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Objective: To identify a credible explanation for the excessively high mortality associated with general practitioners who were flagged up by the Shipman inquiry.
Design: Retrospective analysis of routine data.
Setting: Primary care.
Participants: Two general practitioners in the West Midlands who were associated with an unacceptably high mortality of patients during 1993–2000.
Main outcome measures: Observed and expected number of deaths and deaths in nursing homes.
Results: Preliminary discussions with the general practitioners highlighted deaths in nursing homes as a possible explanatory factor. No relation was found between the expected number of deaths and deaths in nursing homes in each year during 1993–2000 for either general practitioner. In contrast, the magnitude and shape of the curves of a cumulative sum plot for excess number of deaths (observed minus expected) in each year were closely mirrored by the magnitude and shape of the curves of the number of patients dying in nursing homes; and this was reflected in the high correlations (R2 = 0.87 and 0.89) between excess mortality and the number of deaths in nursing homes in each year for the general practitioners. These findings were supported by administrative data.
Conclusions: The excessively high mortality associated with two general practitioners was credibly explained by a nursing home effect. General practitioners associated with high patient mortality, albeit after sophisticated statistical analysis, should not be labelled as having poor performance but instead should be considered as a signal meriting scientific investigation.