In 2013, the latest year for which the data is available, Whangarei Hospital had 439 deaths, 16 more than the predicted number of 423.
The other two outliers' mortality figures are: Whakatane, 173 deaths - 17 more than the predicted 156; and Gisborne, 176 - 35 more than the predicted 141.
Nationally, the ratio of actual to predicted deaths declined from 2007 to 2013.
There is international debate about the usefulness of this kind of data, called hospital standardised mortality ratios or HSMRs.
Auckland District Health Board, whose ratio is below the national average, considers the data to be a "key" measure of "quality and safety", according to its Health Needs Assessment report.
"For Auckland Hospital, [the ratio] has remained stable for the past four years at around the average level for comparable hospitals. For Starship hospital, the HSMR level is stable but sits 25 per cent higher than the average for other hospitals. This may be due to its relatively small size and the high complexity of the patients."
The ministry says the ratios should not be used to compare hospitals, to calculate "avoidable deaths" or to draw "simplistic conclusions about quality of care". But they can be a warning of potential problems and the need for investigation if the HSMR suddenly increases or is outside the statistical "control limits", such as for the three outliers.
The three hospitals say they provide safe or good-quality care and their results are higher in part because of the inclusion of palliative care in the data. Their centres have poorer access to hospice care - meaning higher proportions die in hospital or soon after - and terminally ill patients are not always recorded as such.
Gisborne and Whangarei say other factors which may not be accurately reflected in the data are their populations' high levels of deprivation and multiple illnesses.
Northland DHB chief medical officer Dr Mike Roberts said Whangarei's result was out of line with the low and stable findings under a previous assessment method and did not reflect the hospital's average or better performance on several direct measures of clinical quality.
"We have been working with the ministry to see if we can understand why this result is so different, and why it particularly disadvantages a few DHBs with similar demographic challenges and extremely high-need populations."
To check the mortality at your hospital see http://tinyurl.com/nzhHospitalStandards
Northland District Health Board chief medical officer Dr Mike Roberts responds concerning Whangarei Hospital
The Ministry of Health has recently introduced a model for measuring Hospital Standardised Mortality Ratio (HSMR) which is different to that previously used by DHBs in New Zealand, which was provided by the Health Round Table (HRT).
Is your DHB/hospital concerned by the relevant hospital having had a statistically significantly high Hospital Standardised Mortality Ratio in 2013?
HSMR is one tool for examining patient mortality. HSMR compares actual deaths within 30 days of an admission to hospital (wherever these occur) with the number we would have predicted based on the mix of patients who were admitted.
Direct measures of quality in Northland, already publicly reported do not show concerning results - if anything rather the reverse.
Does it indicate problems with the quality of health care provided at the facility, Do you believe that the facility provides safe health care
HSMR is not a direct measure of quality of services. The variation between the actual number of deaths and the predicted number of deaths can be for various reasons including differences in how end of life care is organised and differences in the risk of patients that we cannot adjust for. It is important to note that we cannot tell from the number alone what the reason for the death was.
The Quality and Safety Markers show that in safety processes Northland performs at the national average or better for infection control measures like hand hygiene, actions to prevent surgical site infections and for use of the surgical safety checklist.
Outcomes are currently in line with national performance for post-operative sepsis (having been higher in previous years) Northland has not had the increase in post-operative sepsis seen across the country, while reported Staphylococcus aureus bacteraemia and post-operative DVT/PEs are lower than the national average and stable.
Surgical site infections at Northland DHB, for hip and knee surgery are the second lowest in the country over the last 18 months (although not statistically significantly different from the national average). In short, direct measures of quality, already publicly reported do not show concerning results.
What investigations have taken place by the DHB/hospital and/or ministry as a result of the 2013 result?
As this is a single result and the previous HRT methodology used across Australasia has shown Northlands HSMR to be low and stable, we have been working with the Ministry to see if we can understand why this result is so different, and why it particularly disadvantages a few DHBs with similar demographic challenges and extremely high need populations.
A useful piece of analysis we are undertaking is to look at all deaths among Northland residents, and see how many of these had been in hospital within 30 days of their demise (i.e. are included in the HSMR measure). This will give us further insight into how organisation of end of life care in Northland compares to that in the rest of the country.
What might the reasons be for the high result?
