"The weakness of UK survival data across a range of conditions
might suggest that patients who would survive, for example, their cardiac
disease, or cancer, or CVA if managed elsewhere in the developed world may be
being prematurely written off in the UK. The "palliative care"
option in the guise of the LCP [4] [6] [7] [8] may make this kind of non-care
or option for death easy and all but impossible to prevent. This whole rather
murky area is in need of urgent examination."
Patient coding and the ratings game
Possible misuse of "palliative care" coding in UK
7 May 2010
Many of the criticisms of HSMRs made by authors such as Black [2], and Lilford and Pronovost [3], relate in practise to the failure of Trusts to code in depth, and to variations in results depending on which HSMR was used. That different techniques give different results should of course surprise no-one.
Nigel Hawkes [1] in his informative scrutiny of HSMRs examines a still more serious concern, which is that HSMRs can and are being ‘gamed’ by labelling high proportions of admissions (over 80% in one DGH) as needing palliative care. Apart from the sheer improbability of such high proportions of unselected "takes" comprising such cases, there is the concern that this approach could conceal seriously deficient practice. Relevant to these concerns are the arguably lax entry criteria for the Liverpool Care Pathway (LCP) [5], and the poorly explained but significantly higher mortality rates across a range of common conditions in the UK compared to other developed countries. The suggestion that these deaths are "expected" begs the question of how this should be defined, and whether there is not in reality unacceptably wide variation between individual clinicians in what consists an expected death. The weakness of UK survival data across a range of conditions might suggest that patients who would survive, for example, their cardiac disease, or cancer, or CVA if managed elsewhere in the developed world may be being prematurely written off in the UK. The "palliative care" option in the guise of the LCP [4] [6] [7] [8] may make this kind of non-care or option for death easy and all but impossible to prevent. This whole rather murky area is in need of urgent examination.
Yours etc
Ronald J Clearkin
[1] Hawkes N. Patient coding and the ratings game. BMJ 2010;340:c2153
[2] Black N. Assessing the quality of hospitals. BMJ 2010;340:c2066
[3] Lilford R, Pronovost P. Using hospital mortality rates to judge hospital performance: a bad idea that just won’t go away. BMJ 2010:340:c2016
[5] Dr Adrian Treloar. Dutch research reflects problems with the Liverpool Care Pathway. BMJ;336:p905 (26 April 2008)
[6] Mary Knowles. Continuous Deep Sedation and LCP concerns. BMJ; 336:p905 (26 April 2008)
Competing interests: None declared
Ronald J Clearkin, Physician
"High mortality rates can be
"re-coded" by describing patients' conditions as terminal, Inquiry
told"
Linked document -
NHS Bolton End of Life Template
Content including Read Codes for InPS
NHS Bolton End of Life Template
Content includes Read Codes for InPS.
InPS develops, deploys and supports clinical software solutions
that are used extensively within primary care settings and the wider healthcare
environment throughout the UK.
Z515 is the diagnosis code for palliative
care or LCP on the summary care record although this is not included here.
Patients 'being coded as palliative to cut death rates', inquiry told
Patients with diabetes and rheumatoid arthritis are being coded under palliative care to reduce death rates, a leading expert has told the Mid Staffordshire Foundation Trust public inquiry.
Are the 'murky' waters clearing...?
"HSMRs can and are being ‘gamed’ by labelling high proportions of admissions (over 80% in one DGH) as needing palliative care. Apart from the sheer improbability of such high proportions of unselected "takes" comprising such cases, there is the concern that this approach could conceal seriously deficient practice. Relevant to these concerns are the arguably lax entry criteria for the Liverpool Care Pathway (LCP) [5], and the poorly explained but significantly higher mortality rates across a range of common conditions in the UK compared to other developed countries."
ReplyDeleteDr Clearkin is to be thanked for speaking out. Well said, Dr Clearkin, your honesty is a beam of sunshine - the best disinfectant of all, as the Prime Minister once stated - among the murkey fog of obfuscation which so many use to cloud the reality of the LCP!
Although Dr Clearkin's honesty of course begs the question of why so many others who work in the health service or the palliative care industry either remain silent or try to gloss over the worrying deficiencies of so called End Of Life programme.