title: Variations and inter-relationship in outcome from emergency admissions in England: a retrospective analysis of Hospital Episode Statistics from 2005-2010.
abstract: BACKGROUND
  The quality of care delivered and clinical outcomes of care are of paramount importance. Wide variations in the outcome of emergency care have been suggested, but the scale of variation, and the way in which outcomes are inter-related are poorly defined and are critical to understand how best to improve services. This study quantifies the scale of variation in three outcomes for a contemporary cohort of patients undergoing emergency medical and surgical admissions. The way in which the outcomes of different diagnoses relate to each other is investigated.
  
  
  METHODS
  A retrospective study using the English Hospital Episode Statistics 2005-2010 with one-year follow-up for all patients with one of 20 of the commonest and highest-risk emergency medical or surgical conditions. The primary outcome was in-hospital all-cause risk-standardised mortality rate (in-RSMR). Secondary outcomes were 1-year all-cause risk-standardised mortality rate (1 yr-RSMR) and 28-day all-cause emergency readmission rate (RSRR).
  
  
  RESULTS
  2,406,709 adult patients underwent emergency medical or surgical admissions in the groups of interest. Clinically and statistically significant variations in outcome were observed between providers for all three outcomes (p < 0.001). For some diagnoses including heart failure, acute myocardial infarction, stroke and fractured neck of femur, more than 20% of hospitals lay above the upper 95% control limit and were statistical outliers. The risk-standardised outcomes within a given hospital for an individual diagnostic group were significantly associated with the aggregated outcome of the other clinical groups.
  
  
  CONCLUSIONS
  Hospital-level risk-standardised outcomes for emergency admissions across a range of specialties vary considerably and cross traditional speciality boundaries. This suggests that global institutional infra-structure and processes of care influence outcomes. The implications are far reaching, both in terms of investigating performance at individual hospitals and in understanding how hospitals can learn from the best performers to improve outcomes.
authors.forename: Peter James Edward
authors.initials: PJ
authors.lastname: Holt
authors.forename: Sidhartha
authors.initials: S
authors.lastname: Sinha
authors.forename: Baris Ata
authors.initials: BA
authors.lastname: Ozdemir
authors.affiliation: Department of Outcomes Research, St George's University of London, London, UK. alankarthi@gmail.com.
authors.forename: Alan
authors.initials: A
authors.lastname: Karthikesalingam
authors.forename: Jan Dominik
authors.initials: JD
authors.lastname: Poloniecki
authors.forename: Matt Merfyn
authors.initials: MM
authors.lastname: Thompson
mesh_terms: D000328:Adult; D000368:Aged; D002423:Cause of Death; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D004739:England / Q000453:epidemiology; D017050:Episode of Care; D005260:Female; D006302:Health Services Research; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010343:Patient Admission / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors