This week in the BMJ
Volume 327, Number 7405, Issue of 5 Jul 2003Risk stratified rates better than surgeon specific mortality data
Risk stratified rates better than surgeon specific mortality data
Crude comparisons of surgeon specific death rates can be misleading, and release of such information into the public domain may encourage surgeons to practise risk averse behaviour. Bridgewater and colleagues (p 13) analysed data for 8572 patients who had had isolated bypass graft surgery for the first time during 1999-2002 in the north west of England. They found that most of the predicted variability in death rates among surgeons was due to a small but differing number of high risk patients. The authors recommend a comparison of death rates that is stratified by risk and based on low risk cases as the national benchmark for assessing consultant specific performance.
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Risk of liver injury from NSAIDs is small
The risk of hepatotoxicity associated with non-steroidal anti-inflammatory drugs, including nimesulide, is small. A five year retrospective cohort study by Traversa and colleagues looked at almost 2 million prescriptions in the Umbria region of Italy (p 18). It found no significant increase in risk when the incidence of hepatopathy among users of nimesulide was compared with other non-steroidal anti-inflammatory drugs. Nimesulide has been withdrawn from use in Finland and Spain because of reported increases in liver injury.
Respiratory vaccine for infants is still a long way off
Viral infections of the lower respiratory tract impose a considerable burden on healthcare budgets. Van Wonsel and colleagues (p 36) review their epidemiology, symptoms, and treatment in infections in young children. They conclude that viral lower respiratory tract infections are mild and self limiting in most cases, and that treatment is mainly supportive, but varies widely worldwide. Apart from influenza vaccine, research into vaccination has mainly focused on respiratory syncytial virus. Although progress has been made, particularly with live attenuated vaccines, it will be another decade before routine vaccination is available.
Prehospital thrombolysis by paramedics saves time
Early thrombolysis for acute myocardial infarction has been shown unequivocally to improve outcome, but the current national target of delivery of thrombolysis in less than 60 minutes is difficult to meet in rural areas. Pedley and colleagues (p 22) report on a system of prehospital thrombolysis delivered by paramedics, with remote decision support provided by the local accident and emergency department using a mobile telemetry link. This resulted in a reduction in median call to needle time for rural patients of 73 minutes compared with a similar group of patients treated in the conventional manner. In another paper this week, Keeling and colleagues (p 27) report that autonomous prehospital thrombolysis can be effectively and safely administered by paramedics. Their feasibility study showed an average time saving of 48 minutes from the call to drug administration.
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Effectiveness of nicotine patches is overstated
Former smokers using nicotine patches often return to smoking. In an eight year follow up of people who took part in a randomised trial of the patch, Yudkin and colleagues (p 28) report that nearly half of those who had given up smoking for a year in the original trial had taken it up again, and that relapse rates were similar in nicotine patch and placebo groups. The cost effectiveness of nicotine replacement therapy is therefore overestimated when it is based on relatively short term results. Of all trial entrants, 88% were smoking eight years later, underlining the difficulty that smokers have in giving up.
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Complications of mastoiditis are rare but life threatening
Partially treated mastoiditis can mask the classic symptoms of intracranial and extracranial complications. Jose and colleagues (p 41) report two cases of lateral sinus thrombosis and a case of Bezold's abscess, which emphasise the importance of a high index of suspicion in patients with ear infections that fail to respond predictably. The authors say that magnetic resonance imaging is better than computed tomography in identifying intracranial complications.
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Knowledge translation helps close a gap
When education and persuasion of doctors cannot close the gap between evidence and practice, "knowledge translation" may — by including groups other than doctors and investigating issues more comprehensively than the educational strategies of CME and CPD. This system of exchange, synthesis, and ethically sound application of knowledge can capture the benefits of research, say Davis and colleagues (p 33). They present a model containing interventions that might be effective at various stages of the change process, which could promote the rapid uptake of evidence based knowledge.
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