The three areas of the country with higher than national average HSMRs are demographically, geographically and socio-economically similar: Northland, Tairāwhiti and East Bay of Plenty (Whakatane Hospital). All are remote, relatively deprived, with high Māori populations.
This may lead to sicker patients entering hospital (acuity won't be picked up by the risk model) leading to patients entering hospital being actually riskier than the mortality prediction suggests.
Another reason for the difference relates to the care of patients with terminal illnesses. In many areas of the country these patients are cared for in a hospice rather than a hospital. There are very few hospice beds in Northland and so most of these patients come to a hospital. HRT take account of these variations by excluding patients receiving palliative care from their analysis. The MoH data does not take into account this variance.
Were insufficiencies of staffing or funding a factor?
No.
Has the ratio for your hospital (Whangarei, Pukekohe, Gisborne or Whakatane as the case may be) increased, decreased or remained the same since 2013.
HRT data has repeatedly shown Northland to have an HSMR significantly lower than the national average (i.e. fewer than expected deaths). Ministry of Health data suggests that the rate of HSMR counted deaths for Northland DHB is higher than average. HSMR counted about 35% of deaths occurring outside of hospital in Northland, compared with a national average of 25%.
Hospital Standardised Mortality Ratios (HSMRs) are one among many tools for quality improvement in hospitals.
Northland DHB has recently purchased Copeland's Risk Adjusted Barometer (CRAB) software which provides a much more in-depth analysis of mortality and morbidity than that given by either the HRT or MoH models. We are the first in New Zealand to use this software, and when the data becomes available, it will be a very useful tool to monitor quality of care.
Tairawhiti District Health Board chief executive Jim Green, responding concerning Gisborne Hospital:
Is your DHB/hospital concerned by the relevant hospital having had a statistically significantly high Hospital Standardised Mortality Ratio in 2013
Yes in terms of continually looking at the care we are providing, the outcomes achieved and how we can improve on them. We do this case by case and as a whole for the DHB.
Does it indicate problems with the quality of health care provided at the facility
No. We have reviewed whole periods of deaths one by one and have a clinically led group looking at all deaths that have occurred in the hospital in the previous month. The purpose of this is to find instances where we can improve and implement those changes where we can. We believe there are factors in our population and in the pattern of health services in the district that are relevant to the HSMR. For instance there is no hospice in Tairāwhiti and this service is provided at Gisborne Hospital. We serve the most deprived population in the country who have high levels of co-morbidities.
Do you believe that the facility provides safe health care
Yes. We have comprehensive systems for reporting and investigating incidents in care and review all deaths in hospital. Our performance on other indicators of quality in care - for example infections in hospital or falls, do not show any issues of concern.
What investigations have taken place by the DHB/hospital and/or ministry as a result of the 2013 result
We have been reviewing deaths in hospital for many years and have done this in relation to Health Round Table information as well. The MoH/HQSC data augments what we have in place.
What might the reasons be for the high result
As above.
Were insufficiencies of staffing or funding a factor
No.
Has the ratio for your hospital (... Gisborne ...) increased, decreased or remained the same since 2013.
Total deaths at Gisborne are on a downward trend.
Bay of Plenty District Health Board (BOPDHB) Chief Operations Officer Pete Chandler:
"Whakatāne is a smaller secondary care hospital and the volume of patients it serves means small fluctuations in mortality numbers will cause disproportionately significant statistical variations.
"The limited availability of community care capacity for palliative patients in the Eastern Bay of Plenty means many receive their end-of-life care at Whakatāne Hospital. This means these patients are counted within the Hospital Standardised Mortality Ratio (HSMR) for the hospital which further skews the figures. Palliative patients in larger centres will have access to greater options for their end-of-life care and as such will not affect the HSMR for their local hospital.
"The BOPDHB's Mortality Review Committee, led by Medical Director Dr Hugh Lees, reviews every death at both of our hospitals. The Committee is charged with identifying if there are any concerning aspects to a death and to disseminate the information gained from the review to clinicians.
"The Mortality Review Committee also utilises the BOPDHB's highly skilled Data Analysis Team to help them investigate any statistically significant variation identified in the HSMR report.
"We are satisfied from the work of the Mortality Review Committee, supported by the Data Analysis Team, that the published HSMR figures are in keeping with the population we serve and the type of admissions we experience."
Do you believe that the facility provides safe health care
Yes
Has the ratio for your hospital (... Whakatane ...) increased, decreased or remained the same since 2013.
Around the same.
