are the same, and is the average across England.

2.6 The funnel plots display the SHMI on the vertical axis against the number of expected deaths (the denominator) along the horizontal axis. Trusts are identified as outliers if their SHMI value places them outside the control limits on the funnel plots. The 95% Control Limits with adjustment for over-dispersion are used for banding Trusts as ‘low’, ‘as expected’, or ‘high’ and this funnel plot has been reproduced in this report.

2.7 Trends through time are presented for each Trust using 14 quarters of data from April 2010 to

September 2013 for both SHMI and unadjusted mortality. Charts display the SHMI and the

unadjusted (or crude) mortality rate for each Trust. The trends have not been subjected to

statistical testing for significance (a method for doing so has yet to be agreed nationally) and

so caution must be exercised in interpreting variation of SHMI through time.

1 http://www.hscic.nhs.uk/SHMI

http://www.hscic.gov.uk/article/4743/Review-of-Processes-for-Release-of-Data

http://www.hscic.nhs.uk/SHMI



3 Comparisons of hospital mortality between Trusts

3.1 Figure 1 shows the SHMI for all Trusts in England for October 2012 to September 2013, using the funnel plot adjusted for over-dispersion. Table 1 shows the SHMI, total discharges, banding and proportion of deaths that occurred in patients aged 75 or older for all the NE acute Trusts in the latest tranche of data released by the HSCIC.

Figure 1: SHMI funnel plot by acute trust using 95% Control Limits and adjustment for over-dispersion for Oct 12 to Sept 13

Table 1: SHMI, total discharges, observed and expected deaths, % aged 75+ and banding by acute trust for Oct 12 to Sept 13

3.2 North Tees and Hartlepool is a high outlier in this release of data. This is the second consecutive quarter in which the Trust has been a SHMI outlier. North Tees show a SHMI value of 113.1 for this period, slightly higher than the last period.

South Tyneside

Gateshead

North Tees

Sunderland

Newcastle

South TeesCDD

Northumbria

0

25

50

75

100

125

0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000

SHM

I

Expected deaths

SHMI with banding using 95% Control Limits and with adjustment for over-dispersion

Other Acutes North East 95% Lower Limit 95% Upper Limit

Source: Summary Hospital-level Mortality Indicator (SHMI). Data released by the HSCIC, May 2014

Provider Discharges Observed % aged 75+ Expected SHMI Category

County Durham and Darlington NHS FT 84030 3075 69.2 2962 103.8 as expected

North Tees and Hartlepool NHS FT 48731 1943 67.8 1718 113.1 Higher than expected

South Tees Hospitals NHS FT 90117 2818 64.6 2709 104.0 as expected

Gateshead Health NHS FT 34350 1468 69.9 1459 100.6 as expected

South Tyneside NHS FT 22654 1112 68.9 1001 111.0 as expected

City Hospitals Sunderland NHS FT 59422 2099 69.7 1925 109.1 as expected

The Newcastle Upon Tyne Hospitals NHS FT 105130 2523 57.2 2773 91.0 as expected

Northumbria Healthcare NHS FT 58097 3063 71.5 2785 110.0 as expected

North Cumbria University Hospitals NHS Trust 45230 1707 69.1 1673 102.0 as expected



3.3 HSCIC reported Trusts that were high outliers in the current period and in the same period in 2011/12, mirroring the method chosen by Keogh to identify trusts with persistently high SHMI or HSMR (ie over a two year period). Key facts for the period from 1 October 2012 to 30 September 2013 (against the same period a year ago):

8 trusts had a 'higher than expected' SHMI value compared to 10 trusts previously.

17 trusts had a 'lower than expected' SHMI value, compared to 18 trusts previously.

116 trusts had an 'as expected' SHMI value, compared to 114 trusts previously.

3.4 North Tees are the only SHMI outlier in the NE in any of the eleven releases of the data from the HSCIC. Whilst this is of concern, particularly as this is the second release in which the SHMI is ‘higher than expected’, and the trust will want to continue to examine its mortality, the SHMI has not been persistently high and so does not yet require the level of external scrutiny applied to Trusts reviewed by Keogh. The highest priority is clinical review of deaths and examining pathways for pneumonia care.

