SHMI
The SHMI for Mid and South Essex for Oct 2019 to Sep 2020 is 1.063. This is as expected and is higher (worse) than for the previous period (September 2019 to August 2020) when it was 1.055 and as expected.
Across England there were 10 trusts with SHMI higher than expected, and 15 with lower than expected SHMI.
By condition
The conditions with highest number of excess deaths are Other R codes(60 deaths) , Pneumonia (excluding TB/STD) (50 deaths) and Urinary tract infections (45 deaths). Amongst the conditions with least number of excess deaths are Intracranial injury (-15 deaths), Intestinal infection (-10 deaths) and Cardiac arrest and ventricular fibrillation (-10 deaths).
In the NHSD published data there are no conditions that are significantly elevated on the Over Dispersion model.
Changes in counts
The number of deaths at the trust or within 30 days of discharge has risen faster (0%) compared to England (-1%) since March 2011.
The number of spells at the trust has risen faster (9.1%) compared to England (-2.2%) since March 2011.
Data quality
The trust has a higher (worse) percentage of Primary diagnoses (15.2%) that are signs and symptoms (England 13.2%) . Reducing the use of ‘R’ codes will both provide a better insight into what patients are admitted for as well as having a potentially positive effect on the SHMI and other mortality measures.
Coding depth for electives is 4.9, which is lower compared to England (5.2), and for non-electives 5.1 this is lower than England (5.6). Mid and South Essex is in the midrange of trusts for mean coding depth for nonelective admissions. Mid and South Essex is in the lowest 40% of trusts for mean coding depth for nonelective admissions. Coding depth is associated with the Charlson score that adjusts for ‘severity’ of a patient’s condition. Capturing co-mordities will both provide a better insight into the complexity of patients who are admitted as well as having a potentially positive effect on the SHMI and other mortality measures.
0.8% of spells have an invalid diagnosis (R69 codes). Mid and South Essex is in the highest 20% of trusts for percentage of spells with an invalid primary diagnosis_code. This is higher than England (0.6%).
End of life
64.3% Patients died in hospital, this was lower than compared to England (66.2%). Mid and South Essex is in the lowest 40% of trusts for percentage of deaths which occurred in hospital.
Of those patients who died 30.2% had a palliative care code in their last spell, this is lower than England (36.3%). Mid and South Essex is in the lowest 40% of trusts for percentage of deaths with either palliative care specialty or diagnosis_coding. For all spells, 1.7% had a palliative care code, this is lower than England (1.9%). Mid and South Essex is in the lowest 40% of trusts for percentage of spells with either palliative care specialty or diagnosis_coding.
| Measure | Mid and South Essex |
|---|---|
| SHMI | 1.063 |
| SHMI lower limit | 0.893 |
| SHMI upper limit | 1.120 |
| Measure | Mid and South Essex |
|---|---|
| Spells | 170720 |
| Deaths | 5780 |
| Expected | 5435 |
| Excess deaths | 345 |
| Measure | England | Mid and South Essex |
|---|---|---|
| Elective crude mortality | 0.66 | 0.85 |
| Non-elective crude mortality | 3.56 | 3.63 |
| Crude rate | 3.24 | 3.39 |
| Measure | England | Mid and South Essex |
|---|---|---|
| Depth of coding - Elective | 5.2 | 4.9 |
| Depth of coding - Non Elective | 5.6 | 5.1 |
| Primary diagnosis symptom or sign (%) | 13.2 | 15.2 |
| Invalid primary diagnosis (%) | 0.6 | 0.8 |
| Measure | England | Mid and South Essex |
|---|---|---|
| Deaths in hospital (%) | 66.2 | 64.3 |
| Deaths outside hospital (%) | 33.8 | 35.7 |
| Deaths with palliative care (%) | 36.3 | 30.2 |
| Spells with palliative care (%) | 1.9 | 1.7 |
| Condition | Outlier band | SHMI | Observed | Expected deaths | Excess deaths |
|---|---|---|---|---|---|
| Other R codes | Higher than expected 99.8% limits | 1.75 | 140 | 80 | 60 |
| Urinary tract infections | Higher than expected 99.8% limits | 1.243 | 230 | 185 | 45 |
| Cancer of breast | Higher than expected 95% limits | 2 | 20 | 10 | 10 |
| Diseases of kidneys and ureters, bladder and urethra | Higher than expected 95% limits | 2 | 20 | 10 | 10 |
| Other connective tissue disease | Higher than expected 95% limits | 1.333 | 80 | 60 | 20 |
| Gastrointestinal hemorrhage | Higher than expected 95% limits | 1.312 | 105 | 80 | 25 |
| COPD & bronchiectasis | Higher than expected 95% limits | 1.219 | 195 | 160 | 35 |
| Intracranial injury | Lower than expected 95% limits | 0.769 | 50 | 65 | -15 |
| Disorders of stomach and duodenum | Lower than expected 95% limits | 0.4 | 4 | 10 | -6 |
| Ear and sense organ disorders | Lower than expected 95% limits | 0.4 | 4 | 10 | -6 |
| Esophageal disorders | Lower than expected 95% limits | 0.4 | 4 | 10 | -6 |
| Other cerebrovascular disease | Lower than expected 95% limits | 0.4 | 4 | 10 | -6 |
| Other perinatal conditions | Lower than expected 95% limits | 0.4 | 4 | 10 | -6 |
| Pathological fracture | Lower than expected 95% limits | 0.4 | 4 | 10 | -6 |
| Short gestation and slow fetal growth | Lower than expected 95% limits | 0.4 | 4 | 10 | -6 |
The charts show trusts ranked from the lowest to highest for the period Oct 2019 to Sep 2020. Where it is possible to make a distinction between levels of good or poor performance, this is highlighted with red being poor and blue being good. Where it is not possible to say high is good or bad, the ribbon highlights the highest and lowest in darker shades. The bands are the lowest tenth, 20th centile, 40th centile, mid range (40-60 centiles), 80%th centile, 90th centile and the highest tenth of trusts.
