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Press releases Saturday 11 March 2006

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(1) FALLING BLOOD PRESSURE NOT DOWN TO DRUGS, SAY EXPERTS

(2) WARNING OVER “POOR SURGERY” AT PRIVATE TREATMENT CENTRES

(3) POOR CLINICAL HANDOVER THREATENING PATIENT CARE

(4) CONCERN OVER RAPID RISE OF CHRONIC KIDNEY DISEASE

(1) FALLING BLOOD PRESSURE NOT DOWN TO DRUGS, SAY EXPERTS

Online First
(Pattern of declining blood pressure across replicate population surveys of the WHO MONICA project, mid-1980s to mid-1990s, and the role of medication)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38753.779005.BE

Blood pressure lowering drugs were not responsible for the population decline in blood pressure seen in many countries in the mid-1980s to the mid-1990s, concludes a study published online by the BMJ today.

Blood pressure is a key risk factor for coronary heart disease. Levels are declining in many industrialised countries, but the mechanism is not known.

There are two possible patterns of blood pressure fall in the population. In one, doctors target people with high readings for treatment, leaving others alone. The other, mass population change (from diet, lifestyle or, environmental factors) sees falls in middle and low readings as well. Both change the population average.

So did blood pressure fall from mass population change, or was it pushed down by drugs?

To answer this question, researchers analysed patterns of blood pressure decline, pooling results collected across 38 populations in 21 countries from the mid-1980s to mid-1990s in the World Health Organisation MONICA (monitoring) study.

Averaged results from the 38 populations showed that blood pressure fell equally at all levels of readings. So, better antihypertensive medication made no detectable contribution to the population decline in blood pressure in the mid-1980s to mid-1990s, say the authors.

They suggest that determinants of blood pressure decline other than medication must have been more pervasive and powerful in the population as a whole during that decade but they cannot say exactly what these were.

These findings do not deny the importance of antihypertensive medication in the individual, but are important in understanding blood pressure as a challenge to public health, they conclude.

Contact:

Professor Hugh Tunstall-Pedoe, Cardiovascular Epidemiology Unit, Ninewells Hospital & Medical School, Dundee, Scotland, UK
Email: h.tunstallpedoe@dundee.ac.uk

(2) WARNING OVER “POOR SURGERY” AT PRIVATE TREATMENT CENTRES

(Personal View: Independent sector treatment centres: how the NHS is left to pick up the pieces)
http://bmj.com/cgi/content/full/332/7541/614

NHS surgeons are being left to “pick up the pieces” after poor surgery at private treatment centres, warns a senior doctor in this week’s BMJ.

“The number of patients we are seeing with problems resulting from poor surgery is too great,” argues Angus Wallace, Professor of Orthopaedic Surgery at the University of Nottingham.

There is no doubt that the expansion of orthopaedic services, provided by the Department of Health through private hospitals and independent sector treatment centres (ISTCs), has been a much needed development, but it has occurred at a price, he writes.

What has happened in ISTCs is that junior specialists have been imported from overseas and asked to provide total surgical care without help and supervision from a more senior colleague, a situation that is alien to many of them - hence the reason why the failures find their way to the NHS hospitals.

He suggests that this situation has arisen because of a political philosophy called “additionality.” When ISTCs were set up, there was concern that their development might result in NHS hospitals losing some of their own surgical staff. To ensure that this could not happen a six-month rule was imposed - an NHS surgeon could not work in an ISTC until he or she had stopped working for the NHS for six months.

While this ensured that the NHS hospitals were protected from losing their own staff, it also meant that the ISTCs did not have access to many, or any, senior surgeons who could act as senior consultants and help their colleagues when they ran into trouble.

“Now we are seeing the consequences of this philosophy - poor operations, inadequate supervision of surgeons, and a poor mechanism for remedying any problems that occur,” writes Wallace.

There are also concerns about how clinical governance and appraisal procedures are being addressed in ISTCs, creating a suspicion by NHS staff that corners have been cut in achieving the goals of high productivity and throughput.

But perhaps the issue that should be of most concern is that of training the country’s up and coming surgeons, adds the author. The “straightforward” cases, now dealt with by the ISTCs, had been the cases on which young NHS surgeons learnt their craft. This time honoured and soundly proven method of training has now, sadly, been denied. Consequently the competence of our next generation of surgeons is in jeopardy.

“We, as NHS staff, need to help, and many of us wish to, but we are frustrated by the artificially created divide between the ISTC and the NHS hospital,” he says. “The government has created a two-level health service that is creating many problems. I believe that we should now integrate the ISTCs with the NHS instead of running them as a private healthcare system paid for by the state.”