3.5 The higher number of deaths in the winter of 2012/13 remains in the annual figures. In 2012/13 there were 18,500 deaths occurring at acute hospitals in the NE. This compares to 17,400 deaths in 2011/12 and is an increase of 1,100, or 6% in the number of deaths. Although the deaths have fallen in the next two quarters (ie to September 2013) this has not yet improved the position.

4 Hospital mortality through time for Trusts in the North East

4.1 The SHMI for all Trusts in the North East mirrors unadjusted mortality. Unadjusted mortality varies between Trusts from approximately 2% to 6%. This rate includes all deaths in hospital plus deaths within 30 days of discharge.

4.2 This report presents the SHMI for October 2012 to September 2013 in figure 1 and North Tees are an outlier. Mortality indices are shown quarterly, in figures 3 and 4. The data has not been subjected to statistical testing for trend but the data appears to be broadly stable through time. There is no national agreement on the best method for testing trends statistically. The average SHMI and HSMR across the period is presented together in the graph included as figure 5.

4.3 Table 2 shows the HSMR for the last two years, 2012 and 2013. In 2012 all of the trusts show HSMRs of between 102 and 109; the one exception is Newcastle whose HSMR is low in both years. Six of the trusts show substantial increases in HSMR of more than 5 points with two trusts (Sunderland and North Tees) showing increases of more than 10 points.

Table 2: HSMR, observed and expected deaths, for 2012 and 2013

Provider 2012 2013 HSMR

Observed Expected HSMR Observed Expected HSMR Change

County Durham and Darlington NHS FT 1935 1883 103 1876 1731 108 5.7

North Tees and Hartlepool NHS FT 1147 1116 103 1194 1045 114 11.4

South Tees Hospitals NHS FT 1853 1706 109 1800 1571 115 6.0

Gateshead Health NHS FT 1029 951 108 953 899 106 -2.2

South Tyneside NHS FT 755 703 107 704 613 115 7.5

City Hospitals Sunderland NHS FT 1406 1374 102 1358 1149 118 15.9

The Newcastle Upon Tyne Hospitals NHS FT 1683 1751 96 1548 1697 91 -4.9

Northumbria Healthcare NHS FT 2084 1957 106 2116 1853 114 7.7



4.4 The HSMR requires careful interpretation since for some trusts there is a denominator effect, so that the number of expected deaths has fallen (from Table 2). For all of the trusts the expected deaths have fallen for 2013. In four of the six trusts showing substantial increases in HSMR (CDD, South Tees, South Tyneside, Sunderland) the observed deaths in 2013 fell.

4.5 Figure 2 shows the HSMR for October 2012 to September 2013, using the narrow control limits without adjustment for over-dispersion preferred by Dr Foster; 6 trusts are high outliers.

4.6 High HSMRs attract scrutiny and Trusts will want to understand the factors affecting expected death rates in HSMR calculations. Consideration is given to the important differences between SHMI and HSMR in the next section of the report (page 12).

HSMR with control limits for October 2012 to September 2013 (without adjustment for over-dispersion)

Figure 2: HSMR for October 2012 to September 2013



4.7 Figure 3 shows the SHMI and unadjusted mortality rate for Trusts in the North East by quarter from April 2010 to September 2013.

Figure 3: SHMI and unadjusted mortality rate April 2010 – Sep 2013, by Acute Trust

0%

1%

2%

3%

4%

5%

6%

0

25

50

75

100

125

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14

Un

adju

sted

mo

rtal

ity

rate

(%)

SH

MI

SHMI and Unadjusted Mortality Rate for Sunderland

SHMI Unadjusted rate

Source: NEQOS Hospital Mortality Monitoring: Report 20Data extracted from HED May 2014

0%

1%

2%

3%

4%

5%

6%

0

25

50

75

100

125

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14

Un

ad

just

ed

mo

rta

lity

rat

e (

%)

