Making use of mortality data to improve quality and safety in general practice: a review of current approaches

A systematic analysis of worldwide disasters, epidemics and pandemics associated mortality of 210 countries for 15 years (2001-2015)

In recent years, the unprecedented death tolls resulting from epidemics and natural disasters made everyone interested, from the general public to country heads, to know about the mortality rates. The coronavirus issue is the most recent example all over the media, and everyone is talking about corona-induced mortality. The study aimed to estimate the disaster-induced mortality rates at the global level for two hundred and ten countries for fifteen years (2001-2015). Using a retrospective study design, we extracted datasets from two data sources, EM-DAT and UNFPA, in October 2019. The cut-off time for the data download was midnight Central European Time, October 17, 2019. The most noticeable finding in this study is that, against the common prevailing notion, both developed and developing countries equally carry the brunt of disaster-induced mortality. This study proposes empirical confirmation of the direction and magnitude of any year-over-year correlation of disaster and mortality rates. Furthermore, the analysis of the trend in mortality rate over the past fifteen years concludes it is not linear. However, there are huge variations across the years and the countries. The study is of paramount importance to initiate a debate amongst the concerned policymakers and stakeholders to regularly monitor the disaster-induced mortality rates. So that effective interventions can be devised to decrease the mortality rates.

Achieving Equity in Asian American Healthcare: Critical Issues and Solutions

Equity is a fundamental goal of the US health care system. Asians comprise 6% of the US population, and 60% of the world's population. Less than 1% of National Institutes of Health funding is directed toward Asian health. Asian health outcomes are often worse than non-Hispanic Whites (NHWS) in America. Increasing federal and foundation resources and funding toward Asian health research could illuminate these risks and develop precision interventions to reduce known health disparities. When disaggregated by race/ethnicity, Asian health risks are even more apparent. Here, we discuss critical health outcome differences between the six major Asian American subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) comprising 80% of the US Asian population, highlighting demographic, pharmacologic, disease prevalence, and mortality outcomes. We then outline seven critical issues contributing to Asian American health disparities, including aggregated Asian health data, undersampling, invalid extrapolations, underrepresentation in clinical trials, lack of funding and awareness of disparities, and the model minority myth. Building on the successes of national public health initiatives, we propose nine leverage points to improve Asian American health including the following: obtaining disaggregated Asian health data, improved Asian health research (oversampling Asians, improving clinical trial participation, and increasing research funding), stakeholder collaboration (national and with Asian nations), community engagement, providing culturally precise health care, and expansion of the Asian American research ecosystem. Achieving health equity takes deliberate practice and does not occur by accident. By addressing critical issues that perpetuate Asian health disparities, we grow closer to understanding how to effectively improve Asian health and build a nationally unified mindset toward action that emphasizes equitable care for all.

Comparison of Safety Profiles between Non-operating Room Anesthesia and Operating Room Anesthesia: a Study of 199,764 Cases at a Korean Tertiary Hospital

BACKGROUND

Despite expanding demands for non-operating room anesthesia (NORA) worldwide, studies in this field are scarce. We compared the overall characteristics and the nature of deaths occurring within 48 hours after surgery between NORA and operating room anesthesia (ORA) cases at a Korean tertiary hospital.

METHODS

We retrospectively analyzed the medical records of patients who underwent surgical procedures under anesthesia services in and outside the operating room from January 2013 to November 2017. All of the mortalities were categorized by principal cause into groups such as patient disease or condition, surgery, anesthesia, and others.

