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Title: Quantifying the Potential Bias when Directly Comparing Standardised Mortality Ratios for In-Unit Neonatal Mortality
Authors: Evans, T. Alun
Seaton, Sarah E.
Manktelow, Bradley N.
First Published: 5-Apr-2013
Publisher: Public Library of Science
Citation: PLoS One, 2013, 8 (4), e61237
Abstract: Introduction: The Standardised Mortality Ratio (SMR) is increasingly used to compare the performance of different healthcare providers. However, it has long been known that differences in the populations of the providers can cause biased results when directly comparing two SMRs. This is potentially a particular problem in neonatal medicine where units provide different levels of care. Methods: Using data from The Neonatal Survey (TNS), babies born at 24 to 31 weeks gestational age from 2002 to 2011 and admitted to one of 11 UK neonatal units were identified. Risk-adjusted SMRs were calculated for each unit using a previously published model to estimate the expected number of deaths. The model parameters were then re-estimated based on data from each individual neonatal unit (“reference” unit) and these then applied to each of the other units to estimate the number of deaths each unit would have observed if they had the same underlying mortality rates as each of the “reference” hospitals. The ratios of the SMRs were then calculated under the assumption of identical risk-specific probabilities of death. Results: 7243 babies were included in all analyses. When comparing between Network Neonatal Units (Level 3) the ratio of SMRs ranged from 0.92 to 1.00 and for the comparisons within Local Neonatal Units (Level 2) ranged from 0.79 to 1.56. However when comparing between neonatal units providing different levels of care ratios up to 1.68 were observed. Conclusions: If the populations of healthcare providers differ considerably then it is likely that bias will be an issue when directly comparing SMRs. In neonatal care, the comparison of Network Neonatal Units is likely to be useful but caution is required when comparing Local Neonatal Units or between units of different types. Tools to quantify the likely bias are required.
DOI Link: 10.1371/journal.pone.0061237
eISSN: 1932-6203
Version: Publisher Version
Status: Peer-reviewed
Type: Journal Article
Rights: Copyright © 2013 Evans et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Description: PMCID: PMC3618107
Appears in Collections:Published Articles, Dept. of Health Sciences

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