SH

MI

SHMI and Unadjusted Mortality Rate for County Durham & Darlington


Source: NEQOS Hospital Mortality Monitoring: Report 20

Data extracted from HED May 2014

0%

1%

2%

3%

4%

5%

6%

0

25

50

75

100

125

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14

Un

ad

just

ed

mo

rta

lity

rat

e (

%)

SH

MI

SHMI and Unadjusted Mortality Rate for Gateshead



0%

1%

2%

3%

4%

5%

6%

0

25

50

75

100

125

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14

Un

adju

ste

d m

ort

alit

y ra

te (%

)

SHM

I

SHMI and Unadjusted Mortality Rate for North Tees



0%

1%

2%

3%

4%

5%

6%

0

25

50

75

100

125

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14

Un

adju

sted

mo

rtal

ity

rate

(%)

SHM

I

SHMI and Unadjusted Mortality Rate for South Tyneside



0%

1%

2%

3%

4%

5%

6%

0

25

50

75

100

125

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14U

nad

just

ed

mo

rtal

ity

rate

(%)

SHM

I

SHMI and Unadjusted Mortality Rate for South Tees



0%

1%

2%

3%

4%

5%

6%

0

25

50

75

100

125

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14

Un

adju

ste

d m

ort

alit

y ra

te (%

)

SHM

I

SHMI and Unadjusted Mortality Rate for Northumbria



0%

1%

2%

3%

4%

5%

6%

0

25

50

75

100

125

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14

Un

adju

ste

d m

ort

alit

y ra

te (%

)

SHM

I

SHMI and Unadjusted Mortality Rate for Newcastle





4.8 Figure 4 shows the HSMR and palliative care discharge rate for each trust in the North East by quarter from April 2010 to December 2013.

Figure 4: HSMR and palliative care discharges April 2010 - Dec 2013 by Acute Trust

0%

1%

2%

3%

0

25

50

75

100

125

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3

2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14 2013/14

Pa

llia

tiv

e c

are

dis

cha

rge

ra

te (

%)

HS

MR

HSMR and Palliative Care Coding Rate for Sunderland

HSMR Palliative%


0%

1%

2%

3%

0

25

50

75

100

125


2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14 2013/14

Pal

liati

ve c

are

dis

char

ge r

ate

(%)

HSM

R

HSMR and Palliative Care Coding Rate for County Durham & Darlington

HSMR Palliative%


0%

1%

2%

3%

0

25

50

75

100

125


2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14 2013/14

Pa

llia

tiv

e c

are

dis

cha

rge

ra

te (%

)

HSM

R

HSMR and Palliative Care Coding Rate for Gateshead

HSMR Palliative%


0%

1%

2%

3%

0

25

50

75

100

125


2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14 2013/14

Pal

liati

ve c

are

dis

char

ge r

ate

(%)

HSM

R

HSMR and Palliative Care Coding Rate for North Tees

HSMR Palliative%


0%

1%

2%

3%

0

25

50

75

100

125


2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14 2013/14

Pal

liati

ve c

are

dis

char

ge r

ate

(%)

HSM

R

HSMR and Palliative Care Coding Rate for South Tyneside

HSMR Palliative%


0%

1%

2%

3%

0

25

50

75

100

125


2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14 2013/14P

allia

tiiv

e ca

re d

isch

arge

rat

e (%

)

HSM

R

HSMR and Palliative Care Coding Rate for South Tees

HSMR Palliative%

Source: NEQOS Hospital Mortality Monitoring: Report 20

Data extracted from HED May 2014

0%

1%

2%

3%

0

25

50

75

100

125


2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14 2013/14

Pa

llia

tiv

e c

are

dis

cha

rge

ra

te (

%)

HSM

R

HSMR and Palliative Care Coding Rate for Northumbria

HSMR Palliative%


0%

1%

2%

3%

0

25

50

75

100

125


2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14 2013/14

Pal

liati

ve a

cre

dis

char

ge r

ate

(%)

HSM

R

HSMR and Palliative Care Coding Rate for Newcastle

HSMR Palliative%




4.9 Figure 5 presents the SHMI and HSMR from April 2010 to September 2013. The methodologies for constructing the two indices are different however despite this it is expected that they would produce similar signals and for one of the trusts this is the case. The trusts with the highest differences show variation of 7 points. The apparent variation between indices can be attributable to their construction, natural variation and clinical coding.

