Hospital Mortality Monitoring Report 24: Oct 213 to Sep 214 May 215 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
NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) 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. Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 2
NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) Executive Summary... 4 1 Context and background... 5 2 Methods and measures... 6 3 Comparisons of hospital mortality between Trusts... 6 Figure 1: funnel plot using 95% Control Limits and adjustment for over-dispersion for October 213 to September 214... 7 Table 1:, total discharges, observed and expected deaths, % aged + and banding for October 213 to September 214... 7 Figure 2: by acute trust for 214... 8 4 Hospital mortality through time for Trusts in the North East... 9 Table 2:, observed and expected deaths, for 213 and 214... 9 Figure 3: and crude mortality for NCNTW trusts... 1 Figure 4: and palliative care for NCNTW trusts... 11 Figure 5: mortality indices for DDT trusts... 12 Figure 6: Average and by Acute Trust, Oct 211 to Sep 214... 13 Figure 7: Trend in palliative coding, contextual indicator, July 211 to Sep 214... 13 Figure 8: Monthly by Acute Trust for DDT area, 213 to 214... 14 Figure 9: Monthly by Acute Trust for NCNTW area, 213 to 214... 14 5 by CCS bundle... 15 Table 3: summary of funnel plots of CCS bundles for NE Trusts, October 213 to September 214... 15 6 for selected Cancers... 15 Figure 1: for selected CCS groups (code)... 16 7 Comparison of by Clinical Commissioning Group... 17 Figure 11: by CCG, October 213 to September 214... 17 Table 4: by CCG, October 213 to September 214... 17 8 Comorbidity coding... 18 Figure 12: Number of co-morbidities per spell, July 211 to December 214... 18 9 Conclusions... 18 1 Abbreviations and glossary... 19 11 Appendix... 2
NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) Executive Summary This is the twenty-fourth 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 Summary Hospital-level Mortality Indicator () was as expected for all trusts in the NE with the exception of North Tees and Hartlepool and South Tyneside which are high outliers in this release of data, from September 213 to October 214. This is the sixth consecutive quarter in which North Tees and Hartlepool has been a outlier, with a value of 119. for 214 shows two trusts which are high outliers: South Tyneside and North Tees (for the seventh consecutive quarter). The headline mortality indicators do not yet include the winter peak but it is anticipated that in early 215 observed mortality will be higher and this suggests that there will be no improvement in the and. The risk is high that North Tees will become a Keogh outlier. The Public Health England Weekly All-cause Mortality Surveillance report published on 3 th April 215 confirmed that England experienced a notable increase in winter deaths particularly in 65+ year olds. The Regional Mortality Group is assisting trusts in using mean centered displays to understand the and ; developing a consistent approach across the region to mortality review which will feed into the national indicator; helping trusts to develop their specialist palliative care teams to match the changing roles of these teams nationally, as reflected by rising coding levels. The report includes the following conclusions: The is the main measure used to monitor hospital mortality rate. In the period October 213 to September 214 two NE trusts have higher than expected mortality. North Tees is 119 and South Tyneside is 118. North Tees is an outlier for the sixth consecutive quarter. The risk is high that North Tees will remain a high outlier for the eight quarters used to identify Keogh outliers. s remain high for two NE trusts, South Tyneside and North Tees. In South Tyneside the presence of the hospice is affecting both and. Falling rates of specialist palliative care coding affect the for both trusts. Trusts need to understand variation through time within diagnosis groups (using their VLADs), and to consider what this means in terms of the care processes for specific patient groups. The for Sunderland CCG is 115 which is above the expected range and warrants further investigation. The NHS Outcomes Framework indicator 5a Deaths attributable to problems in healthcare is being developed in 215/16 and the Regional Mortality Group will be engaged in this work. Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 4
NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) 1 Context and background 1.1 This is the twenty-fourth report for NHS organisations in the North East (NE) reviewing hospital mortality. The objective is to give providers and commissioners hospital mortality monitoring data and benchmarking to assist with assurance. The report is provided to organisations subscribing to the North East Quality Observatory System (NEQOS) and covers the Academic Health Science Network: North East and North Cumbria (AHSN-NENC) area. 1.2 The NHS Outcomes Framework for 215/16 retains the proposed indicator 5a Deaths attributable to problems in healthcare 1. On behalf of NHS England, the Healthcare Quality Improvement Partnership (HQIP) are developing a tendering process to appoint a partner to deliver a National Retrospective Care Record Review (NRCRR) method to collect data from Trusts for this indicator. The region will be represented in this process and the views of North East Trusts will be coordinated through the Regional Mortality Group. 1.3 Although the Regional Mortality Group bid submitted to the Patient Safety Collaborative (PSC) 2 to support regional mortality review work was unsuccessful, further discussions are progressing. The importance of measuring preventable hospital deaths directly was reinforced with the publication of an exploratory analysis of the relationship between preventable mortality (as measured in PRISM 1) and other measures of safety, confirming the absence of a relationship with mortality indicators 3. Further analysis using PRISM 2 data will be needed before firm conclusions can be drawn. 1.4 The Public Health England Weekly All-cause Mortality Surveillance report published on 3 th April 215 confirmed that England experienced a notable increase in winter deaths particularly in 65+ year olds. The report states This period of statistically significant excess coincided with circulating influenza and cold snaps 4. Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 5 1 https://www.gov.uk/government/publications/nhs-outcomes-framework-215-to-216 2 http://www.ahsn-nenc.org.uk/project_type/patient_safety 3 Hogan H, Healey F, Neale G, Thomson R, Vincent C and Black N. Relationship between preventable hospital deaths and other measures of safety: an exploratory study. International Journal of Quality in Health Care 214; 26(3): 298-37 4 https://www.gov.uk/government/statistics/mortality-weekly-all-cause-mortality-surveillance
NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) 2 Methods and measures 2.1 is the hospital-level indicator which reports all deaths in hospital and all deaths that occur within 3 days of discharge from hospital across the NHS in England 5. It compares the observed number of deaths with the number expected calculated from a statistical model that takes account of 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. Primary diagnosis is the main condition treated or investigated during the episode and where there is no definitive diagnosis, is the main symptom, abnormal findings or problem (represented by an R-Code). 2.3 Details of how is calculated when the primary diagnosis is an R-code (i.e. from within the ICD-1 Signs and Symptoms chapter) are given in the guidance. This methodology applies to the derivation of the Dr Foster as well as to the HSCIC s. 2.4 was designed for non-specialist acute trusts and so trusts including community services may be disadvantaged because the period of the spell is increased to include the community episode with deaths more likely to occur for these trusts within 3 days of discharge. 2.5 The latest tranche of data, published 29 th April 215 covers October 213 to September 214. Patient level data is released allowing the calculation of VLADs by diagnosis group. 2.6 The HSCIC model coefficients have been rebased in the latest tranche of data to ensure the England average remains at. 2.7 The and are extracted from the Healthcare Evaluation Data (HED) system supplied by University Hospitals Birmingham NHS Foundation Trust (UHB). HED reproduce the mortality indicators to a high degree of accuracy and NEQOS use these within this report. 2.8 This report presents the latest data using funnel plots for the cross sectional analysis of Trusts in 214/15. The is the ratio of observed over expected deaths, where indicates that both the observed and expected deaths are the same, and is the average across England. 