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(1)Publishing
surgeons' performance may encorage risk
averse behaviour
(2) Emergency treatment for chest pain saves lives
(3) Helping people quit remains a challenge
(1)Publishing
surgeons' performance may encorage risk
averse behaviour
(Surgeon specific mortality
in adult cardiac surgery:
comparison between
crude and risk stratified data )
http://bmj.com/cgi/content/full/327/7405/13
Publishing the performance
of individual surgeons using
crude figures on death rates
(as is planned in the United
Kingdom) can be misleading
and is not in the best
interests of patients, conclude
researchers in this week's
BMJ.
All 8,572 patients undergoing
heart bypass surgery for
the first time between April
1999 and March 2002 in
north west England were
included in the study. Crude
mortality for each surgeon
and predicted mortality for
each patient was calculated
using a recognised scoring
system. Mortality was defined
as any in-hospital death.
A total of 23 surgeons performed
these operations.
Observed mortality between
surgeons ranged from 0%
to 3.7% while predicted
mortality ranged from 2% to
3.7%. Most (85%) of patients
had a low predicted
mortality. Differences in
predicted mortality between
surgeons were due to a small
proportion of high risk
patients.
Crude comparisons of death
rates are unfair and may
encourage surgeons to practise
risk averse behaviour,
say the authors. Cardiac
surgeons already work in a
stressful environment, and
the perception that a "bad
run" might jeopardise their
career may lead to a
tendency to turn down high
risk patients.
Instead, they recommend a
comparison of death rates
based on low risk patients
as the national benchmark
for assessing consultant
specific performance.
Contact:
Ben Bridgewater, Consultant
Cardiac Surgeon, South
Manchester University Hospital,
Manchester
Email: ben.bridgewater@smuht.nwest.nhs.uk
(2) Emergency treatment for chest pain saves lives
(Prospective observational
cohort study of time saved
by prehospital thrombolysis
for ST elevation myocardial
infarction delivered
by paramedics)
http://bmj.com/cgi/content/full/327/7405/22
(Safety and feasibility
of prehospital thrombolysis carried
out by paramedics)
http://bmj.com/cgi/content/full/327/7405/27
(Editorial: Prehospital
thrombolysis)
http://bmj.com/cgi/content/full/327/7405/1
A system whereby paramedics
administer anti-clotting
drugs to patients with emergency
chest pain
(thrombolysis) before they
reach hospital is safe,
feasible, and saves lives,
according to two studies in this
week's BMJ.
This system also meets the
UK target of a "call to
needle time" (from the initial
call for help to treatment)
of less than 60 minutes.
The first study involved
201 patients with emergency
chest pain living in the
catchment area of a large
teaching hospital in Scotland.
Patients either received
thrombolytics in hospital
or were treated by paramedics
in ambulances before they
arrived in hospital.
The average call to needle
time for patients treated
before reaching hospital
was 52 minutes, while patients
from similar rural areas
who were treated in hospital
had an average time of 125
minutes. Patients from
urban areas waited an average
of 80 minutes for
treatment.
Pre-hospital thrombolysis
saved an average of 73
minutes over patients from
rural areas and 28 minutes
over patients from urban
areas, say the authors. "Our
data show a time saving
of more than one hour in the
prehospital group, we might
expect two extra lives
saved per 100 patients treated."
The second study shows that
paramedics can safely
administer thrombolysis
in the community. All 64
paramedics serving South
Devon Healthcare Trust were
trained to diagnose heart
attack and assess suitability
for thrombolysis.
The goal of call to needle
time in less than 60 minutes
was met in 95% of cases,
and 22% of patients would
have received thrombolysis
within 60 minutes of onset
of symptoms. At present
only 3% do so, say the
authors.
"Autonomous paramedic prehospital
thrombolysis
seemed feasible and safe
and was associated with
improved call to needle
times," they conclude.
Contacts:
Paper 1: David Pedley, Specialist
Registrar in Accident
& Emergency, Ninewells
Hospital and Medical School,
Dundee, Scotland
Email: david.pedley@tuht.scot.nhs.uk
Paper 2: Phil Keeling, Consultant
Cardiologist, South
Devon Healthcare Trust,
Torquay, Devon, UK
Email: phil.keeling@nhs.net
(3) Helping people quit remains a challenge
(Abstinence from smoking
eight years after participation
in randomised controlled
of nicotine patch)
http://bmj.com/cgi/content/full/327/7405/28
Over half the people who
stopped smoking for a year
during a trial of nicotine
replacement therapy were still
not smoking eight years
later, according to a study in
this week's BMJ. But these
long-term quitters
represented only 5% of all
those who had entered the
trial, suggesting a need
to find more effective ways to
help people to give up smoking.
A total of 1,625 general
practice patients smoking at
least 15 cigarettes a day
took part in a trial of the
nicotine patch in 1991-2,
of whom 840 completed a
follow-up questionnaire
about smoking in 1999-2000.
It was assumed that those
lost to follow up were still
smoking.
Of the 153 (9%) patients
who had stopped smoking for
a year in the original trial,
83 were still not smoking at
follow up, giving an eight
year abstinence rate of 5%
and a relapse rate of 46%.
Although the patch
increased the odds of quitting
for eight years by 39%,
this increase was not statistically
significant.
Of the 1,472 who did not
quit for a year in the trial, 89
(6%) had not smoked for
a year or more at follow up.
Overall at follow up therefore,
11% of trial participants
had not smoked for a year
or more. Another 2% had
quit for less than a year,
and 88% were still smoking.
Finding more effective ways
to help people give up
smoking remains an ongoing
challenge.
Contact:
Patricia Yudkin, Reader in
Medical Statistics,
Department of Primary HealthCare,
University of
Oxford, Institute of Health
Sciences, Oxford
Email: pat.yudkin@dphpc.ox.ac.uk
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