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Press releases Saturday 16 April 2005

Please remember to credit the BMJ as source when publicising an article and to tell your readers that they can read its full text on the journal's web site (http://bmj.com).

(1) CAN HOSPITAL DATA DETECT POOR PERFORMING DOCTORS?

(2) ONE-METER WAISTLINE PREDICTS HIGH RISK OF DIABETES AND HEART DISEASE

(3) STEADY RISE IN ALLERGIC DISEASES OVER QUARTER OF A CENTURY

(4) ADOLESCENT HEALTH ILL-CATERED FOR IN THE NHS

(1) CAN HOSPITAL DATA DETECT POOR PERFORMING DOCTORS?

Online First
(Was Rodney Ledward a statistical outlier? Retrospective analysis using routine hospital data to identify gynaecologist' performance)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38377.675440.8F

Can routine hospital data be used to detect poor quality service delivery among surgeons?

For over 20 years, routine data sources such as the hospital episode statistics have been widely perceived as being of little value because of problems with completeness and accuracy, and the Department of Health has in the past dismissed their use for identifying poor quality services.

But, despite these concerns, hospital episode statistics data were used to investigate hospital level death rates after heart surgery in the Bristol inquiry, and more recently death rates for individual cardiac consultants have been published.

A paper published online by the BMJ today extends this theme to more general measures of clinical quality where death may not be the outcome.

The authors investigated whether routinely collected data from hospital episode statistics could be used to identify the gynaecologist Rodney Ledward, who was suspended in 1996 and was the subject of the Ritchie inquiry into quality and practice within the NHS.

The research team compared the performance of 142 gynaecology consultants with the performance of Ledward over a five year period, to determine if Ledward was a statistical outlier according to seven indicators from hospital episode statistics. The indicators were specifically chosen for their potential link with poor quality of service.

Their analysis identified Ledward as an outlier in three of the five years. Eight other consultants were also identified as outliers, but the researchers strongly caution against over-interpreting these consultants as having "poor" performance because valid reasons may exist that could credibly explain their results.

For example, cancer specialists may have high values for several indicators (such as surgical complications and long stays in hospital) because they carry out difficult operations on very ill patients, say the authors. The method therefore needs to be refined to deal with case mix variation.

The authors also warn of the potential limitations of statistics, including missing or poor quality data that can hamper all analyses, and they stress that the interpretation of outlier status is still as yet unclear. They recommend a structured approach to seeking explanations for outlier status.

"Further evaluation of our method is warranted, but our overall approach may be potentially useful in other settings, especially where performance entails several indicator variables," they conclude.

Contact:

Mike Harley, Director, Inter-Authority Comparisons and Consultancy, Health Services Management Centre, University of Birmingham, UK
Email: m.j.harley@bham.ac.uk

(2) ONE-METER WAISTLINE PREDICTS HIGH RISK OF DIABETES AND HEART DISEASE

Online First
(Use of waist circumference to predict insulin resistance: retrospective study)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38429.473310.AE

People with a waistline of one meter or more are at serious risk of insulin resistance - an early stage in the development of diabetes and heart disease, finds a study published online by the BMJ today.

No easy test exists for predicting the insulin resistance of an individual. Current guidelines suggest a cut-off for heart disease of 102 cm in men and 88 cm in women, but there are questions over the accuracy of these figures. So researchers in Sweden set out to assess the ability of different body measurements and biological markers to predict insulin sensitivity.

Their study involved 2,746 healthy male and female volunteers aged between 18-72 years with body mass indexes from 18-60 kg/m2 and waist circumferences from 65-150 cm.

Height, weight, waist and hip circumference were measured and a blood sample was taken to determine insulin sensitivity. Statistical modelling was then used to assess the predictive power of each variable

Waist circumference was a very strong independent predictor of insulin sensitivity. A waist circumference of less than 100 cm excluded insulin resistance in both sexes. It replaces body mass index, waist:hip ratio, and other measures of total body fat as a predictor of insulin resistance, say the authors.