2.9 The funnel plot displays the on the vertical axis against the number of expected deaths (the denominator) along the horizontal axis. Trusts are identified as outliers if their 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. 2.1 Trends through time are presented for each trust for and the unadjusted mortality rate (Figure 3). The trends have not been statistically tested for significance (a method for doing so has yet to be agreed nationally) and so caution must be exercised in interpretation. 3 Comparisons of hospital mortality between Trusts 3.1 Figure 1 shows the for all Trusts in England for October 213 to September 214, using the funnel plot adjusted for over-dispersion. Table 1 shows the, total discharges, banding and proportion of deaths that occurred in patients aged or older for all the NE acute Trusts in the latest tranche of data released by the HSCIC. 5 http://www.hscic.gov.uk/ Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 6
NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) with banding using 95% Control Limits and with adjustment for over-dispersion 1 South Tyneside North Tees Gateshead Sunderland North Cumbria South Tees Northumbria CDD Newcastle 5 Source: Summary Hospital-level Mortality Indicator (). Data released by the HSCIC, April 215 5 15 2 3 35 4 45 5 Expected deaths Other Acutes North East 95% Lower Limit 95% Upper Limit Figure 1: funnel plot using 95% Control Limits and adjustment for over-dispersion for October 213 to September 214 Provider Discharges Observed % aged + Expected Category County Durham and Darlington NHS FT 84298 294 67.4 2816 13.1 as expected North Tees and Hartlepool NHS FT 45872 1827 67.3 1536 118.9 Higher than expected South Tees Hospitals NHS FT 9223 2634 62.7 7 12.5 as expected Gateshead Health NHS FT 35285 147 68.5 14.5 as expected South Tyneside NHS FT 22656 11 65.3 951 118.3 Higher than expected City Hospitals Sunderland NHS FT 589 1999 68.3 181 111. as expected The Newcastle Upon Tyne Hospitals NHS FT 16621 12 54.9 2629 95.6 as expected Northumbria Healthcare NHS FT 64427 2929 71.4 2762 16.1 as expected North Cumbria University Hospitals NHS Trust 48481 1661 68.4 1718 96.7 as expected Table 1:, total discharges, observed and expected deaths, % aged + and banding for October 213 to September 214 Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 7 3.2 North Tees and Hartlepool is a high outlier for the sixth consecutive quarter, with a of 119, higher than the last period. South Tyneside are high outliers for the third time. 3.3 North Tees is outlying on (and for the seventh quarter for ) whilst 8 consecutive quarters (outlying on either or ) were used to identify the Keogh Trusts. The risk is high that the Trust will become a Keogh outlier. NEQOS completed a detailed review of mortality for the Board of North Tees and Hartlepool in January 215. 3.4 Key facts for 1 October 213 to 3 September 214 (against the same period a year ago): 9 trusts had a 'higher than expected' value compared to 8 trusts previously. 16 trusts had a 'lower than expected' value compared to 17 trusts previously. 112 trusts had an 'as expected' value, compared to 116 trusts previously.
NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) 3.5 Figure 2 shows the for January 214 to December 214, using the narrow control limits without adjustment for over-dispersion preferred by Dr Foster. South Tyneside and North Tees are high outliers. 3.6 High s attract scrutiny and both Trusts have considered the factors affecting expected death rates in the calculations. The analysis for selected cancers presented in section 6 is also useful in understanding the variation in South Tyneside. for January to December 214 (with 99.9% and 95% control limits without adjustment for over-dispersion) Figure 2: by acute trust for 214 Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 8
NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) 4 Hospital mortality through time for Trusts in the North East 4.1 Table 2 shows the for the last two years. All of the trusts (with the exception of Newcastle) have s above. All the trusts show some change in their between the 2 years with Sunderland decreasing by 17 points, North Tees has increased by 9 points and South Tyneside rising by 14 points. 4.2 North Tees and South Tyneside have been outliers for since the corresponding period a year ago; this is the seventh and sixth consecutive rolling 12 month periods respectively in which they are higher than expected. 