Figure 5: Average SHMI and HSMR by Acute Trust, Q1 2010/11 to Q2 2013/14

4.10 HSMR, unlike SHMI, is adjusted for discharges with a specialist palliative care code (Z515 diagnosis code or 315 specialty code). The rate of discharges included in HSMR with a palliative care code is presented in figure 6. This shows four trusts (CDD, Gateshead, South Tees and Sunderland) are in the lowest quintile for specialist palliative care coding nationally.

4.11 Deaths with palliative care coding October 2012 to September 2013

Figure 6: Proportion of deaths with palliative care coding, Oct 12 to Sept 13

4.12 Nationally the palliative care coding has increased by 2.5 points from 18% to 20.5% over the last year, in the same period palliative coding has been more or less static in the North East and it has fallen at North Tees, South Tees, Gateshead and Sunderland. The increase in HSMR

100

108

100101

106

101

93

104

99

101

105

108

111

105

96

106

80

85

90

95

100

105

110

115

120

County Durham& Darlington

North Tees South Tees Gateshead South Tyneside Sunderland Newcastle Northumbria

Ave

rage

SH

MI

SHMI vs HSMR for North East Trusts Q1 2010/11 to Q2 2013/14

Average SHMI Average HSMR England


Northumbria

South Tyneside

Newcastle

North Tees

CDD Gateshead

South Tees

Sunderland

0

5

10

15

20

25

30

35

40

45

50

Dea

ths

wit

h p

all

iati

ve

ca

re c

od

ing

(%

)

Proportion of deaths with palliative care coding

Median

Source: NEQOS Hospital Mortality Monitoring: Report 20Data released by the HSCIC, May 2014



is not being driven by a corresponding rise in the number of deaths but does appear to be linked to the relatively low level of palliative care coding seen in the North East.

4.13 The HSMR is presented monthly in figures 7 and 8 from January 2012 to December 2013 for NE trusts within the two local Area Teams. Monthly data shows more variation than quarterly data and is included to show the pattern of mortality through the recent months.

4.14 Expected improvements in the HSMRs since the 2012/13 winter are not readily discernable, with monthly HSMR rising again in the autumn in DDT area Trusts and staying high in CNTW Trusts (with the exception of Newcastle where the HSMR remains consistently low).

4.15 The winter of 2012-13 had high mortality, driven by respiratory disease, as discussed in previous reports. There are a number of factors that influence the HSMR which may prevent it from following the expected seasonal profile. These particularly include the extent of palliative care and comorbidity coding, which are detailed elsewhere in this report.

Figure 7: Monthly HSMR by Acute Trust for DDT area, January 2012 to December 2013

Figure 8: Monthly HSMR by Acute Trust for CNTW area, January 2012 to December 2013

40

60

80

100

120

140

01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12

2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2013 2013 2013 2013 2013 2013 2013 2013 2013 2013 2013 2013

HSM

R

Monthly HSMR for DDT acute Trusts, 2012 to 2013

CDD

North Tees

South Tees


40

60

80

100

120

140

01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12

2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2013 2013 2013 2013 2013 2013 2013 2013 2013 2013 2013 2013

HSM

R

Monthly HSMR for CNTW acute Trusts, 2012 to 2013

Gateshead South Tyneside Sunderland Newcastle Northumbria




5 SHMI by CCS group

5.1 The HED system holds information about the primary diagnosis in the form of the Clinical Classification System (CCS) code. There are 255 CCS codes covering the range of diagnosis codes within ICD-10 and these are grouped into 140 diagnosis groups in the calculation of SHMI. NEQOS have grouped these diagnosis groups into 7 larger bundles to make the overall pattern of mortality discernable at a lower level by trust. Figure 9 shows the SHMI by CCS bundle. The data for South Tyneside has been adjusted to exclude cancer activity relating to St Benedict’s hospice site. The Appendix details the CCS groups included in each bundle.