RESULTS

Overall, 16,383 NORA cases and 183,381 ORA cases were analyzed. Eighty-six deaths were identified. The mortality rate of NORA cases was similar to that of ORA cases (4.9 per 10,000 cases [95% confidence interval (CI), 2.1-9.6] vs. 4.3 per 10,000 cases [95% CI, 3.4-5.3], respectively). Similar to ORA cases, higher American Society of Anesthesiologists physical status and very young age (< 2 years) were significantly associated with mortality in NORA cases. A patient's disease or condition was the most important cause of mortality (65/86, 75.6%), followed by surgery-related causes (16/86, 18.6%). Two cases of anesthesia-related mortality were only identified in the ORA cases, resulting in an overall anesthesia-related mortality of 0.1 per 10,000 cases (95% CI, 0.0-0.4).

CONCLUSION

Although NORA cases showed an equivalent perioperative mortality rate compared to ORA cases, there may be more room for improving patient safety when considering their favorable characteristics (healthier patients, less invasive and shorter procedures). Trial registry at Clinical Research Information Service, KCT0002719.

Modelling factors in primary care quality improvement: a cross-sectional study of premature CHD mortality

OBJECTIVES

To identify features of primary care quality improvement associated with improved health outcomes using premature coronary heart disease (CHD) mortality as an example, and to determine impacts of different modelling approaches.

DESIGN

Cross-sectional study of mortality rates in 229 general practices.

SETTING

General practices from three East Midlands primary care trusts.

PARTICIPANTS

Patients registered to the practices above between April 2006 and March 2009.

MAIN OUTCOME MEASURES

Numbers of CHD deaths in those aged under 75 (premature mortality) and at all ages in each practice.

RESULTS

Population characteristics and markers of quality of primary care were associated with variations in premature CHD mortality. Increasing levels of deprivation, percentages of practice populations on practice diabetes registers, white, over 65 and male were all associated with increasing levels of premature CHD mortality. Control of serum cholesterol levels in those with CHD and the percentage of patients recalling access to their preferred general practitioner were both associated with decreased levels of premature CHD mortality. Similar results were found for all-age mortality. A combined measure of quality of primary care for CHD comprising 12 quality outcomes framework indicators was associated with decreases in both all-age and premature CHD mortality. The selected models suggest that practices in less deprived areas may have up to 20% lower premature CHD mortality than those with median deprivation and that improvement in the CHD care quality from 83% (lower quartile) to 86% (median) could reduce premature CHD mortality by 3.6%. Different modelling approaches yielded qualitatively similar results.

CONCLUSIONS

High-quality primary care, including aspects of access to and continuity of care, detection and management, appears to be associated with reducing CHD mortality. The impact on premature CHD mortality is greater than on all-age CHD mortality. Determining the most useful measures of quality of primary care needs further consideration.

The 2003 Iraq War and avoidable death toll

Salman Rawaf discusses the implications of the most recent estimate of excess deaths associated with the Iraq war and subsequent occupation in the context of the current situation in Iraq. Please see later in the article for the Editors' Summary.

The injury mortality burden in Guinea

BACKGROUND

The injury mortality burden of Guinea has been rarely addressed. The paper aimed to report patterns of injury mortality burden in Guinea.

METHODS

We retrieved the mortality data from the Guinean Annual Health Statistics Report 2007. The information about underlying cause of deaths was collected based on Guinean hospital discharge data, Hospital Mortuary and City Council Mortuary data. The causes of death are coded in the 9th International Classification of Diseases (ICD-9). Multivariate Poisson regression was used to test the impacts of sex and age on mortality rates. The statistical analyses were performed using Statatm 10.0.

RESULTS

In 2007, 7066 persons were reported dying of injuries in Guinea (mortality: 72.8 per 100,000 population). Transportation, fire/burn, falls, homicide and drowning were the five leading causes of fatal injuries for the whole population, accounting for 37%, 22%, 12%, 10% and 6% of total deaths, respectively. In general, age-specific injury causes displayed similar patterns of the whole population except that poisoning replaced falls as a leading cause among children under five years old. Males were at 30-50% more risk of dying from six commonest causes than females and old age groups had higher injury mortality rates than younger age groups.

