1. Risk adjustment and other reporting issues Shalini Santhakumaran NDAU Statistician Imperial College London

2. Why report outcomes ? Improvements in neonatal care and outcomes Audit Comparison CommissioningAccountability Transparency

3. Data Issues  Completeness  Accuracy

4. Data Issues  Completeness  Accuracy  Agreed case definitions

5. Data Issues  Completeness  Accuracy  Agreed case definitions  Neonatal transfers

6. Analysis issues  Unadjusted data is useful for some purposes  For others a more detailed analysis is required

7. Analysis issues  Unadjusted data is useful for some purposes  For others a more detailed analysis is required  3 reasons for variation in outcome:

8. Analysis issues  Unadjusted data is useful for some purposes  For others a more detailed analysis is required  3 reasons for variation in outcome: 1.Differences in case-mix 2.Random variation 3.Differences in care provided

9. Analysis issues 1.Differences in case-mix 2.Random variation 3.Differences in care provided  Selection of variables  Use of appropriate statistical models  Cannot completely control for case-mix

10. Survival Probability Calculator

13. Analysis issues 1.Differences in case-mix 2.Random variation 3.Differences in care provided  Occurs by chance even if the underlying mortality rate is the same for all providers  Illustrate significance using funnel plots

14. Funnel plot for adjusted SMR 95% confidence interval limits = “warning” 99.8% confidence interval limits = “alarm” ● = complete networks ○ = incomplete networks

15. Analysis issues 1.Differences in case-mix 2.Random variation 3.Differences in care provided  Not necessarily due to good/poor performance  ‘Constant risk fallacy’ and other local effects  Cannot tell us whether deaths were preventable  Needs to be linked to process measures

16. The National Neonatal Database  Individual, not aggregated  Population-based  Detailed clinical record  Electronic  Collaborative access to denominator data

17. The National Neonatal Database  Individual, not aggregated  Population-based  Detailed clinical record  Electronic  Collaborative access to denominator data …ideal for reporting outcomes

18. Acknowledgements All neonatal units contributing to the NDAU NDAU Team NDAU Steering Board Jane Abbott (BLISS)Jacquie Kemp Prof. Peter BrocklehurstProf. Azeem Majeed Prof. Kate CosteloeProf. Neena Modi Prof. Liz DraperProf. Andrew Wilkinson Imperial College London Academic Neonatal Medicine Unit