4.3 There a number of different factors which have caused changes over this period including: changes in coding, excess mortality and epidemiological effects. The observed deaths have risen in 6 of the trusts and show a rise of 5% for North Tees and 1 for South Tyneside. 4.4 Specialist Palliative Care coding continues to affect Trusts in the North East, including South Tyneside and North Tees and is discussed later in this section. Provider Table 2:, observed and expected deaths, for 213 and 214 213 214 Observed Expected Observed Expected County Durham and Darlington NHS FT 1858 1711 19 1793 171 15-3.7 North Tees and Hartlepool NHS FT 1166 12 114 123 1 123 8.6 South Tees Hospitals NHS FT 1779 1561 114 173 1584 18-6.4 Gateshead Health NHS FT 941 883 17 921 92 12-4.5 South Tyneside NHS FT 68 594 115 764 593 129 14.3 City Hospitals Sunderland NHS FT 1346 1129 119 1361 1326 13-16.6 The Newcastle Upon Tyne Hospitals NHS FT 154 16 92 1596 1691 94 2.4 Northumbria Healthcare NHS FT 2 1818 114 296 1957 17-7.1 North Cumbria University Hospitals NHS Trust 183 126 16 1164 1153 11-4.6 Change 4.5 In figures 3, 4 and 5 the mortality indices are shown quarterly over the last three years. There is no national agreement on the best method for testing for statistical trends. 4.6 The for all Trusts in the North East mirrors unadjusted mortality. Unadjusted mortality varies between Trusts from approximately to 6%. This rate includes all deaths in hospital plus deaths within 3 days of discharge. 4.7 The quarterly charts provide a more detailed breakdown of the movement in the and unadjusted mortality for individual trusts with Sunderland showing a clear increase and North Cumbria a decrease following the unadjusted mortality. 4.8 The pattern for is broadly inversely related to the specialist palliative care coding rate ( is sensitive to this coding whilst ignores it) and does not follow the unadjusted mortality rate. Trusts vary considerably in the rate of palliative care coding (with several NE trusts in the lowest quintile) as well as the degree of change through time. The pattern of palliative care coding and the is notable in South Tyneside and Sunderland. Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 9
Unadjusted mortality rate (%) Unadjusted mortality rate (%) Unadjusted mortality rate (%) Unadjusted mortality rate (%) Unadjusted mortality rate (%) Unadjusted mortality rate (%) NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) 4.9 Figure 3 shows the and unadjusted mortality rate for the trusts in the North Cumbria, Northumbria, Tyne & Wear area (NCNTW) by quarter from October 211 to September 214. 1 and Unadjusted Mortality Rate for Sunderland 6% 1 and Unadjusted Mortality Rate for Newcastle 6% 5% 5% 5 5 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 % Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 % 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 Unadjusted rate Unadjusted rate 1 and Unadjusted Mortality Rate for South Tyneside 6% 1 and Unadjusted Mortality Rate for Northumbria 6% 5% 5% 5 5 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 % Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 % 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 Unadjusted rate Unadjusted rate 1 and Unadjusted Mortality Rate for Gateshead 6% 1 and Unadjusted Mortality Rate for North Cumbria 6% 5% 5% 5 5 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 % Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 % 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 Unadjusted rate Unadjusted rate Figure 3: and crude mortality for NCNTW trusts Source: NEQOS Hospital Mortality Monitoring: Report 24 Data extracted from HED May 215 Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 1
Palliative care discharge rate (%) Palliative care discharge rate (%) Palliative care discharge rate (%) Palliative care discharge rate (%) Palliative care discharge rate (%) Palliative acre discharge rate (%) NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) 4.1 Figure 4 shows the and palliative care discharge rate for each trust in the NCNTW area by quarter from October 211 to December 214. 