title: Cumulative risk adjusted mortality chart for detecting changes in death rate: observational study of heart surgery.
abstract: OBJECTIVE
  To detect changes in mortality after surgery, with allowance being made for variations in case mix.
  
  
  METHODS
  Observational study of postoperative mortality from January 1992 to August 1995.
  
  
  METHODS
  Regional cardiothoracic unit.
  
  
  METHODS
  3983 patients aged 16 and over who had open heart operations.
  
  
  METHODS
  Preoperative risk factors and postoperative mortality in hospital within 30 days were recorded for all surgical heart operations. Mortality was adjusted for case mix using a preoperative estimate of risk based on additive Parsonnet factors. The number of operations required for statistical power to detect a doubling of mortality was examined, and control limits at a nominal significance level of P=0.01 for detection of an adverse trend were determined.
  
  
  RESULTS
  Total mortality of 7.0% was 26% below the Parsonnet predictor (P<0.0001). There was a highly significant variation in annual case mix (Parsonnet scores 8.7-10.6, P<0.0001). There was no significant variation in mortality after adjustment for case mix (odds ratio 1-1.5, P=0.18) with monitoring by calendar year. With continuous monitoring, however, nominal 99% control limits based on 16 expected deaths were crossed on two occasions.
  
  
  CONCLUSIONS
  Hospital league tables for mortality from heart surgery will be of limited value because year to year differences in death rate can be large (odds ratio 1.5) even when the underlying risk or case mix does not change. Statistical quality control of a single series with adjustment for case mix is the only way to take into account recent performance when informing a patient of the risk of surgery at a particular hospital. If there is an increase in the number of deaths the chances of the next patient surviving surgery can be calculated from the last 16 deaths.
authors.affiliation: Public Health Sciences, St George's Hospital Medical School, London SW17 0RE. j.poloniecki@sghms.ac.uk
authors.forename: J
authors.initials: J
authors.lastname: Poloniecki
authors.forename: O
authors.initials: O
authors.lastname: Valencia
authors.forename: P
authors.initials: P
authors.lastname: Littlejohns
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006348:Cardiac Surgical Procedures / Q000379:methods / Q000401:mortality*; D003953:Diagnosis-Related Groups; D005260:Female; D006331:Heart Diseases / Q000401:mortality / Q000601:surgery*; D017052:Hospital Mortality; D006779:Hospitals, Public / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D008131:London / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D018570:Risk Assessment; D015996:Survival Rate