1. What do hospitals do for patient outcomes? 30 day mortality after heart attack Future of healthcare in Europe 13 May 2011

2. Variation between hospitals in mortality Krumholz et al JAMA 2009 Target “outliers” ? Improve whole population and shift the mean ?

3. But wide variation remains Public, policy understanding of ‘wide’ variation needs metrics Consider ageing by 5 years A hospital which “ages patients by 5 years” (hazard ratio of 1.3) important for policy How common is such an effect?

4. Important hospital effects on death: common Hazard ratio (1=average across all hospitals) Probability density of hospitals Having a given effect on mortality UK Registry MINAP (Myocardial Ischaemia National Audit Project) n = 150,000 patients in 100 hospitals 21% of UK hospitals have this ‘5 year ageing’ effect

5. How well do we explain this variation? Hazard ratio (1=average across all hospitals) Probability density Case mix Patient treatments Hospital characteristics

6. Measured treatments explain little Crude Treatments + hospital characteristics aspirin, beta-blockers, ACE inhibitors, statins; % patients under cardiologist, angiography on site, volume Case mix Age, sex, admission heart rate, admission BP, smoking, diabetes, type of heart attack Hazard ratio for mortality (1=average across all hospitals)

7. Challenges What else are hospitals doing to influence outcome, which may be actionable? Need for electronic health record research Need for qualitative research What is the picture across Europe? International comparisons in disease prognosis (outcomes research) need to become a priority FP-7

8. “a fiftieth part of the whole die out of the Hospitals at London, and … 20 times that proportion die out of the Paris Hospitals…We Infer that either the Physicians and [Sur]geons of London are better than those of Paris, or that the Air of London is more wholesome” William Petty 1687 “Two essays in political arithmetick concerning the people, housing, hospitals etc. of London and Paris”