100 apples divided by 15 red herrings: a cautionary tale from the mid-19th century on comparing hospital mortality rates

Ann Intern Med. 1996 Jun 15;124(12):1079-85. doi: 10.7326/0003-4819-124-12-199606150-00009.


In 1863, Florence Nightingale argued that London hospitals were dangerous, especially compared with provincial facilities. She bolstered this contention with statistics published in William Farr's Registrar-General report which claimed that 24 London hospitals had mortality rates exceeding 90%, whereas rural hospitals had an average mortality rate of 13%. Farr had calculated mortality rates by dividing the total number of patients who died throughout the year by the number of inpatients on a single day. When calculated as the annual number of deaths divided by the total number of inpatients during the year, the mortality rate of London hospitals was 10%. A raucous debate erupted in the London medical press over how best to calculate hospital mortality rates. Critics claimed that Farr had not adjusted for differences in severity of illness between urban and rural hospitals and that his figures would mislead the public. Farr and Nightingale, in turn, criticized the poor quality of hospital data. This story reinforces the need to understand the methodologic derivation of statistics intended to compare provider quality.

Publication types

  • Historical Article

MeSH terms

  • England
  • History, 19th Century
  • History, 20th Century
  • Hospital Mortality*
  • Hospitals, Rural / history*
  • Hospitals, Rural / statistics & numerical data
  • Hospitals, Urban / history*
  • Hospitals, Urban / statistics & numerical data
  • Humans
  • Statistics as Topic / history
  • Statistics as Topic / standards
  • United States