The UK Case-Note Review Group (Including: Manaseki-Holland, Semira , Lilford, Richard, Bishop, Jonathan R. B., Girling , Alan J., Chen, Y-F.‏‎, Chilton, Peter J. and Hofer, Timothy P.). (2017) Reviewing deaths in British and US hospitals : a study of two scales for assessing preventability. BMJ Quality and Safety, 26 . pp. 408-416. doi:10.1136/bmjqs-2015-004849

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Abstract

Background
Standardised mortality ratios do not provide accurate measures of preventable mortality. This has generated interest in using case-notes to assess the preventable component of mortality. But different methods of measurement have not been compared. We compared the reliability of two scales for assessing preventability and the correspondence between them.
Methods
Medical specialists reviewed case-notes of patients who had died in hospital using two instruments: a five-point Likert scale and a continuous (0-100) scale of preventability. To enhance generalisability we used two different hospital datasets with different types of acute medical patients across different epochs and in two jurisdictions (UK and US). We investigated the reliability of measurement and correspondence of preventability estimates across the two scales. Ordinal mixed effects regression methods were used to analyse the Likert scale and to calibrate it against the continuous scale. We report the estimates of the probability a death could have been prevented accounting for reviewer inconsistency.
Results
Correspondence between the two scales was strong; the Likert categories explained most of the variation (76% UK, 73% US) in the continuous scale. Measurement reliability was low but similar across the two instruments in each dataset (intra-class correlation 0.27 UK, 0.23 US). Adjusting for the inconsistency of reviewer judgements reduced the proportion of cases with high preventability, such that the proportion of all deaths judged probably or definitely preventable on the balance of probability was under 1%.
Conclusions
The correspondence is high between a Likert and continuous scale, although the low reliability of both would suggest careful measurement design would be needed to use either scale. Few to no cases are above the threshold when using a balance of probability approach to determining a preventable death, and in any case there is little evidence supporting anything more than an ordinal correspondence between these reviewer estimates of probability and the true probability. Thus, it would be more defensible to use them as an ordinal measure of the quality of care received by patients who died in the hospital.

Item Type:	Journal Article
Divisions:	Faculty of Social Sciences > Warwick Business School Faculty of Medicine > Warwick Medical School
Journal or Publication Title:	BMJ Quality and Safety
Publisher:	BMJ Group
ISSN:	2044-5423
Official Date:	17 April 2017
Dates:	Date Event 17 April 2017 Published 22 June 2016 Available 8 May 2016 Accepted 17 September 2015 Submitted
Date of first compliant deposit:	10 June 2016
Volume:	26
Page Range:	pp. 408-416
DOI:	10.1136/bmjqs-2015-004849
Status:	Peer Reviewed
Publication Status:	Published
Access rights to Published version:	Open Access
Is Part Of:	Funding: RJL and PJC acknowledge financial support for the submitted work by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West Midlands.

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