CONCLUSION

Transportation, fire/burn, falls, homicide, and drowning accounted for the majority of total injury mortality burden in Guinea. Males and old adults were high-risk population of fatal injuries and should be targeted by injury prevention. Lots of work is needed to improve weak capacities for injury control in order to reduce the injury mortality burden.

Postoperative mortality after inpatient surgery: Incidence and risk factors

Purpose:

This study determined the incidence of and identified risk factors for 48 hour (h) and 30 day (d) postoperative mortality after inpatient operations.

Methods:

A retrospective cohort study was conducted using Anesthesiology’s Quality Indicator database as the main data source. The database was queried for data related to the surgical procedure, anesthetic care, perioperative adverse events, and birth/death/operation dates. The 48 h and 30 d cumulative incidence of postoperative mortality was calculated and data were analyzed using Chi-square or Fisher’s exact test and generalized estimating equations.

Results:

The 48 h and 30 d incidence of postoperative mortality was 0.57% and 2.1%, respectively. Higher American Society of Anesthesiologists physical status scores, extremes of age, emergencies, perioperative adverse events and postoperative Intensive Care Unit admission were identified as risk factors. The use of monitored anesthesia care or general anesthesia versus regional or combined anesthesia was a risk factor for 30 d postoperative mortality only. Time under anesthesia care, perioperative hypothermia, trauma, deliberate hypotension and invasive monitoring via arterial, pulmonary artery or cardiovascular catheters were not identified as risk factors.

Conclusions:

Our findings can be used to track postoperative mortality rates and to test preventative interventions at our institution and elsewhere.

Establishing a standardized quality management system for the European Health Network GA2LEN

BACKGROUND

Quality management is increasingly important in clinical practice. The Global Allergy and Asthma European Network (GA(2)LEN) is a network of clinical and scientific excellence with originally 25 allergy centres in 16 European countries, a scientific society (European Academy of Allergology and Clinical Immunology), and a patient organization (European Federation of Allergy and Airways Diseases Patients' Associations). Although some allergy centres adhere to internal quality criteria, the implementation of a standardized quality management system for allergy centres across Europe was lacking.

OBJECTIVES

To implement standardized quality criteria among allergy centres organized within GA(2)LEN and thus ensure equal standards of diagnosis and care as well as to establish a culture of continuous quality improvement.

METHODS

Quality criteria covering, e.g., diagnostic and therapeutic procedures, and emergency preparedness to assure patient safety were developed and agreed upon by all 25 participating centres. To assure implementation of quality criteria, centres were audited to check quality indicators and document deviations. A follow-up survey was used to assess the usefulness of the project.

RESULTS

Deviations were documented mainly in the areas of emergency care/patient safety (27.3% lacked regular emergency training of doctors and nurses; 22.7% inadequate emergency intervention equipment; 22.7% lacked critical incidence reporting/root cause analyses) and handling of extracts/pharmaceuticals (31.8% lacked temperature logs of fridges; 4.5% inadequate check of expiration dates). Quality improvement was initiated as shown by findings of re-audits. Usefulness of the project was rated high.

CONCLUSION

The establishment of a quality management system with joint standards of care and harmonized procedures can be achieved in an international health network and ensures quality of care.

Neonatal mortality, risk factors and causes: a prospective population-based cohort study in urban Pakistan

OBJECTIVE

To evaluate the prevalence, sex distribution and causes of neonatal mortality, as well as its risk factors, in an urban Pakistani population with access to obstetric and neonatal care.

METHODS

Study area women were enrolled at 20-26 weeks' gestation in a prospective population-based cohort study that was conducted from 2003 to 2005. Physical examinations, antenatal laboratory tests and anthropometric measures were performed, and gestational age was determined by ultrasound to confirm eligibility. Demographic and health data were also collected on pretested study forms by trained female research staff. The women and neonates were seen again within 48 hours postpartum and at day 28 after the birth. All neonatal deaths were reviewed using the Pattinson et al. system to assign obstetric and final causes of death; the circumstances of the death were determined by asking the mother or family and by reviewing hospital records. Frequencies and rates were calculated, and 95% confidence intervals were determined for mortality rates. Relative risks were calculated to evaluate the associations between potential risk factors and neonatal death. Logistic regression models were used to compute adjusted odds ratios.