14 and Palliative Care Coding Rate for Sunderland 14 and Palliative Care Coding Rate for Newcastle 12 12 8 8 6 6 4 4 2 2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 % Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 % 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 214/15 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 214/15 Palliative% Palliative% 14 and Palliative Care Coding Rate for South Tyneside 14 and Palliative Care Coding Rate for Northumbria 12 12 8 8 6 6 4 4 2 2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 % Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 % 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 214/15 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 214/15 Palliative% Palliative% 14 and Palliative Care Coding Rate for Gateshead 14 and Palliative Care Coding Rate for North Cumbria 12 12 8 8 6 6 4 4 2 2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 % Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 % 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 214/15 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 214/15 Palliative% Palliative% Figure 4: and palliative care for NCNTW trusts Source: NEQOS Hospital Mortality Monitoring: Report 24 Data extracted from HED May 215 Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 11
Unadjusted mortality rate (%) Palliatiive care discharge rate (%) Unadjusted mortality rate (%) Palliative care discharge rate (%) Unadjusted mortality rate (%) Palliative care discharge rate (%) NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) 4.11 Figure 5 shows the and for the trusts in the Durham, Darlington and Tees area by quarter from October 211 to September 214. 1 and Unadjusted Mortality Rate for County Durham & Darlington 6% 14 and Palliative Care Coding Rate for County Durham & Darlington 5% 12 8 5 6 4 2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 % Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 % 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 214/15 Unadjusted rate Palliative% 1 and Unadjusted Mortality Rate for North Tees 6% 14 and Palliative Care Coding Rate for North Tees 5% 12 8 5 6 4 2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 % Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 % 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 214/15 Unadjusted rate Palliative% 1 and Unadjusted Mortality Rate for South Tees 6% 14 and Palliative Care Coding Rate for South Tees 5% 12 8 5 6 4 2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 % Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 % 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 214/15 Unadjusted rate Palliative% Figure 5: mortality indices for DDT trusts Source: NEQOS Hospital Mortality Monitoring: Report 24 Data extracted from HED May 215 Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 12 4.12 Figure 6 presents the and from October 211 to September 214. The methodologies for constructing the two indices are different however despite this it is expected that they would produce similar signals and for two trusts this is the case. The trust with the highest difference shows variation of 7 points. The apparent variation between indices can be attributable to their construction, natural variation and clinical coding.
Deaths with Palliative Care Coding (%) Average / NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) 12 vs for North East Trusts Oct 211 to Sep 214 Source: NEQOS Hospital Mortality Monitoring: Report 24 Data extracted from HED May 215 113 112 112 117 11 13 15 12 19 11 17 14 18 17 19 13 18 93 94 9 8 CDD North Tees South Tees Gateshead South Tyneside Average Average England Sunderland Newcastle Northumbria North Cumbria Figure 6: Average and by Acute Trust, Oct 211 to Sep 214 4.13, unlike, is adjusted for discharges with a specialist palliative care code (Z515 diagnosis code or 315 specialty code). This coding provides a very limited view of palliative care in hospitals, with variation in practice across the NHS. The HSCIC have consulted on a new Data Collection 6 which will provide a more comprehensive picture. 4.14 Figure 7 shows the rolling 12 month proportion of deaths with specialist palliative care coding by trust using the HSCIC contextual indicator. It shows the increasing level of coding in England with only Northumbria and Newcastle showing a similar upward trend. South Tyneside fall below average towards the end of the period. North Tees show the largest fall whilst the remaining trusts are broadly stable, but therefore worsening relative to England. 4.15 In South Tyneside the presence of the hospice is affecting both and (analysis suggests the main hospital site is not outlying). It also has a falling rate of specialist palliative care coding. In North Tees specialist palliative care coding is affecting the (as it is in South Tees). 35 Proportion of deaths with palliative care coding (rolling year) 3 2 15 1 5 ENGLAND Sunderland Gateshead South Tyneside North Cumbria Newcastle Source: NEQOS Hospital Mortality Monitoring: Report 24 Data from HSCIC contextual indicators, May 215 March12 June12 Sep12 Dec12 March13 June13 Sep13 Dec13 March14 June14 Sep14 Rolling year - end point Northumbria North Tees South Tees CDD Figure 7: Trend in palliative coding, contextual indicator, July 211 to Sep 214 6 https://consultations.infostandards.org/rocr/c378f995 Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 13
NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) 4.16 The is presented monthly in figures 8 and 9 from January 213 to December 214 for NE trusts within the sub regions. Monthly data shows more variation than quarterly data and is included to show the pattern of mortality through the recent months. 4.17 In the last six months has remained high for both North Tees and South Tyneside. The data does not yet include the winter peak described in the first section, but it is anticipated in early 215 observed mortality will be higher and this suggests that there will be no improvement in the and. 14 Monthly for DDT acute Trusts, 213 to 214 12 8 6 CDD North Tees South Tees 4 Source: NEQOS Hospital Mortality Monitoring: Report 24 Data extracted from HED April 215 1 2 3 4 5 6 7 8 9 1 11 12 1 2 3 4 5 6 7 8 9 1 11 12 213 213 213 213 213 213 213 213 213 213 213 213 214 214 214 214 214 214 214 214 214 214 214 214 Figure 8: Monthly by Acute Trust for DDT area, 213 to 214 14 Monthly for NCNTW acute Trusts, 213 to 214 12 8 6 Gateshead Sunderland South Tyneside Newcastle 4 Northumbria North Cumbria Source: NEQOSHospital Mortality Monitoring: Report 24 Data extracted from HED April 215 1 2 3 4 5 6 7 8 9 1 11 12 1 2 3 4 5 6 7 8 9 1 11 12 213 213 213 213 213 213 213 213 213 213 213 213 214 214 214 214 214 214 214 214 214 214 214 214 Figure 9: Monthly by Acute Trust for NCNTW area, 213 to 214 Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 14
NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) 5 by CCS bundle 5.1 The HED system holds information about the primary diagnosis in the form of the Clinical Classification System (CCS) code. There are 5 CCS codes covering the range of diagnosis codes within ICD-1 and these are grouped into 14 diagnosis groups in the calculation of. NEQOS have grouped these diagnosis groups into 7 larger bundles to make the overall pattern of mortality discernable at a lower level by trust. 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 14 diagnosis groups), although using funnel plots is consistent with the method used for Trust level s. Three standard deviation funnel plots are calculated (ie funnel plots using 99.8% Poisson control limits) for each of the 7 CCS bundles 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. CCS Groups County Durham North Tees South Tees Gateshead South Tyneside Sunderland Newcastle Northumbria North Cumbria Cancer as expected High 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 as expected 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 High as expected as expected Other causes as expected as expected as expected 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 as expected High as expected as expected as expected as expected as expected as expected as expected Table 3: summary of funnel plots of CCS bundles for NE Trusts, October 213 to September 214 6 for selected Cancers 6.1 In this report 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 212/13, 213/14 and 214/15 (Q1 and Q2) to show the variation between years. 6.2 The CCS bundles shown previously can be broken-down into the 14 constituent diagnostic groups used in the statistical model. In this report data is presented for Lung Cancer, Colorectal and Secondary Malignancy. Looking at the by CCS group reduces systematic variation at the expense of increasing random variation, since the sample is more consistent, but smaller. 6.3 At this scale using funnel plots to identify outliers may fail to detect important patterns. Analysis within trusts is more important than comparison between trusts and therefore a funnel plot method is less helpful than using VLADs. 6.4 The lung cancer s appear to be stable over time with trusts tending to be similar from year to year. The data for 214/15 (April to September 214) shows most trusts below with Gateshead and Northumbria at the higher end. Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 15
NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) 6.5 Secondary malignancies shows more variation between years with some trusts (e.g. North Tees) showing notable drops in 214/15. The picture for 214/15 may change as coding is updated. 6.6 Colorectal cancers show similar variation to the secondary malignancy with a notable rise in the for South Tees in 214/15. Careful interpretation of these charts is required since for Secondary malignancies and Colorectal cancer as they are based on a relatively small number of deaths available to trusts in the patient-level data they download from the HSCIC site. 15 for Lung Cancer (15) 15 for Secondary Malignancies (3) 1 1 5 5 CDD North Tees South Tees Gateshead South Tyneside Sunderland Newcastle Northumbria North Cumbria CDD North Tees South Tees Gateshead South Tyneside Sunderland Newcastle Northumbria North Cumbria 212/13 213/14 214/15 212/13 213/14 214/15 1 for Colorectal Cancer 15 1 5 CDD North Tees South Tees Gateshead South Tyneside Sunderland Newcastle Northumbria North Cumbria 212/13 213/14 214/15 Figure 1: for selected CCS groups (code) Source: NEQOS Hospital Mortality Monitoring: Report 24 Data extracted from HED May 215 Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 16
NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) 7 Comparison of by Clinical Commissioning Group 7.1 The Clinical Commissioning Groups formally came into being on the 1 st April 213 and in line with the NHS Mandate we provide a breakdown of by CCG. Control limits have been calculated to be consistent with the funnel plot for acute Trusts in figure 1. 7.2 The for Sunderland CCG is 115 for October 213 to September 214 which falls above the expected range for the period reported. The acute trusts in South Tyneside and Sunderland both shows as mortality outliers for this period. The CCG will want to understand the patient flows to its various providers (including hospices). 7.3 Deaths for individual CCGs occur in multiple acute providers and the observed number of deaths for all NE CCGs is approximately 9 fewer than the observed deaths in NE acute trusts for the period. This difference 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. 14 for North East Clinical Commissioning Groups (including North Cumbria) 12 HAST Sunderland South Tees DDES Northumberland Newcastle W Darlington South Tyneside North Durham Newcastle NE Gateshead North Tyneside North Cumbria 8 6 4 2 2 3 4 5 Source: Summary Hospital-level Mortality Indicator () Data extracted from HED, April 215 Expected deaths 95% Lower Limit 95% Upper Limit North East CCGs Figure 11: by CCG, October 213 to September 214 CCG Observed Expected Category Cumbria 2844 2892 98 as expected Darlington 627 615 12 as expected DDES 1889 1 18 as expected Gateshead 1358 1367 99 as expected HAST 1611 1432 112 as expected Newcastle NE 64 652 98 as expected Newcastle W 744 11 as expected North Durham 131 129 12 as expected North Tyneside 1429 1451 98 as expected Northumberland 2141 229 16 as expected South Tees 17 1591 17 as expected South Tyneside 111 189 11 as expected Sunderland 196 1656 115 Higher than expected Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 17 Table 4: by CCG, October 213 to September 214
Comorbidity score per spell NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) 8 Comorbidity coding 8.1 Figure 12 shows the number of comorbidities included in the Charlson Index 7 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; the last three quarters for Newcastle show a dip below England. 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. 6 Comorbidity score per FCE by Trust, July 211 to December 214 5 4 3 CDD 2 Gateshead Newcastle North Tees Northumbria 1 Source: NEQOS Hospital Mortality Monitoring: Report 24 Data extracted from HED, May 215 North Cumbria South Tees South Tyneside Sunderland ENGLAND Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 211/12 211/12 211/12 212/13 212/13 212/13 212/13 213/14 213/14 213/14 213/14 214/15 214/15 214/15 Figure 12: Number of co-morbidities per spell, July 211 to December 214 9 Conclusions 9.1 The is the main measure used to monitor hospital mortality rate. In the period October 213 to September 214 two NE trusts have higher than expected mortality. North Tees is 119 and South Tyneside is 118. 9.2 North Tees is an outlier for the sixth consecutive quarter. The risk is high that North Tees will remain a high outlier for the eight quarters used to identify Keogh outliers. 