5.2 There is no nationally agreed method for identifying outlying values below Trust level (ie including all 140 diagnosis groups), although using funnel plots is consistent with the method used for Trust level SHMIs. Whilst our approach is still being refined, we have calculated 3 standard deviation funnel plots (ie funnel plots using 99.8% Poisson control limits) for each of the CCS bundles in figure 9 and this output is summarised in table 3.

5.3 The table highlights areas that have higher than expected mortality. Trusts will want to examine their own data (including coding) and review case notes where appropriate to investigate the causes of variation. Note: some of the CCS bundles will contain relatively low numbers of deaths (e.g. injury) and hence will show wider variation for the smaller trusts.

Figure 9: SHMI by CCS bundle for North East Trusts, October 2012 to September 2013

Table 3: SHMI summary of funnel plots of CCS bundles for NE Trusts, October 2012 to September 2013

0

20

40

60

80

100

120

140

CDD North Tees South Tees Gateshead South Tyneside Sunderland Newcastle Northumbria

SHMI by CCS Super-group for NE Acute Trusts, Oct 2012 to Sept 2013

Cancer Cardiac Gut Injury Other causes Other Medical Respiratory disease

Source: NEQOS Hospital Mortality Monitoring: Report 20Data extracted from HED, May 2014

CCS Groups County Durham North Tees South Tees Gateshead South Tyneside Sunderland Newcastle Northumbria North Cumbria

Cancer as expected as expected as expected as expected as expected as expected Low High as expected

Cardiac as expected as expected as expected as expected as expected as expected Low as expected as expected

Gut as expected as expected as expected as expected as expected as expected as expected as expected as expected

Injury as expected as expected as expected as expected as expected as expected as expected as expected as expected

Other causes as expected as expected High as expected as expected as expected as expected as expected as expected

Other Medical as expected as expected as expected as expected as expected as expected as expected as expected as expected

Respiratory High High as expected as expected as expected High as expected High as expected



6 SHMI for selected cancer CCS Groups

6.1 In this and forthcoming reports information will be provided on the CCS groups which make a substantial contribution to overall mortality and provide a useful clinical focus. Data is shown for 2011/12, 2012/13 and 2013/14 (April-September 2013).

6.2 The CCS bundles shown previously can be broken-down in to the 140 constituent diagnostic groups used in the SHMI statistical model. In this report we present data for Lung, Colo-Rectal and Secondary cancers. Looking at the SHMI by CCS group reduces systematic variation at the expense of increasing random variation, since the sample is more consistent, but smaller.

6.3 The National Cancer Intelligence Network provides information resources to support the commissioning of cancer services to improve patients’ experience of care and outcomes: https://www.cancertoolkit.co.uk/

6.4 The lung cancer chart shows the variation in SHMI across the region with Northumbria, Gateshead and South Tyneside at the higher end of the range and Newcastle and South Tees at the lower end. Variation between years in individual trusts is important in the charts for Secondary and Colo-Rectal Cancer; trusts may wish to investigate drivers of these changes for their trust.

Figure 10: SHMI for lung cancer, colo-rectal cancer and other secondary cancers

0

20

40

60

80

100

120

140

CDD North Tees South Tees Gateshead SouthTyneside

Sunderland Newcastle Northumbria

SHM

I

SHMI for Lung Cancer

2011/12 2012/13 2013/14Source: NEQOS Hospital Mortality Monitoring: Report 20Data extracted from HED May 2014

0

20

40

60

80

100

120

140



SHM

I

SHMI for Secondary Cancer


0

20

40

60

80

100

120

140



SHM

I

SHMI for Colo-Rectal Cancer


https://www.cancertoolkit.co.uk/



7 Comparison of SHMI by Clinical Commissioning Group

7.1 The Clinical Commissioning Groups formally came into being on the 1st April 2013 and in line with the NHS Mandate we provide a breakdown of SHMI by CCG. The SHMI for Sunderland CCG is 112.7 which falls outside of the expected range for the period reported. Control limits have been calculated to be consistent with the funnel plot for acute Trusts in figure 1.

