Guidelines on constructing funnel plots for quality indicators: A case study on mortality in intensive care unit patients

Verburg, Ilona W. M.; Holman, Rebecca; Peek, Niels; Abu‐Hanna, Ameen; Keizer, Nicolette F. de

doi:10.1177/0962280217700169

Cited by 36 publications

(38 citation statements)

References 42 publications

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“…For creating funnel plots, we used the funnelcompar command in stata statistical package version 15 (which is based on Spiegelhalter), 23 we identified whether SMR relative to the number of index admissions 24 was within acceptable limits (i.e. within 2 SD; 95%), between 2 and 3 SD, or beyond 3 SD (99.8%).…”

Section: Methodsmentioning

confidence: 99%

Reducing variation in hospital mortality for alcohol‐related liver disease in North West England

Kallis

Dixon

Silberberg

et al. 2020

Aliment Pharmacol Ther

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Summary Background Variations in emergency care quality for alcohol‐related liver disease (ARLD) have been highlighted. Aim To determine whether introduction of a regional quality improvement (QI) programme was associated with a reduction in potentially avoidable inpatient mortality. Method Retrospective observational cohort study using hospital administrative data spanning a 1‐year period before (2014/2015) and 3 years after a QI initiative at seven acute hospitals in North West England. The intervention included serial audit of a bundle of process metrics. An algorithm was developed to identify index (“first”) emergency admissions for ARLD (n = 3887). We created a standardised mortality ratio (SMR) to compare relative mortality and regression models to examine risk‐adjusted odds of death. Results In 2014/2015, three of seven hospitals had an SMR above the upper control limit (“outliers”). Adjusted odds of death for patients admitted to outlier hospitals was higher than non‐outliers (OR 2.13, 95% CI 1.32‐3.44, P = 0.002). Following the QI programme there was a step‐wise reduction in outliers (none in 2017/2018). Odds of death was 67% lower in 2017/2018 compared to 2014/2015 at original outlier hospitals, but unchanged at other hospitals. Process audit performance of outliers was worse than non‐outliers at baseline, but improved after intervention. Conclusions There was a reduction in unexplained variation in hospital mortality following the QI intervention. This challenges the pessimism that is prevalent for achieving better outcomes for patients with ARLD. Notwithstanding the limitations of an uncontrolled observational study, these data provide hope that co‐ordinated efforts to drive adoption of evidence‐based practice can save lives.

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Section: Methodsmentioning

confidence: 99%

Reducing variation in hospital mortality for alcohol‐related liver disease in North West England

Kallis

Dixon

Silberberg

et al. 2020

Aliment Pharmacol Ther

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“…The 95% (2SD) and 99.8% (3SD) control limits were constructed using the exact binomial methods to identify outliers. 14,15 These control limits reflect 'moderate' and 'moderate to strong' evidence, respectively, against the null hypothesis that the proportions adhering to NICE by practice are as expected, given…”

Section: Discussionmentioning

confidence: 96%

Route to heart failure diagnosis in English primary care: a retrospective cohort study of variation

et al. 2019

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BackgroundDespite the existence of evidence-based guidelines supporting the identification of heart failure (HF) in primary care, the proportion of patients diagnosed in this setting remains low. Understanding variation in patients’ routes to diagnosis will better inform HF management.AimTo identify the factors associated with variation in patients’ routes to HF diagnosis in primary care.Design and settingA retrospective cohort study of 13 897 patients diagnosed with HF between 1 January 2010 and 31 March 2013 in English primary care.MethodThis study used primary care electronic health records to identify routes to HF diagnosis, defined using the National Institute for Health and Care Excellence (NICE) guidelines, and adherence to the NICE-recommended guidelines. Multilevel logistic regression was used to investigate factors associated with the recommended route to HF diagnosis, and funnel plots were used to visualise variation between practices.ResultsFew patients (7%, n = 976) followed the recommended route to HF diagnosis. Adherence to guidelines was significantly associated with younger age (P = 0.001), lower deprivation level (P = 0.007), HF diagnosis source (P<0.001), not having chronic pulmonary disease (P<0.001), receiving further consultation for symptom(s) suggestive of HF (P<0.001), and presenting with breathlessness (P<0.001). Route to diagnosis also varied significantly between GP practices (P<0.001).ConclusionThe significant association of certain patient characteristics with route to HF diagnosis and the variation between GP practices raises concerns about equitable HF management. Further studies should investigate reasons for this variation to improve the diagnosis of HF in primary care. However, these must consider the complexities of a patient group often affected by frailty and multiple comorbidities.

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“…This method is based on scatter plots of the treatment effect estimated by individual studies vs. a measure of study size or precision. In this graphical representation, larger and more precise studies are plotted at the top, near the combined effect size, while smaller and less precise studies show a wider distribution below (17). All statistical tests were two sided, and differences were considered significant if p < 0.05.…”

Section: Discussionmentioning

confidence: 99%

Meta-Analysis of Dyslipidemia Management for the Prevention of Ischemic Stroke Recurrence in China

Chen

Zhong

Ran³

et al. 2020

Front. Neurol.

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Background: The benefit of blood cholesterol reduction for secondary prevention of ischemic stroke remains undetermined in Chinese patients. The purpose of this meta-analysis was to determine whether lipid-lowering agents including statins, fibrates, nicotinic acid, and ezetimibe reduced the risk of recurrent stroke in ischemic stroke patients in China and whether such findings could inform treatment decisions for blood lipid-lowering treatment in China.Methods: The English electronic databases PubMed, EMBASE, Cochrane Library and Chinese databases CNKI, Sino-Med, Wan Fang, and VIP were searched for studies published between January 1990 and April 2020. This meta-analysis included published data from trials that randomly assigned patients to groups treated with either blood lipid-lowering regimens or placebo. Effect comparisons were made using fixed effects model in meta-analysis and linear and spline regression were performed to identify the relative risk of stroke recurrence. The primary outcome was the reduction of total ischemic stroke events, and relative risk values were obtained using a risk prediction equation developed from the control groups of the included trials.Results: Five studies including 4,999 individuals with available data met the inclusion criteria. Relative to the control groups, the pooled estimated odds ratio (OR) for recurrent stroke among those who received lipid-lowering therapy was 0.79 (95% confidence interval [CI]: 0.63–1.00). A 50% or greater reduction in low-density lipoprotein cholesterol (LDL-C) significantly reduced the risk of ischemic stroke recurrence (OR: 0.15 [95% CI: 0.11–0.20]). The overall beneficial effect of statin therapy was confirmed to prevent ischemic stroke with an OR of 0.51 (95% CI: 0.36–0.72).Conclusions: Effective lipid-lowering therapy could decrease the blood LDL-C level, which had a protective effect against stroke recurrence. These results support the use of predicted baseline cerebrovascular disease risk equations to inform decisions regarding blood lipid-lowering treatment in ischemic stroke patients in China.

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Guidelines on constructing funnel plots for quality indicators: A case study on mortality in intensive care unit patients

Cited by 36 publications

References 42 publications

Reducing variation in hospital mortality for alcohol‐related liver disease in North West England

Reducing variation in hospital mortality for alcohol‐related liver disease in North West England

Route to heart failure diagnosis in English primary care: a retrospective cohort study of variation

Meta-Analysis of Dyslipidemia Management for the Prevention of Ischemic Stroke Recurrence in China

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