FINDINGS

Birth outcomes were ascertained for 1280 (94%) of the 1369 women enrolled. The 28-day neonatal mortality rate was 47.3 per 1000 live births. Preterm birth, Caesarean section and intrapartum complications were associated with neonatal death. Some 45% of the deaths occurred within 48 hours and 73% within the first week. The primary obstetric causes of death were preterm labour (34%) and intrapartum asphyxia (21%). Final causes were classified as immaturity-related (26%), birth asphyxia or hypoxia (26%) and infection (23%). Neither delivery in a health facility nor by health professionals was associated with fewer neonatal deaths. The Caesarean section rate was 19%. Almost all (88%) neonates who died received treatment and 75% died in the hospital.

CONCLUSION

In an urban population with good access to professional care, we found a high neonatal mortality rate, often due to preventable conditions. These results suggest that, to decrease neonatal mortality, improved health service quality is crucial.

Routine mortality monitoring for detecting mass murder in UK general practice: test of effectiveness using modelling

BACKGROUND

The Shipman Inquiry recommended mortality rate monitoring if it could be 'shown to be workable' in detecting a future mass murderer in general practice.

AIM

To examine the effectiveness of cumulative sum (CUSUM) charts, cross-sectional Shewhart charts, and exponentially-weighted, moving-average control charts in mortality monitoring at practice level.

DESIGN OF STUDY

Analysis of Scottish routine general practice data combined with estimation of control chart effectiveness in detecting a 'murderer' in a simulated dataset.

METHOD

Practice stability was calculated from routine data to determine feasible lengths of monitoring. A simulated dataset of 405,000 'patients' was created, registered with 75 'practices' whose underlying mortality rates varied with the same distribution as case-mix-adjusted mortality in all Scottish practices. The sensitivity of each chart to detect five and 10 excess deaths was examined in repeated simulations. The sensitivity of control charts to excess deaths in simulated data, and the number of alarm signals when control charts were applied to routine data were estimated.

RESULTS

Practice instability limited the length of monitoring and modelling was consequently restricted to a 3-year period. Monitoring mortality over 3 years, CUSUM charts were most sensitive but only reliably achieved >50% successful detection for 10 excess deaths per year and generated multiple false alarms (>15%).

CONCLUSION

At best, mortality monitoring can act as a backstop to detect a particularly prolific serial killer when other means of detection have failed. Policy should focus on changes likely to improve detection of individual murders, such as reform of death certification and the coroner system.

Primary healthcare teams' views on using mortality data to review clinical policies

BACKGROUND AND OBJECTIVE

A UK-wide scheme to monitor mortality in general practices has been recommended to improve safety. A monitoring scheme might also have a role in improving quality by informing clinical policies. This study investigated the views of primary care teams on the desirable characteristics of mortality data to help them review and plan their clinical policies.

SETTING

10 general practices in Leicestershire, UK.

METHODS

Development of a format for presentation of mortality data for primary care teams, presentations of the data to team meetings, and subsequent interviews of 16 general practitioners and nurses to identify issues about the improvement and use of the data for informing clinical policies.

RESULTS

The presentation was important in helping teams to understand the data. Comparisons should be between practices with similar patient populations, and information provided on deaths from diseases potentially amenable to prevention through clinical intervention. Practice teams used the data in reflecting on their own clinical care.

CONCLUSIONS

Presentation of data about mortality in practice populations can enable practices to reflect on their clinical policies. The proposed national scheme for monitoring mortality should provide data in a format that helps teams to improve the quality of care as well as improve patient safety.