7.2 Deaths for individual CCGs occur in multiple acute providers and the observed number of deaths for all North East CCGs is approximately 850 fewer than the number of deaths in all the North East acute trusts in the period. This difference is slightly greater than in the previous report and arises because some patients registered to GP practices in North East CCGs die in acute trusts outside the North East whilst some deaths in our providers are of patients from outside of the region. There are also a small number of deaths where the CCG cannot be identified; around 3,600 nationally out of the 280,000 total deaths.

Figure 11: SHMI by North East CCGs, October 2012 to September 2013

Table 4: SHMI for North East CCGs, October 2012 to September 2013

Darlington

DDES

Gateshead

Newcastle NE

Newcastle W North Durham

HAST

NorthumberlandSouth Tees

South Tyneside

North Tyneside

Sunderland

0

20

40

60

80

100

120

140

0 1000 2000 3000 4000 5000

SHM

I

Expected deaths

SHMI for North East Clinical Commissioning Groups

SHMI 95% Lower Limit 95% Upper Limit North East CCGsSource: Summary Hospital-level Mortality Indicator (SHMI)Data extracted from HED, May 2014

North East CCGs Observed Expected SHMI

Darlington 617 617 100

Durham Dales, Easington & Sedgefield 1956 1847 106

Gateshead 1444 1431 101

Hartlepool & Stockton-on-Tees 1711 1529 112

Newcastle North and East 626 704 89

Newcastle West 778 762 102

North Durham 1454 1385 105

North Tyneside 1464 1441 102

Northumberland 2196 2068 106

South Tees 1885 1724 109

South Tyneside 1134 1141 99

Sunderland 1998 1773 113



8 Comorbidity coding

8.1 Figure 12 shows the number of comorbidities included in the Charlson Index recorded per hospital spell. The general trend is upwards, although there is variation in the increase for each trust with most trusts showing higher comorbidities than England. Sunderland shows an important reduction which the trust may wish to investigate further. The comorbidity count matters because of its impact on the risk adjustment used in modelling mortality. Combined with palliative care coding, coding depth has a substantial impact on the mortality indicators.

Figure 12: Number of comorbidities per spell, by Acute Trust for April 2010 to December 2013

9 Conclusions

9.1 The Summary Hospital-level Mortality Indicator (SHMI) is the main measure used to monitor hospital mortality rate. All NE Trusts continue to be as expected for SHMI with the exception of North Tees with a SHMI of 113.1 which is above the upper limit of the funnel plot.

9.2 As the mortality indicators being reported here include the hard winter of 2012/13, the high level of respiratory deaths discussed in previous reports continues to be an important factor.

9.3 The SHMI for North Tees is slightly higher than for the last release of data when the Trust was also an outlier. Whilst this is of concern and the trust will want to examine its mortality, the SHMI has not been persistently high and so does not yet require the level of external scrutiny applied to Trusts reviewed by Keogh. The highest priority is clinical review of deaths and examining pathways for pneumonia care.

9.4 HSMR remains important and is included along with the unadjusted mortality rate (all deaths divided by all spells in SHMI). The CQC use HSMR in their Intelligent Monitoring Reports.

9.5 The HSMR continues to be high for a number of trusts in the North East and the fall in specialist palliative care coding seen at several trusts in the region, contributes to this.

0

1

2

3

4

5

6


2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14 2013/14

Co

mo

rbid

ity

sco

re p

er

spe

ll

Comorbidity score per FCE by Trust April 2010 to December 2013

CDD

Gateshead

Newcastle

North Tees

Northumbria

South Tees

South Tyneside

Sunderland

ENGLANDSource: NEQOS Hospital Mortality Monitoring: Report 20Data extracted from HED, May 2014



10 Abbreviations and glossary

AT NHS England Area Team

CCS Clinical Classification System

CSU Commissioning Support Unit

CCG Clinical Commissioning Group

CNTW Cumbria, Northumbria, Tyne and Wear

CQC Care Quality Commission

CuSum Cumulative Sum control chart

DDT Darlington, Durham and Tees

FPH Faculty of Public Health

HED Healthcare Evaluation Data. Tool to access mortality data.

