There was a statistically significant reduction in the in-hospital mortality rate for acute myocardial infarction (AMI), heart failure and ischaemic stroke over the 10-year period from 2014 to 2023, according to the most recent National Audit of Hospital Mortality carried out by the National Office of Clinical Audit. (NOCA).
The audit provides new information on six conditions that impact heavily on the Irish health system- AMI, Heart Failure, Ischaemic Stroke,Haemorrhagic Stroke, Chronic Obstructive Pulmonary Disease (COPD) and Pneumonia.
In hospital deaths from AMI fell from 58 deaths per 1,000 discharges in 2014 to 47 deaths per 1,000 discharges in 2023. Over the ten year period, there were 1,258 in-hospital female deaths and 1,935 male deaths in cases of AMI. However, the rate of deaths per 1,000 discharges for females was greater.
In-hospital mortality in cases of heart failure, fell from 82 deaths to72 deaths per 1,000 discharges over the ten year period, while in-hospital mortality in cases of ischaemic stroke reduced significantly (by 42%) from 109 deaths per 1,000 discharges in 2014 to 63 per 1,000 discharges in 2023.
There has been a continued increase in the numbers of patients presenting to hospital with ischaemic stroke, rising from 5,387 in 2021 to 5,548 in 2022, and to 6,100 in 2023.
While the 12% decrease in the crude mortality rate for haemorrhagic stroke between 2014 and 2023 was not statistically significant, there has been a decreasing trend in the mortality rate since 2017, with the crude mortality rate decreasing significantly from 335 deaths per 1,000 discharges in 2017 to 266 deaths per 1,000 discharges in 2023. There has been an increase in discharges of patients with haemorrhagic stroke, from 860 discharges in 2014 to 1,075 discharges in 2023. The audit said the increase was most likely related to an ageing and growing population.
Chronic Obstructive Pulmonary Disease (COPD)
While there was an increasing trend in the in-hospital crude mortality rate for chronic obstructive pulmonary disease (COPD) cases during the COVID-19 pandemic years 2020–2022, the mortality rate in 2023 has returned to pre-COVID-19 pandemic levels, and overall there was no statistically significant difference between the crude mortality rate of 37 deaths per 1,000 discharges in 2014 and 38 deaths per 1,000 discharges in 2023. The number of patients discharged with a diagnosis of COPD decreased during the COVID-19 pandemic and is now returning to pre-COVID-19 pandemic numbers, with 14,032 discharges in 2023.
Pneumonia
Crude mortality rates for patients with a diagnosis of pneumonia have decreased steadily and significantly since the peak of the COVID-19 pandemic, from 140 deaths per 1,000 discharges in 2021 to 100 deaths per 1,000 discharges in 2023. The number of pneumonia patients presenting with COVID-19 has similarly decreased. Sex is a statistically significant factor in relation to survival outcomes for patients with a principal diagnosis of pneumonia, based on the results of logistic regression models fitted to Irish in-hospital discharge data for each diagnosis. The finding from the model fitted for pneumonia indicated that the risk of dying from pneumonia wss marginally greater for males than for females.
Diagnoses
Following a gradual decline since 2014, the crude in-hospital mortality rate for all diagnoses increased in 2020 and 2021, corresponding to the major COVID-19 pandemic waves, and subsequently declined by 2023, but remained significantly higher than the pre-COVID-19 pandemic rates. The National Office of Clinical Audit (NOCA) is to explore these patterns in further detail, with the inclusion of 2024 and 2025 data, and publish the findings. While the number of all diagnoses discharges decreased during the COVID-19 pandemic, they returned to pre-COVID-19 pandemic levels in 2023.
Equity Stratifiers
For the first time, the NAHM report included a preliminary analysis of in-hospital crude mortality in the context of a number of potential inequality and equity stratifiers. These included age, sex, medical card status for those aged under 70 years as a proxy for deprivation, public/private healthcare status, and civil status (previously referred toas marital status). When further equity stratifiers become available in the Hospital In-Patient Enquiry (HIPE) dataset, their relevance to in-hospital mortality outcomes will beexplored in the context of international evidence and their ability to enhance the NAHM analytical model, which currently includes age, sex and medical card status as parameters. NOCA says a possible future development would be to use stratifier data from the patient administration system (PAS)to generate a Pobal HP Deprivation Index score, which can be appended to the HIPE record without having to divulgesensitive address data, such as Eircode.
The audit said that there had been marked improvements in the health of the population of Ireland in recent years. “While we now have one of the highest life expectancies in Europe and most people in Ireland are living longer, healthier lives, we know that poorer people have poorer health outcomes. The reform of the Health Service Executive (HSE) brings a new focus to addressing health inequalities while improving health and health services.
Outliers
“Documentation of palliative care treatment and accuracy of principal diagnosis have been identified in hospital reviews as areas needing quality improvement.
A total of 44 publicly funded hospitals provided data for the NAHM audit.
Commenting on the audit, Dr Diarmuid O’Donovan, Director of National Health Improvement, HSE Public Health said, “There have been marked improvements in the health of the population of Ireland in recent years. While we now have one of the highest life expectancies in Europe and most people in Ireland are living longer, healthier lives, we know that poorer people have poorer health outcomes. The reform of the Health Service Executive (HSE) brings a new focus to addressing health inequalities while improving health and health services.
Recommendations
NOCA will undertake a study into in-hospital crude mortality rates in Ireland, across all conditions, and publish the findings.
NOCA will work with the HPO to gather data to carry out geocoding in order to produce small area deprivation codes for analysis of in-hospital mortality based on deprivation.
Each hospital should establish a local working group including clinicians and HIPE coders in order to promote collaboration between the disciplines and ensure that regular checks on the quality of medical chart documentation and subsequent coding are carried out.
A discharge summary specifically for deceased patients should be designed and inserted as a pro forma document in the basic hospital medical chart. It should be completed for all patients who die in hospital and it should include specific information that will enable accurate coding. This will be conducted as a trial in Cork University Hospital for a 6-month period.
POINTS FOR CONSIDERATION/LEARNING
Patient administration systems (PAS) in hospitals should be expanded on an ongoing basis to include feasible equity stratifiers.
