This presentation by the Bureau of Health Information looks at deaths within 30 days of hospitalisation. We look at five clinical conditions; heart attack, ischaemic stroke, haemorrhagic stroke, pneumonia and hip fracture surgery, in NSW between July 2009 and June 2012. The presentation highlights key points from our report "Insights into Care: 30-day mortality following hospitalisation, five clinical conditions, NSW, July 2009 – 2012". The full report is available for free download at www.bhi.nsw.gov.au

1. 30-day mortality for five clinical conditions
NSW hospitals, July 2009 – June 2012

2. Variation in mortality – international
“What is firmly established based on the evidence I have
seen is that the various mortality statistics were sufficiently
significant to require an in-depth investigation of the areas
of service apparently involved.”
Francis Report, Paragraph 58, page 369
The mortality data paradox
There is a particular problem with publishing data about something
everyone understands – death – manipulated statistically into an
indicator almost no-one understands – a standardised ratio.

3. Why report mortality?
•
•
Mortality statistics are an important element in monitoring quality
For the first time, hospital-level data, adjusted to make fair
comparisons, are available in NSW for the five clinical conditions

4. The Insights Series: 30-day mortality in NSW
•
•
This report draws on 12 years of information to provide our
analyses of 30-day mortality following hospitalisation for
five clinical conditions.
The report includes deaths in and outside hospital within 30 days,
in line with international best practice.
•
•
This captures both in hospital care as well as the broader
healthcare system following discharge from hospital.
This is the first time in Australia these mortality measures are
being published for individual hospitals for these conditions.

5. Why are we reporting this measure?
•
•
•
Mortality following hospitalisation is reported internationally
to identify if there are required improvements.
Reporting this measure ensures that care is of the best possible
quality for patients.
Mortality ratios provide a piece of the picture about hospital
performance and are complementary to other quality and safety
measures currently used.

6. The five clinical conditions – infographic

7. What is the measure about?
•
It compares the number of deaths that occurred in the 30-days
following admission to hospital with the number of „expected’
deaths.
•
•
•
A statistical model is used to calculate the „expected‟ number
of deaths based on the characteristics of the patients presenting
at each hospital.
Hospitals with patients that are or sicker than the average
hospital will have a higher „expected’ mortality.
The findings are not appropriate for comparing or ranking
hospitals or for identifying avoidable deaths.

8. Information publicly released
•
The Insights Series: 30-day mortality report
•
•
•
Results presented for five clinical conditions
NSW results and variation within the state
Hospital profiles
•
Up to 21 pages of content for each hospital
•
Technical supplement
•
Spotlight on measurement
•
Discussion of the approach and sensitivity analyses

9. Cohort – identifying cases and deaths
•
Privilege of linked data
•
•
•
Cases identified by ICD-10 codes for principal / primary
diagnosis (in line with international practice)
Multiple episodes considered in a single period of care
Fact of death
•
Deaths in hospital and outside within 30 days of hospitalisation
(captures discharge practices)

10. Risk adjustment and attribution
•
Modelling - random intercept logistic regression
•
•
•
•
International best practice for nominal reporting
Allows control of multiple variables
Smaller hospitals are reportable
Attribution
•
•
•
2 attribution approaches (first / last hospital)
– the Bureau chose to attribute deaths to the first hospital
Transfers - extensive investigation and sensitivity analyses
Implications reported in technical document

11. Due diligence
•
Fairness
•
•
•
•
Precise and thorough
•
•
•
•
Unadjusted mortality ratios
Age-sex adjusted ratios
Risk-standardised mortality ratios (RSMRs)
4 modelling approaches
3 comorbidity methods (Charlson, Elixhauser, Australian
Commission on Safety and Quality in Health Care - ACSQHC)
Index; 1-year; 3-year; and 5-year look back
Sensitive to context
•
Drew on the expertise of a wide range of experts including
clinicians, statisticians, policy developers and health service
researchers to ensure relevance, validity and fairness

12. Nominal reporting rules
•
•
•
All patients included in NSW-level data
Hospitals with < 50 patients in the three-year period
July 2009 – June 2012 are not reported nominally (not named)
Internal communication to LHDs on all outliers < 50 patients

13. Understanding the results
•
Random intercept logistic regression model calculates
„expected‟ mortality for each hospital, given its case mix
•
•
•
„Observed‟ mortality is compared to „expected‟ mortality [O/E]
to form a ratio
Takes into account a range of patient level factors that have been
shown to influence the likelihood of dying
A ratio less than 1.0 indicates lower-than-expected mortality, and
a ratio higher than 1.0 indicates higher-than-expected mortality
•
•
Small deviations from 1.0 are not considered to be meaningful
A mortality ratio of 1.25 may be within the control limits for one
hospital but outside the limits for another hospital

26. Interpreting the results
•
RSMRs are screening tools. They provide an indication of
where further assessment may be needed
•
•
•
•
•
Mortality data are not standalone indicators of quality
or performance
Mortality ratios are not be used to compare performance
between hospitals
RSMRs are not a reflection of the number of avoidable deaths
Mortality data reflect performance of the healthcare system,
not just hospitals
The goals for NSW should be to „shift the curve‟; and to
reduce unwarranted variation

28. Mortality in hospital and following discharge

30. Hospitals with higher than expected results

32. Hospitals with one or more results higher
than expected

36. Key findings
•
In all five conditions mortality has decreased in NSW since 2000
•
NSW compares well in the international context
•
•
Among 80 referral, major and district hospitals, 58 did not have
higher than expected mortality for any of the five conditions and
no hospital had higher than expected mortality for all five conditions
18 had higher than expected mortality for only one of the
five conditions
•
3 had higher than expected mortality for two conditions
•
1 had higher than expected mortality for four conditions
•
Hospitals with higher than expected mortality were found in
urban and rural settings

37. What’s next?
•
•
•
The Bureau of Health Information has a mandate to inform
the population, clinicians, policy-makers and members of
Parliament in a way that both supports improvement in the
system and promotes accountability.
Hospitals should consider their results and identify where
improvements can be made.
Together with these results, other quality and safety measures,
such as clinical audit and review panels, can further assess
models of care.