HSMR Hospital Standardised Mortality Ratio

HSCIC The Health and Social Care Information Centre

ICD-10 International Classification of Disease (version 10)

IMD Index of Multiple Deprivation

IMR Intelligent Monitoring Report, used by the CQC to band Hospital Trusts in terms of risk of providing poor quality care

NEQOS The North East Quality Observatory System

ONS Office for National Statistics

PHE Public Health England

QSG Quality Surveillance Group

SHMI Summary Hospital-level Mortality Indicator

Unadjusted mortality rate

The count of deaths divided by the number of hospital spells. No adjustments for the age, sex or comorbidities of patients.

UHB University Hospitals Birmingham NHS Foundation Trust

VLADs Variable Life Adjusted Displays



11 Appendix

CCS bundles Description of bundles

SHMI diagnosis groups (140)

CCS groups (255)

Cancer All cancers 7 - 33 11 - 47; 167

Cardiac All cardio-vascular disease

54 – 71 96 - 117

Gut Diseases of the digestive system

83 – 98; 138 135, 138 - 155; 251

Injury Trauma and poisoning

120 - 133 225 - 244

Other Medical

Infections, Endocrine, Renal and Urological conditions

2; 34 - 38; 99 - 103

2; 48 - 53 , 55 , 58; 156 - 163; 249

Respiratory All lung disease 1; 73-82 1; 56; 122 - 134

Other causes All other CCS groups

All other CCS groups

All other CCS groups



DOCUMENT GOVERNANCE

Document name Hospital Mortality Monitoring

Report 20: October 2012 to September 2013

Document type Report

Version FINAL

Date June 2014

Document Classification This report is confidential to the NHS organisations in the North East. Other NHS organisations can know that this kind of report into mortality has been done and is within the capabilities of the NEQOS team.

Prepared on behalf of The subscribing Acute Trusts, CCGs, NECS and NHS England Area Teams in NHS North East

Created by Tony Roberts and Michael Walkley

Approved by Epidemiologist Prototype report discussed by group of epidemiologists

Approved by Project Director Tony Roberts

Peer Reviewed by (if appropriate) Andrea Brown

Originating organisation North East Quality Observatory System (NEQOS)

Website of originating organisation www.neqos.nhs.uk - Please contact the NEQOS advisory service through this web link for further information or to enquire about NEQOS undertaking similar work.

Contact email address [email protected]

Public file location

Internal file location

http://www.neqos.nhs.uk/

mailto:[email protected]



VERSION CONTROL

Version Document Type Date Amendments By

1 Draft Report 14/05/2014 First draft Tony Roberts Michael Walkley Andrea Brown

2 Draft Report 19/05/2014 Second draft Tony Roberts Michael Walkley

3 Draft Report 22/05/2014 Third draft Andrea Brown

4 Draft Report 27/05/2014 Fourth draft Alistair Beattie

5 Final Report 03/06/2014 Final report Tony Roberts Michael Walkley

PLEASE SEND FINAL REPORT TO NEQOS OFFICE FOR DISTRIBUTION

CONFIDENTIALITY CHECKLIST – FOR COMPLETION PRIOR TO ANY DRAFTS SENT TO CLIENTS

Does the report include any small numbers? No

If yes, can we produce a meaningful suppressed version?

N/A

If not, the Epidemiologist AND Director must justify why not here, highlight, and agree the need for an NDA

N/A

Have HES at IC approved use of NDA in order to disclose small numbers?

N/A

Has the recipient of the report signed the NDA? N/A

Documents

Hospital Mortality Monitoring of... · 2020-05-21 · NEQOS Hospital Mortality Monitoring report 20: October 2012 to September 2013 June 2014 (FINAL) North East Quality Observatory