Information from NHS Digital, licensed under the current version of the Open Government Licence Source: https://digital.nhs.uk/data-and-information/publications/clinical-indicators/shmi
The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there. It includes deaths which occurred in hospital and deaths which occurred outside of hospital within 30 days (inclusive) of discharge. Deaths related to COVID-19 are excluded from the SHMI.
The SHMI gives an indication for each non-specialist acute NHS trust in England whether the observed number of deaths within 30 days of discharge from hospital was ‘higher than expected’ (SHMI banding=1), ‘as expected’ (SHMI banding=2) or ‘lower than expected’ (SHMI banding=3) when compared to the national baseline.
(Source: NHS Digital - https://digital.nhs.uk/data-and-information/publications/clinical-indicators/shmi/current/shmi-data)
The conditions with the highest excess deaths are shown. Where there are more deaths than expected (excess deaths) these are shown in orange, and where there are fewer deaths than expected these are shown in green. The length of the bar is the total deaths (expected + excess deaths).
Conditions with 5 or fewer excess deaths are not shown to ease reading. All conditions are listed in the Conditions over time page.
The SHMI is not a measure of quality of care. A higher/lower than expected number of deaths should not immediately be interpreted as indicating poor/good performance and instead should be viewed as a ‘smoke alarm’ which requires further investigation.
The SHMI cannot be used to directly compare mortality outcomes between trusts and it is inappropriate to rank trusts by their SHMI. Instead, the SHMI banding can be used to compare mortality outcomes to the national baseline. If two trusts have the same SHMI banding, it cannot be concluded that the trust with the lower SHMI value has better mortality outcomes
NHS Digital’s interpretation guidance https://files.digital.nhs.uk/96/EE14DB/SHMI%20interpretation%20guidance.pdf
Observed Deaths: This is a count of the number of deaths which occurred in hospital or within 30 days of discharge for each trust. Deaths related to COVID-19 are excluded from the SHMI. If the patient is treated by another trust within those 30 days their death will only be attributed to the last non-specialist acute NHS trust to treat them. Specialist trusts, mental health trusts, community trusts and independent sector providers are excluded from the SHMI. A full list of excluded NHS trusts can be found in Appendix C of the SHMI methodology specification document, which is available on the NHS Digital website at http://digital.nhs.uk/SHMI.
Expected Deaths: The risk of the patient dying in hospital or within 30 days of discharge is estimated from statistical models based on the following variables:
the condition the patient is in hospital for other underlying conditions the patient suffers from
the age of the patient
the sex of the patient
the method of admission to hospital (elective/non-elective/unknown)
the month of admission
the birthweight of the patient (perinatal diagnosis groups only)
The expected number of deaths is obtained by summing the estimated risks for all finished provider spells for a trust. The statistical models are derived using thirty-six months of data from trusts throughout England. The final twelve months of this period are used to calculate the SHMI for each individual trust. Details of the dataset used in the SHMI calculation can be found in the SHMI publication timetable which is available on the NHS Digital website at http://digital.nhs.uk/SHMI.
(Source: NHS Digital https://files.digital.nhs.uk/DB/48BBE9/SHMI%20FAQs.pdf)
Crude mortality
Number of patients dying in hospital or within 30 days of discharge divided by the number of spells.
England is shown as a guide but due to variations in case mix you cannot draw any statistical comparison between the two.
Deaths for non-elective admissions
This indicator presents crude percentage rates of non-elective admissions where a death occurred either in-hospital or within 30 days (inclusive) of being discharged from hospital.
An adjustment is made for admission method in the SHMI methodology because crude mortality rates for elective admissions tend to be lower than crude mortality rates for non-elective admissions.
Counts are rounded to 5 in line with HES disclosure control.
To learn more go to: https://files.digital.nhs.uk/65/85E399/SHMI%20contextual%20indicator%20specifications.zip
Deaths for elective admissions
This indicator presents crude percentage rates of elective admissions where a death occurred either in-hospital or within 30 days (inclusive) of being discharged from hospital..
