Audit of contributory factors and potentially avoidable perinatal related deaths · 2017-07-02 ·...
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Audit of contributory factors and potentially avoidable
perinatal related deathsLynn Sadler, Epidemiologist, PMMRC
PMMRC Conference, 13 June 2017
Te Papa, Wellington
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Introduction
All perinatal related deaths in NZ are reviewed locally at DHBs with a multidisciplinary process, using a standard tool, contributory factors identified, and deaths determined to be potentially avoidable or not
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Introduction
Among potentially avoidable perinatal related deaths:
• The proportion where the main contributory factor was barriers to access and/or engagement with care factors was statistically significantly higher for Māori women than for NZE women
• The proportion where organisation and management, or personnel factors were the main CF was significantly lower for Māori women than for NZE women
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Main contributory factor(s) in potentially avoidable perinatal related deaths by maternal ethnicity (2011-2012)
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Introduction
Hypothesised that this may be due to information bias:
• In the face of more than one factor reviewers may be more likely to focus on the barriers for Māori mothers
• In the face of a non-specific factor, reviewers may be more likely to conceptualise it as a barrier than a personnel or organisation and management factor for a Māori mother
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Aim
To determine whether there is ethnicity bias in the identification of contributory factors and potentially avoidable death in local review of perinatal deaths
• by independent review
• and blinding of ethnicity age and place of birth
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Methods
• Cases were deaths in 2012 where the mother had identified as Māori or NZE and local review had determined the death as potentially avoidable
• Case summaries excluding identifiers of ethnicity, including age, DHB of care or residence and socioeconomic status
• Independent review committee was not told that all cases had been identified as potentially avoidable at local review
• Review used the PMMRC standardised tool and process
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Primary death classification by ethnicityNew Zealand European
N=37
Māori
N=45 Chi-squared
Primary Perinatal Death Classification n % n % p
Congenital abnormality 1 3 0 0
Perinatal infection 1 3 3 7
Hypertension 0 0 2 4
Antepartum haemorrhage 2 5 3 7
Maternal conditions 4 11 4 9
Specific perinatal conditions 8 22 2 4
Hypoxic peripartum death 5 14 3 7
Fetal growth restriction 7 19 5 11
Spontaneous preterm 3 8 19 42
Unexplained antepartum death 5 14 3 7
No obstetric antecedent 1 3 1 2 0.03
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Findings: Any contributing factor(s) by ethnicity at local review
0
20
40
60
80
100Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Any CF Org/ManPersonnel Barriers
Local review
p<0.001
p<0.001
p=0.009
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Findings: Any contributing factor(s) by ethnicity and review
0
20
40
60
80
100Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Any CF Org/ManPersonnelBarriers Any CF Org/ManPersonnelBarriers
Local review Independent review
p=0.009
p<0.001
p<0.001 p<0.001
p<0.001
p=0.03
p=0.8
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0
20
40
60
80
100Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
PA Org/ManPersonnelBarriers
p=0.012
p<0.001
p<0.001
Findings: Main contributing factor(s) by ethnicity at local review
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Findings: Potentially avoidable death and main contributing factor(s) by ethnicity and review
0
20
40
60
80
100Māo
ri
NZ
E
Māo
ri
NZ
E
Māo
ri
NZ
E
Māo
ri
NZ
E
Māo
ri
NZ
E
Māo
ri
NZ
E
Māo
ri
NZ
E
Māo
ri
NZ
E
PA Org/ManPersonnelBarriers PA Org/ManPersonnelBarriers
Local review Independent review
p=0.012p=0.07
p=0.002p<0.001
p<0.001
p<0.001
p=0.09
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Any contributory factor: Organisation and management by local and independent review
Independent review
Overall NZ European MāoriMcNemar
p=
Local review No Yes No Yes No Yes
OverallNo 56 8
Yes 12 6 0.5
NZ EuropeanNo 20 4
Yes 7 6 0.5
MāoriNo 36 4
Yes 5 0 1.0
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Any contributory factor: Personnel by local and independent review
Independent review
Overall NZ European MāoriMcNemar
p=
Local review No Yes No Yes No Yes
OverallNo 39 12
Yes 4 27 0.08
NZ EuropeanNo 9 6
Yes 2 20 0.2
MāoriNo 30 6
Yes 2 7 0.3
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Any contributory factor: Barriers to access and/or engagement with care by local and independent review
Independent review
Overall NZ European MāoriMcNemar
p=
Local review No Yes No Yes No Yes
OverallNo 24 3
Yes 4 51 1.0
NZ EuropeanNo 21 2
Yes 2 12 1.0
MāoriNo 3 1
Yes 2 39 1.0
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Main contributory factor: Organisation and management by local and independent review
Independent review
Overall NZ European MāoriMcNemar
p=
Local review No Yes No Yes No Yes
OverallNo 62 7
Yes 12 1 0.36
NZ EuropeanNo 22 5
Yes 9 1 0.42
MāoriNo 40 2
Yes 3 0 1
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Main contributory factor: Personnel by local and independent review
Independent review
Overall NZ European MāoriMcNemar
p=
Local review No Yes No Yes No Yes
OverallNo 42 15
Yes 5 20 0.04
NZ EuropeanNo 10 8
Yes 2 17 0.11
MāoriNo 32 7
Yes 3 3 0.34
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Main contributory factor: Barriers by local and independent review
Independent review
Overall NZ European MāoriMcNemar
p=
Local review No Yes No Yes No Yes
OverallNo 26 5
Yes 16 35 0.03
NZ EuropeanNo 22 1
Yes 4 10 0.38
MāoriNo 4 4
Yes 12 25 0.08
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Summary
• At independent blinded review the initial findings were confirmed
• At independent blinded review, deaths were assigned as potentially avoidable in 78% of cases.
• Non-significantly fewer deaths were identified as potentially avoidable among Māori at independent blinded review (71% M v 86% NZE, p=0.09)• this was due to a reduction in cases with barriers identified as potentially
avoidable (p=0.03 overall; p=0.08 among Māori)
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• Significantly more personnel factors were identified as a main factor in potentially avoidable deaths (43% v 30%, p=0.04)
• There was no significant change in the number of barriers factors identified at independent review; but there was a significant reduction in barriers factors as a main factor in potentially avoidable deaths
Summary
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Conclusions
• There is some evidence of ethnicity bias in the identification of barriers factors as a cause of potentially avoidable death in perinatal related deaths at local review
• There is evidence of reduced identification of personnel factors at local review