OBJECTIVES: Use of cumulative mortality adjusted for\ud case mix in patients with acute myocardial infarction\ud for early detection of variation in clinical practice.\ud \ud DESIGN: Observational study.\ud \ud SETTING: 20 hospitals across the former Yorkshire\ud region.\ud \ud PARTICIPANTS: All 2153 consecutive patients with\ud confirmed acute myocardial infarction identified\ud during three months.\ud \ud MAIN OUTCOME MEASURES: Variable lifeadjusted\ud displays showing cumulative differences between\ud observed and expected mortality of patients; expected\ud mortality calculated from risk model based on\ud admission characteristics of age, heart rate, and\ud systolic blood pressure.\ud \ud RESULTS: The performance of two individual hospitals\ud over three months was examined as an example. One,\ud the smallest district hospital in the region, had a series\ud of 30 consecutive patients but had five more deaths\ud than predicted. The variable lifeadjusted display\ud showed minimal variation from that predicted for the\ud first 15 patients followed by a run of unexpectedly\ud high mortality. The second example was the main\ud tertiary referral centre for the region, which admitted\ud 188 consecutive patients. The display showed a period\ud of apparently poor performance followed by\ud substantial improvement, where the plot rose steadily\ud from a cumulative net lives saved of - 4 to 7. These\ud variations in patient outcome are unlikely to have\ud been revealed during conventional audit practice.\ud \ud CONCLUSIONS: Variable lifeadjusted display has been\ud integrated into surgical care as a graphical display of\ud riskadjusted survival for individual surgeons or centres.\ud In combination with a simple risk model, it may have a\ud role in monitoring performance and outcome in\ud patients with acute myocardial infarction
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