An investigation into GPs with high patient mortality rates: a retrospective study.

BACKGROUND As part of the work of the Shipman Inquiry, five general practitioners (GPs) in West Sussex were identified as having excessively high mortality rates. The aim of this study was to identify reasons for the higher-than-expected mortality rates of these five GPs. METHODS A retrospective analysis was made of routine mortality and patient registration data from primary-care practices in West Sussex, and the case notes of deceased patients were reviewed. Outcome measures included standardized mortality ratios (SMRs), proportion of deaths in nursing homes, and reviewers' concordance with GP decisions to issue a death certificate. RESULTS The high death rates were not explained by the age and sex composition of each GP's patient population. SMRs ranged from 145 to 239 (average for West Sussex = 100) and all differences from the West Sussex average were statistically significant (p <0.02). SMRs were highly correlated with the proportion of deaths occurring in nursing homes (Pearson's correlation coefficient = 0.95, p = 0.015). Analysis of 153 deceased patients' notes revealed no evidence of poor clinical practice. In 114 cases, at least one independent reviewer agreed with the decision to issue a death certificate. In the remaining 39 (25 per cent) cases, inadequate information in the patient's record explained the reviewers' uncertainty about issuing a certificate. CONCLUSION A proportionately high registration of nursing home residents is the most likely explanation for the excessive mortality rates of these five GPs. This investigation was time-consuming and costly, and highlights the potential ramifications for primary-care organizations of introducing a national system for monitoring death rates in primary care.