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This case study describes a significant new index used to monitor death rates in hospitals. The Summary Hospital Mortality Index (SHMI) was developed as a direct result of research carried out at the School of Health and Related Research (ScHARR). This was implemented nationally in October 2011 and the SHMI is now the main mortality indicator used by the NHS. Following publication of the high profile Francis Inquiry on Mid Staffordshire in February 2013, set up to investigate excess mortality in the Trust, the Government has used the SHMI to identify and target 8 further hospitals for investigation.
Imperial College researchers have developed methods and indicators for highlighting potential variations in healthcare performance and safety using routinely collected health data. Analytical tools based on our methodological research are used by managers and clinicians in over two thirds of NHS hospital trusts, and hospitals throughout the world. The results of our analyses helped detect problems at Mid Staffordshire NHS Foundation Trust and triggered the initial investigation and subsequent public inquiry with wide ranging recommendations based on the recognition of their value and their use in enhancing the safety of healthcare.
Statistical analysis and methodological development carried out by Imperial College London on data from the Bristol Royal Infirmary Inquiry and the Shipman Inquiry have led to new monitoring systems in healthcare. Using routinely collected healthcare information, we have highlighted variations in performance and safety, impacting the NHS through direct interventions and/or policy change. For example: (i) findings and recommendations arising from our research for the Bristol Inquiry were reflected in the final inquiry outputs, which highlighted the importance of routinely collected hospital data to be used to undertake the monitoring of a range of healthcare outcomes, (ii) a range of monitoring recommendations have arisen as a direct result of the research on data from the Shipman Inquiry, (iii) analytical tools based on our methodological research are used by managers and clinicians in over two thirds of NHS hospital trusts, (iv) Imperial's monthly mortality alerts to the Care Quality Commission were major triggers leading to the Healthcare Commission investigation into the Mid Staffordshire NHS Trust.
Research carried out from 2003 by Currie (Maxwell Institute) and his PhD students Djeundje, Kirkby and Richards (also Longevitas), and international collaborators Eilers and Durban, created new, flexible smoothing and forecasting methods. These methods are now widely used by insurance and pension providers to forecast mortality when determining pricing and reserving strategy for pensions. The methods were incorporated by the SME Longevitas in its forecasting package Projections Toolkit launched in 2009. This generated impact in the form of £400K turnover for Longevitas in licensing and consultancy fees, with further impact on the pricing and reserving strategies on Longevitas's customers. Since 2010 the methods have been adopted by the Office for National Statistics (ONS) to make the forecasts required to underpin public policy in pensions, social care and health and by The Continuous Mortality Investigation (CMI) to model and provide forecasts on mortality to the pensions and insurance industries. As a result, the research has changed practices in these advisory agencies and in the insurance industry.
The Variable Life-Adjusted Display (VLAD) is a graphical tool for monitoring clinical outcomes. It has been widely adopted by UK cardiac surgery centres, and has helped a shift in culture towards more open outcome assessment in adult cardiac surgery, which has been credited with reduced mortality rates. VLAD is also being used for a broad range of other clinical outcomes by regulatory bodies worldwide. For example, Queensland Health uses VLAD as a major part of its Patient Safety and Quality Improvement Service to monitor 34 outcomes across 64 public hospitals, and NHS Blood and Transplant uses VLAD to monitor early outcomes of all UK transplants.
Research in the MONICA project set the standards for national cardiovascular health surveys in Europe, by establishing quality assessment benchmarks for how cardiovascular health should be monitored in populations. These standards were subsequently adopted by the European Union, and by local health bodies, to improve their commissioning decisions. This research has had an important impact on public health monitoring, enabling robust epidemiological comparisons across countries and the sort of analysis that policy makers need to inform the balance between primary and secondary prevention for cardiovascular health.
Our research has used epidemiological insights, data and methods to enable Legal & General (L&G), a major pensions and annuity provider, to understand the drivers of long-term trends in the annual rates of improvement in mortality in older ages. Our first-ever analysis of inequalities in mortality trends by cause of death over 25 years in England, and future projections of these, has resulted in better informed pricing and risk management (capital reserving) practices at L&G. We also modelled how much of the decline in coronary heart disease, the main contributor to improving life expectancy, was due to improved healthcare versus healthier lifestyles. Projections of these, based on plausible scenarios of evolution of risk factors and disease management, helped strengthen the evidence base for L&G's assumptions of mortality improvements for the UK financial regulators.
LSHTM research led to the development of a computer-based tool known as the Lives Saved Tool (LiST), which has been made available to international organisations, governments and NGOs free of charge. It allows policy-makers and programme managers in the 75 countries with the highest number of child deaths to identify which policy and programme choices are likely to have the greatest impact in cutting neonatal and child mortality. Since its 2008 launch, LiST has been used widely by international agencies, foundations, bilateral agencies, large NGOs and individual countries to determine investment priorities and programme choices.
Graduated period life tables for men and women, based on the mortality experience of the population of England and Wales, have been published by the Office for National Statistics (ONS) using data from the 2001 Census. These tables are the sixteenth in a series known as the English Life Tables which are associated with decennial population censuses, beginning with the Census of 1841. Errors in crude census data owing to the small numbers of deaths involved, particularly in childhood and at very advanced ages, can be reduced by a statistical process of smoothing. A smoothing methodology developed at Cass Business School, City University London has been used in the latest ONS Decennial Life Tables. The tables show the increasing longevity of the population of England and Wales over a long period. The impact of this research is broad as life tables are used extensively in pensions planning, demography, insurance, economics and medicine. Life tables using this statistical smoothing methodology have also been prepared for Scotland, Northern Ireland, the Republic of Ireland and Canada.