An adjustment is made for admission method in the SHMI methodology because crude mortality rates for elective admissions tend to be lower than crude mortality rates for non-elective admissions.
Counts are rounded to 5 in line with HES disclosure control.
To learn more go to: https://files.digital.nhs.uk/65/85E399/SHMI%20contextual%20indicator%20specifications.zip
Spells
Spells Number of spells in a 12 month period.
More detail on how spells are constructed can be found here https://files.digital.nhs.uk/92/4DEC97/Provider%20spells%20methodology.zip
Observed and expected
Count of deaths in hospital or within 30 days of discharge, and the expected deaths as produced by the SHMI model. The difference between the observed and expected is highlighted.
Counts are rounded to 5 in line with HES disclosure control.
To learn more go to: https://files.digital.nhs.uk/02/3013C8/SHMI%20specification%20v1.32.pdf
SHMI by diagnosis condition
The SHMI is composed of 142 different diagnosis groups For a subset of diagnosis groups, an indication of whether the observed number of deaths within 30 days of discharge from hospital was ‘higher than expected’, ‘as expected’ or ‘lower than expected’ when compared to the national baseline is also provided. It is possible for conditions to have a statistically high or low SHMI, but if it is not in the subset it is not possible to identify these,
Due to the suppression applied by NHS Digital, the SHMI values may differ slightly compared to those published. The approach here has been to comprimse on precision and present a wider range of conditions.
To learn more go to: https://files.digital.nhs.uk/02/3013C8/SHMI%20specification%20v1.32.pdf
Outliers SHMI by condition
Using a funnel plot it is possible to determine whether there are other conditions that may be statistically elevated, especially where there may be not so many deaths. The table below lists the outliers, either high or low, based on the Poisson limits at 95% or 99.8% as highlighted in the funnel plot.
The funnel plot shows only those conditions where there was a death in the period.
Excess deaths by condition
This chart presents the changes in the SHMI and excess deaths over time. The larger the circle the greater the excess deaths, the darker the colour the higher the SHMI. The SHMI in this presentation is capped to 3 as small increases in the observed deaths can lead to large increases in conditions with low mortality, leading to exceptionally high and meaningless SHMI. Excess deaths are rounded to 5 in line with HES disclosure control.
Signs and symptoms
This indicator presents the percentage of finished provider spells with a primary diagnosis which is a symptom or sign (identified by ICD-10 codes beginning with the letter ‘R’).
A high percentage may indicate problems with data quality or timely diagnosis of patients, but may also reflect the case-mix of patients or the service model of the trust (e.g. a high level of admissions to acute admissions wards for assessment and stabilisation).
Depth of coding
This indicator presents the mean number of secondary diagnosis codes per finished provider spell (mean depth of coding) by elective and non-elective admission method, for each trust. A higher mean depth of coding may indicate a higher proportion of patients with multiple conditions and/or comorbidities, but may also be due to differences in coding practices between trusts.
To learn more go to: https://files.digital.nhs.uk/65/85E399/SHMI%20contextual%20indicator%20specifications.zip
To learn more go to: https://files.digital.nhs.uk/65/85E399/SHMI%20contextual%20indicator%20specifications.zip
Palliative care coding This indicator presents crude percentage rates of deaths reported in the SHMI with palliative care coding at either diagnosis or treatment specialty level.
Note that the SHMI makes no adjustments for patients who are recorded as receiving palliative care. This is because there is considerable variation between trusts in the way that palliative care codes are used.
To learn more go to: https://files.digital.nhs.uk/65/85E399/SHMI%20contextual%20indicator%20specifications.zip
Place of death
This indicator presents crude percentage rates of deaths reported in the SHMI which occurred in hospital and deaths reported in the SHMI which occurred outside hospital within 30 days (inclusive) of discharge.
To learn more go to: https://files.digital.nhs.uk/65/85E399/SHMI%20contextual%20indicator%20specifications.zip
Trusts may be located at multiple sites and may be responsible for one or more hospitals.
The SHMI is calculated at the level of the provider spell, which is a continuous period of time spent as a patient within a single trust (provider). A spell may be composed of more than one episode (a single period of care under one consultant). If a patient is moved between hospitals or sites within the same trust, the provider spell continues. Most spells consist of a single episode and so there is no complication when presenting SHMI data at site level because the entire provider spell occurred at a single site. However, spells consisting of multiple episodes may have occurred over multiple sites and only one of these sites can be associated with the spell. This has been chosen to be the site of the first episode in the spell. This may result in hospital deaths being attributed to a site other than the one in which they occurred, with an impact on the SHMI values presented for the sites concerned. This impact is likely to be greater for sites within trusts showing higher percentages for this contextual indicator.
Deprivation is not included as a factor in the SHMI. It is interesting to reflect on how deprivation affects admission patterns and mortality for your trust. The quintiles are order from 1 the most deprived to 5 the most affluent.
These charts show four alternative views of the SHMI, alongside the published value:
These are NOT official measures, and are included only to provide a view of how the SHMI compares to the patient cohorts used in the HSMR.
They are compared against the index value of 1 (dashed line).