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1 Over time

Dec 2019 to Nov 2020

The SHMI for Dartford and Gravesham for the 12 months from Dec 2019 to Nov 2020 is 1.059. This is as expected and is higher (worse) than for the previous period (November 2019 to October 2020) when it was 1.055 and as expected.

2 Compared to other trusts

Across England there were 9 trusts with SHMI higher than expected (highlighted in red), and 13 that were lower than expected (highlighted in green). Your trust is in blue. The limits are estimated and may be different to those calculated by NHSD, hence a trust may sit slightly below or above the limits.

3 Crude death rate

The charts below show the crude (unadjusted) mortality rate per 100 spells, for all patients and split by admission method, compared to England.

3.1 Crude rate of deaths compared across trusts

As the crude mortality rate is not case-mix adjusted, and it is not possible to conclude that a high rate is bad or that a low rate is good. The variation between different trusts will be due to differences for example in demographics or service provision. The rates are provided here to show the variation that exists, and for trusts to see how that relates to themselves.

4 Sites

This trust has no other sites apart from their main hospital with more than 7 deaths and with a calculated SHMI.

5 By condition

The conditions with highest number of excess deaths are Septicaemia (except in labour) (20 deaths) , Fracture of neck of femur (hip) (15 deaths) and COPD & bronchiectasis (10 deaths). Amongst the conditions with least number of excess deaths are Anaemia (-11 deaths), Joint disorders, fractures & sprains (-6 deaths) and Leukemias (-6 deaths).

5.1 Excess deaths by condition, period up to Nov 2020.

5.2 Outlier SHMI by condition

NHS Digital test 10 of the conditions as to whether they are outliers. For Dartford and Gravesham in the NHSD published data there are no conditions that are significantly elevated on the Over Dispersion model.

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%.

The funnel plot shows only those conditions where there was a death in the period.

Condition Outlier band SHMI Observed Expected deaths Excess deaths
Fracture of neck of femur (hip) Higher than expected 95% limits 1.6 40 25 15
Joint disorders, fractures & sprains Lower than expected 95% limits 0.4 4 10 -6
Leukemias Lower than expected 95% limits 0.4 4 10 -6
Nutritional, endocrine and metabolic disorders Lower than expected 95% limits 0.4 4 10 -6
Pulmonary heart disease Lower than expected 95% limits 0.4 4 10 -6
Anaemia Lower than expected 95% limits 0.267 4 15 -11

5.3 Conditions over time

Changes in SHMI and excess deaths over time. The darker the colour the larger the SHMI, the BIGGER the circle the more excess deaths.

6 Changes in counts of activity and deaths

The charts show the change over time in:

6.1 Relative activity changes

The number of deaths at the trust or within 30days of discharge has risen faster (-7.7%) compared to England (-4.7%) since March 2011.

The number of spells at the trust has risen faster (38.1%) compared to England (-5.7%) since March 2011.

7 Data quality

The trust has a higher (worse) percentage of Primary diagnoses (15.4%) that are signs and symptoms (England 13.3%) . 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. Dartford and Gravesham is in the highest 20% of trusts for percentage of spells with a primary diagnosis which is a symptom or sign.

Coding depth for electives is 2.6, which is lower compared to England (5.4), and for non-electives 3.7 this is lower than England (5.7). Dartford and Gravesham has the lowest Mean coding depth for nonelective admissions Dartford and Gravesham has the lowest 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.

Measure England Dartford and Gravesham
Depth of coding - Elective 5.4 2.6
Depth of coding - Non Elective 5.7 3.7
Primary diagnosis symptom or sign (%) 13.3 15.4
Invalid primary diagnosis (%) 0.6 0.5

7.1 Coding compared to other trusts

The charts show trusts ranked from the lowest to highest for the period Dec 2019 to Nov 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.

0.5% of spells have an invalid diagnosis (R69 codes). Dartford and Gravesham is above the average for percentage of spells with an invalid primary diagnosis code. This is lower than England (0.6%).

8 End of life

65.1% Patients died in hospital, this was lower than compared to England (65.7%). Dartford and Gravesham is in the midrange of trusts for percentage of deaths which occurred in hospital.

The SHMI does not include an adjustment for palliative care due to the considerable variation between trusts in its coding. It is included in the HSMR.

Measure England Dartford and Gravesham
Deaths in hospital (%) 65.7 65.1
Deaths outside hospital (%) 34.3 34.9
Deaths with palliative care (%) 36.3 33.3
Spells with palliative care (%) 1.9 1.1

Of those patients who died 33.3% had a palliative care code in their last spell, this is lower than England (36.3%). Dartford and Gravesham is in the midrange of trusts for percentage of deaths with either palliative care specialty or diagnosis_coding. For all spells, 1.1% had a palliative care code, this is lower than England (1.9%). Dartford and Gravesham is in the lowest 10% of trusts for percentage of spells with either palliative care specialty or diagnosis_coding.

8.1 End of life compared to other trusts

There is no set ‘best practice’ for the ratio of deaths in hospital or outside, nor is it possible to determine whether the coding rate is too high or too low as it will depend on local service models, therefore these charts are presented in dark-light-dark to show the variation in these measures without judgment on what is appropriate. The charts are to inform reflection as to wether this what a trust believes is right for its patients and recording their care.

9 Deprivation

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. Across England there is a lower rate of mortality for the most deprived quintile. This is due to the fact that they make up a greater proportion of the spells. Patients from the most deprived quintiles will experience higher population mortality rates, and are admitted more frequently than those from affluent areas. As the mortality measures are affected by the ratio of numerator to denominator, the large number of spells reduces the rate of death.

The charts show the profile for the crude mortality rate (per 100 spells) by quintile from most deprived to most affluent, along with the percentage of all deaths and percentage of all spells. These are compared to the spread across England (in orange)

9.1 Crude rate over time for Dartford and Gravesham

The quintiles are order from 1 the most deprived to 5 the most affluent.

10 Alternative views of SHMI

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). The vertical dashed blue line shows the impact of COVID-19 in March 2020.

10.0.1 Values for most recent period, Dec 2019 to Nov 2020

Measure Value
SHMI 1.0591
SHMI in hospital 1.0480
SHMI outside hospital 1.0740
SHMI(56) 1.0670
SHMI(ex56) 0.8620