Contact:

Angus Wallace, Professor of Orthopaedic and Accident Surgery, Queen’s Medical Centre, University of Nottingham, UK
Email: angus.wallace@rcsed.ac.uk

(3) POOR CLINICAL HANDOVER THREATENING PATIENT CARE

(Letter: “That’s all I got handed over”)
http://bmj.com/cgi/content/full/332/7541/610

Poor clinical handover in hospitals is rendering the system prone to misses and near misses, warn doctors in a letter to this week’s BMJ.

The introduction of the European Working Time Directive has led many UK hospitals to move to full or partial shift systems. The feasibility of shift systems hinges on safe and effective clinical handover.

The Department of Health’s Hospital at Night report highlights clinical handover as a “critical element of the model,” yet it recommends only that medical and surgical handovers should be combined, that it should be clear who is leading the handover, that all team members should attend, and that handover should take place in a dedicated room.

During 2005, researchers surveyed house officers on call in general surgery in the 17 hospitals in Wales.

In six hospitals there was no allocated place for handover, and in none of the hospitals was handover bleep-free and uninterrupted. Allocated handover time was no longer than 30 minutes in 16 hospitals and no longer than 20 minutes in 11.

Only two hospitals had developed a handover proforma, giving information such as outstanding investigations and patient reviews. Instead, personal lists were used in most hospitals, with the potential of patients being lost if lists are mislaid.

Six house officers never, and five only sometimes received feedback of their management decisions at handover. Eight of them never or rarely presented to the consultant on call.

The benefit to the patient of being treated by less tired doctors who work in shifts is offset by information breakdown due to poor handover, rendering the system prone to misses and near misses, warn the authors.

They favour a post-take bedside ward round, not only from a medicolegal point of view, but also as an opportunity for bedside teaching and learning by giving feedback to the outgoing team. And they suggest that the leadership of senior doctors in the handover process would be of great benefit.

Rotas may also need to be adjusted to allow sufficient overlap between junior doctors’ shifts and senior doctors’ working days, they conclude.

Contact:

Breden O'Riordan, Consultant surgeon, West Wales General Hospital, Carmarthen, Wales

Ludger Barthelmes, Specialist registrar, West Wales General Hospital, Carmarthen, Wales
Email: barthelmes@tinyonline.co.uk

(4) CONCERN OVER RAPID RISE OF CHRONIC KIDNEY DISEASE

(Editorial: The burden of chronic kidney disease)
http://bmj.com/cgi/content/full/332/7541/563

Chronic kidney disease is rising rapidly worldwide and is becoming a global healthcare problem, warn experts in this week’s BMJ.

In the United Kingdom, the annual incidence of end stage renal disease is around 100 per 1,000,000 population. This figure has doubled over the past decade and is expected to continue to rise by 5-8% annually, but it still remains well below the European average (around 135/1,000,000) and that of the United States (336/1,000,000).

The rise in end stage renal disease worldwide probably reflects the global epidemic of type 2 diabetes and the ageing of the populations in developed countries (the annual incidence in people over 65 in the UK is greater than 350/1,000,000, and in the US it is greater than 1,200/1,000,000).

The number of people with diabetes worldwide, currently around 154 million, is also set to double within the next 20 years, and the increase will be most notable in the developing world, where the number of patients with diabetes is due to reach 286 million by 2025.

The cost of treating end stage renal disease is substantial and poses a great challenge to provision of care. In Europe, less than 0.1% of the population needs renal replacement therapy, which accounts for 2% of the healthcare budget. In the US, the annual cost of treatment for end stage renal disease is expected to reach $29 billion by 2010. Few countries will be able to meet these growing medical and financial demands.

More than 100 developing countries, with a population in excess of 600 million, do not have any provision for renal replacement therapy. Consequently, more than a million people may die every year worldwide from end stage renal disease.

Programmes to detect chronic kidney disease, linked to comprehensive primary and secondary prevention strategies, are needed urgently, say the authors.

Mass population screening for chronic kidney disease is neither practical nor likely to be successful or cost effective. But structured and well resourced programs targeting at risk individuals, such as those suffering from diabetes and hypertension, along with primary prevention programmes based on reducing risk factors across the whole population could make a big difference.

The authors believe that such an approach to risk reduction may slow or even reverse declining renal function.

Contact:

Professor Meguid El Nahas, Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Email: M.el-nahas@sheffield.ac.uk

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