Waist circumference is a simple tool to exclude insulin resistance and to identify those at greatest risk (therefore those who would benefit most from lifestyle changes), they conclude.

Contact:

Hans Wahrenberg, Associate Professor, Department of Medicine, Karolinska University Hospital, Stockholm, Sweden
Email: hans.wahrenberg@medhs.ki.se

(3) STEADY RISE IN ALLERGIC DISEASES OVER QUARTER OF A CENTURY

Online First
(Changes in atopy over a quarter of a century, based on cross sectional data at three time periods)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38435.582975.AE

The rate of allergic diseases (atopy) in adults has steadily increased over the last quarter of the 20th century, but the reason for the increase is still unknown, according to a study published online by the BMJ today.

Researchers analysed blood samples from 513 middle-aged men attending a medical centre for a routine examination between 1996 and 1998. The samples were then matched to those from 513 men seen in 1981-2 and 513 seen in 1975-6.

All samples were tested for sensitivity to Phadiatop - a standard preparation of 11 common allergens such as grass pollen, pet dander (skin flakes) and house dust mite.

Positive samples were re-tested for levels of specific IgE (an immune system response) to three inhaled allergens ? grass and tree pollen, and cat dander. The samples were also tested for antibodies to hepatitis A and to H. Pylori infections.

The team found highly significant increases over time in the proportion of men testing positive to Phadiatop and with specific IgE to the three inhaled allergens. The average rate of increase was equivalent to an additional 4.5% of men becoming Phadiatop positive each decade.

There was no tendency for atopy to decline as men grew older. There was also no link between past infections and adult atopy.

These data show that atopy in middle aged men has increased during the last quarter of the 20th century, and that the prevalence of atopy does not decline with increasing age, as previous studies have suggested, say the authors.

The reason for the increase in atopy is unknown, but it is unlikely to be due to either an increased exposure to specific allergens or to declining childhood infections, they conclude.

Contact:

Professor Malcolm Law, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, London, UK
Email: m.r.law@qmul.ac.uk

(4) ADOLESCENT HEALTH ILL-CATERED FOR IN THE NHS

(Young people's health: the need for action)
http://bmj.com/cgi/content/full/330/7496/901

The NHS must overhaul its approach to adolescent health if it is to meet the health needs of young people in the UK, says a paper in the BMJ this week.

While the health of children and older people has improved considerably, young people have fallen through the gap in targeted services, argues Dr Russell Viner, the UK's only consultant in adolescent medicine.

Mortality rates for adolescents from injury and suicide have increased fivefold over the last century - rising from 11% of total deaths for 15-19 year olds in 1901-10, to 57% in 2003. Rates of obesity, sexually transmitted infections, smoking and teenage pregnancies among adolescents have also increased or shown no improvement over the last twenty years.

"Adolescence is a critical period for engaging the population in health" says Dr Viner, as behaviour and attitudes towards health are maintained into adulthood. Yet current strategies do not target young people appropriately, and do not engage them with their own healthcare. Existing policies also ignore health inequalities - which have a considerable influence on adolescent health, he argues.

Young people must be recognised as a distinct group in devising public health policies, says Dr Viner, and staff must be properly skilled to address their health needs. The exclusive focus on one issue or target - such as teenage pregnancy - misses the other influencing factors in adolescent behaviours, so approaches must be developed which cross education, social services and the justice system.

At the age of 14-15 adolescents should also be "re-registered" with general practitioners, allowing them to establish a relationship with their GP outside of the family context, says Dr Viner. New health services designed for and by young people - including sexual health and counselling services - should also be developed in urban areas.

Investment in improving adolescent health is an essential component of improving the health of the whole population, and ensuring that we can afford the NHS in twenty years time, he concludes.

Contact:

Dr Russell Viner, Consultant in Adolescent Medicine, Institute of Child Health, University College London, UK
Email: r.viner@ich.ucl.ac.uk

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