9.3 s remain high for two NE trusts, South Tyneside and North Tees. In South Tyneside the presence of the hospice is affecting both and. Falling rates of specialist palliative care coding affect the for both trusts. 9.4 Trusts need to understand variation through time within diagnosis groups (using their VLADs), and to consider what this means in terms of the care processes for specific patient groups. 9.5 The for Sunderland CCG is 115 which is above the expected range and warrants further investigation. 9.6 The NHS Outcomes Framework indicator 5a Deaths attributable to problems in healthcare is being developed in 215/16 and the Regional Mortality Group will be engaged in this work. 7 Indicator Specification http://www.hscic.gov.uk/media/1611/indicator-specification-summary-hospital-level-mortality-indicatormethodology-updated/pdf/_specification.pdf Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 18
NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) 1 Abbreviations and glossary AT AHSN-NENC CCS CSU CCG NCNTW CQC CuSum DDT FCE FPH HED HSCIC NHS England Area Team Academic Health Science Network: North East and North Cumbria Clinical Classification System Commissioning Support Unit Clinical Commissioning Group North Cumbria, Northumbria, Tyne and Wear Care Quality Commission Cumulative Sum control chart Durham, Darlington and Tees Finished Consultant Episode Faculty of Public Health Healthcare Evaluation Data. Tool to access mortality data. Hospital Standardised Mortality Ratio The Health and Social Care Information Centre ICD-1 International Classification of Disease (version 1) IMD IMR NEQOS ONS PHE QSG Unadjusted mortality rate UHB VLADs Index of Multiple Deprivation Intelligent Monitoring Report, used by the CQC to band Trusts The North East Quality Observatory System Office for National Statistics Public Health England Quality Surveillance Group Summary Hospital-level Mortality Indicator The count of deaths divided by the number of hospital spells. No adjustments for the age, sex or comorbidities of patients. University Hospitals Birmingham NHS Foundation Trust Variable Life Adjusted Displays Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 19
NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) 11 Appendix CCS bundles Description of bundles diagnosis groups (14) CCS groups (5) Cancer All cancers 7-33 11-47; 167 Cardiac Gut Injury All cardio-vascular disease Diseases of the digestive system Trauma and poisoning 54 71 96-117 83 98; 138 135, 138-155; 1 12-133 2-244 Other Medical Infections, Endocrine, Renal and Urological conditions 2; 34-38; 99-13 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 Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 2
NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) DOCUMENT GOVERNANCE Document name Document type Version Hospital Mortality Monitoring Report 24: October 213 to September 214 Report FINAL Date May 215 Document Classification Prepared on behalf of Created by Approved by Epidemiologist Approved by Project Director Peer Reviewed by (if appropriate) Originating organisation Website of originating organisation Contact email address 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. The subscribing Acute Trusts, CCGs, NECS and NHS England Area Teams in NHS North East Tony Roberts and Michael Walkley Prototype report discussed by group of epidemiologists Tony Roberts Andrea Brown North East Quality Observatory System (NEQOS) 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. neqos@nhs.net Public file location Internal file location Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 21
NEQOS Hospital Mortality Monitoring report 24: October 213 to September 214 May 215 (FINAL) VERSION CONTROL Version Document Type Date Amendments By 1 Draft Report 1/5/215 First draft Michael Walkley 2 Draft Report 6/5/215 Second draft 3 Draft Report 7/5/215 Third draft 4 Draft Report 18/5/215 7 Final Report 18/5/215 Final Report Fourth draft incorporating comments from reviewers Tony Roberts Michael Walkley Tony Roberts Michael Walkley Andrea Brown and Alastair Beattie 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? If yes, can we produce a meaningful suppressed version? If not, the Epidemiologist AND Director must justify why not here, highlight, and agree the need for an NDA Have HES at IC approved use of NDA in order to disclose small numbers? Has the recipient of the report signed the NDA? No N/A N/A N/A N/A Ridley House, Henry Street, Newcastle upon Tyne, NE3 1DQ 191 245 678 Page 22