Saving Lives: No high ground in low death rate

By Martin Johnston

Auckland medical adviser says ranking by mortality can overlook DHB's access to palliative care.

Dr Colin McArthur says mortality rates don't tell the whole story.  Photo / Dean Purcell
Dr Colin McArthur says mortality rates don't tell the whole story. Photo / Dean Purcell

Auckland District Health Board consistently has one of the lowest hospital death rates, but its leaders are far from claiming any sort of superiority.

The DHB which provides the country's most complex healthcare had the second lowest in-hospital mortality rate in 2010/11 after the figures were standardised by the Health Ministry to allow fair comparisons between health boards each with its own population mix and profile of disease and injuries. In line with the national trend, Auckland DHB's rate is declining almost every year. The 897 deaths in 2010/11 was 95 fewer than five years earlier.

But Auckland DHB medical adviser on quality Dr Colin McArthur won't rely on the mortality data to claim credit for providing better care than other health boards.

In-hospital mortality rates were potentially misleading as they overlooked things like better access to step-down health services such as hospices and community palliative care for the dying, he said.

He cited data from the Australasian Health Roundtable which he said indicated Auckland DHB might have better access to community palliative care than other DHBs and especially Australia: its in-hospital cancer death rate had been less than half the Australasian average.

"That kind of difference just cannot be explained by differences in treatment. Therefore we are reasonably certain that it has to do with the fact that patients who have a fatal disorder are in the cohort ... their death will occur in hospital, whereas with us it is outside the hospital."

He listed his DHB's quality and patient safety initiatives - which mirror schemes nationally - for instance in infection control and reducing the harm from pressure sores and falls. But he emphasised there was not a strong link between the schemes and the DHB's in-hospital death rate. "[The initiatives are in areas that] do have an associated mortality, but it's relatively low compared to the main drivers for mortality, which have got to do with the patient's primary disease."

The serious and sentinel event reporting system has identified gaps, leading to important safety improvements, such as in the transfer of patients from primary care or other hospitals.

One is Auckland DHB's creation of a central referrals office, although the cardiology department did not send the fax about Northland heart patient Barry Searles, who died of a heart attack while on the Auckland DHB waiting list, to this office, and the DHB was unable to explain why to the Health and Disability Commissioner.

Most general practices in the Auckland region have replaced paper- and fax-based referrals to hospitals' non-acute and diagnostic services with a web-based electronic system. In Northland, acute and emergency services are included too. Further developments are intended to include inter-hospital referrals between specialist services within a year.

An Auckland DHB spokesman said: "Both of these systems will eliminate the risk of lost paper referrals, standardise content to improve prioritisation decisions, improve legibility and provide a tracking system for receipt and response."

Paper has already gone from Auckland DHB radiology reports after clinicians overlooked several patients' reports of chest x-rays indicating lung cancer, an unexpected finding because the patients were x-rayed for other reasons.

An opportunity was missed to start treatment soon after the x-ray, said Dr McArthur, although it was uncertain if treatment at the time would have changed the patients' outcomes.

At least one had died, although lung cancer was a high-mortality condition even if detected early.

"We didn't have a reliable system for ensuring the report was read," he said.

Radiology images had been digital at the DHB for about a decade, but Dr McArthur said the lung cancer cases prompted the conversion to a paperless radiology request and reporting system. Now, if clinicians did not electronically mark and accept a radiology report within a specified time, the next person up the chain was automatically notified.

The series

Five years of hospital death rates have been made public for the first time - in the Herald. We compare health boards, investigate where lives are being lost and the battle to save them.

This week

Monday - District health boards compared, is death rate linked to healthcare quality, and how a simple checklist helps surgeons to avoid mistakes.

Tuesday - Waitemata DHB boosts heart-care capacity. A bereaved father questions medical justice.

Yesterday - Waikato DHB strives to understand its high death rate, medication safety, and a doctor's apology.

Today - Palliative care helps Auckland DHB's good performance. A widow fights for changes.

Tomorrow - Obesity skews the statistics in South Auckland. Lives saved by reduction of blood infections.

Contact us: Tell us your experience of hospital care.
Email: martin.johnston@nzherald.co.nz

- NZ Herald

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