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There has been an increasing focus on quality of care within the whole of Western medicine in recent years and this has been particularly evident within the National Health Service (NHS) in the UK. By identifying areas of good practice, care plans can then be implemented to improve care nationally.1 There is danger within the perinatal sphere that the complex process of measuring quality is reduced to focusing on crude mortality rates. Although the UK's early childhood mortality rates are low by international standards, published figures are consistently higher than similar developed countries (http://www.bbc.co.uk/news/health-27251908) and there is significant regional variation between different geographical populations.2 It is important to understand whether the apparent differences are real or due to artefacts of data collation or presentation.3 ,4 Despite the attraction of crude mortality measures (in terms of ease of public understanding), the policy of focusing high-risk perinatal care on a small number of specialist units5 means these simplistic comparisons of mortality are unsound.
Risk adjustment is one possible solution6 ,7 but the systems used must be robust—something that is very difficult to achieve where numbers of particular categories of death are low and the data supplied are either inaccurate or incomplete. These were the circumstances that appeared to underpin the confusion surrounding the assessment of care at the Leeds paediatric cardiology centre in 2013 (http://www.independent.co.uk/life-style/health-and-families/health-news/war-of-words-continues-over-closure-of-leeds-child-heart-unit-8554813.html).
However it would be wrong to assume that problems of understanding ‘good’ and ‘poor’ rates of survival are simply a matter of ascertaining the correct number of deaths and adjusting the rates by type of hospital. There are a range of factors: administrative, ethical and practical that must be addressed before we can have a clear insight of what constitutes the best quality of care:8
Defining the comparison …
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