Press releases Monday 19 April to Friday 23 April 2010

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

(1) Concern over hearing loss from personal music players
(2) Using death rates to judge hospital performance "a bad idea"
(3) Computer model better than clinical judgement for diagnosing fever in young children
(4) Men from deprived areas less likely to be treated for prostate cancer

(1) Concern over hearing loss from personal music players
(Editorial: Hearing loss and personal music players)
http://www.bmj.com/cgi/content/full/340/apr19_2/c1261

Young people who listen to personal music players for several hours a day at high volume could be putting their hearing at risk, warns an expert in an editorial published on bmj.com today.

Professor Peter Rabinowitz from Yale University School of Medicine says that personal music devices such as MP3 players can generate levels of sound at the ear in excess of 120 decibels, similar in intensity to a jet engine, especially when used with earphones that insert into the ear canal.

The use of these devices is high in young people - more than 90% in surveys from Europe and the United States - and "has grown faster than our ability to assess their potential health consequences," he writes.

However, evidence that music players are causing hearing loss in young people is mixed, suggesting that the true population effects may only now be starting to be detectable, says the author.

Other health effects may also need to be considered. For example, some studies have shown that use of personal music players can interfere with concentration and performance when driving, in a similar way to mobile phones.

Although evidence based guidance is lacking, Rabinowitz believes that the importance of hearing loss as a public health problem makes it reasonable to encourage patients of all ages to promote "hearing health" through avoidance of excessive noise exposure.

He also suggests it would be prudent to remove earphones while driving and performing other safety sensitive tasks, and calls for more comprehensive and ongoing surveys of the hearing health of young people.

"Personal music players provide a reminder that our hunger for new technology should be accompanied by equally vigorous efforts to understand and manage the health consequences of changing lifestyles," he concludes.

Contact:
Peter Rabinowitz, Associate Professor of Medicine and Director of Clinical Services, Yale Occupational and Environmental Medicine Program, Yale University School of Medicine, New Haven, CT, USA
Email: peter.rabinowitz@yale.edu

Mortality rates are a poor measure of the quality of hospital care and should not be a trigger for public inquiries such as the investigation at the Mid Staffordshire hospital, argue experts in a paper published on bmj.com today.

The hospital standardised mortality ratio (HSMR) is used to measure the quality and safety of hospital care in the United Kingdom and around the world. The ratio identifies hospitals where more patients die than would be expected ('bad' hospitals) and hospitals with fewer deaths than expected ('good' hospitals).

The validity of this ratio has been criticised because it may not adequately adjust for the type of patients treated at a particular hospital (case mix) or account for measurement errors between hospitals. Yet it continues to be used as a measure of quality.

Richard Lilford from the University of Birmingham and Peter Pronovost from Johns Hopkins University School of Medicine, say that "hospital mortality rates are a poor diagnostic test for quality" and "they should not be used to calculate excess deaths resulting from poor care." They point out that Mid Staffordshire hospital "was blamed for 400 excess deaths on this precarious basis."

They believe that "the practice is kept alive by well-meaning decision makers who want the idea that mortality reflects quality to be true."

There is an argument for use of hospital mortality rates as an initial signal for scientific study. But they warn that public inquiries can lead to hospitals being unjustly singled out and may undermine improvements in other areas.

The authors are not arguing that health care providers should be exempt from accountability or that patients should not be protected. On the contrary, they say "the search for robust measurements should not be impeded by fixing prematurely on a parameter that offers false hope."

As such, they strongly advocate measuring quality by observing selected outcomes (such as blood stream infection rates) that really do reflect quality of care. Above all, however, they argue for increasing use of direct measures of the quality of care by checking hospital case notes as recommended by the House of Commons Select Committee. "Examining selected case notes to ensure that the correct treatment has been given and errors avoided is much more informative than trying to pick out 'bad apples' using the blunt instrument of hospital wide mortality rates," they say.

"If we really want to improve care, then managers are going to have to learn more statistics and statisticians more management. In the meantime, performance management of medical care by hospital mortality is not the answer," they conclude.

These views are supported in an accompanying editorial which suggests turning to more specialised sources of data to measure the quality of hospital care. Professor Nick Black at the London School of Hygiene & Tropical Medicine says that a shift to this approach "would gain the credibility and support of clinicians and provide a much richer and more valid account for the public of how a hospital was performing."

This should be accompanied by the abandonment of HMSRs, which are not fit for purpose, he concludes. has its defects, it is a self correcting process. Time is, perhaps, the wisest counsellor of all," Wright concludes. "In the meantime, this case offers a salutary reminder for researchers and journal editors alike that coauthorship means bearing responsibility for what is written."

Contacts:
Analysis: Richard Lilford, Professor of Clinical Epidemiology, School of Health and Population Sciences, University of Birmingham, UK
Email: r.j.lilford@bham.ac.uk
Editorial: Nick Black, Professor of Health Services Research, London School of Hygiene & Tropical Medicine, London, UK
Email: nick.black@lshtm.ac.uk

(3) Computer model better than clinical judgement for diagnosing fever in young children
(Research: The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: prospective cohort study of 15 781 febrile illnesses)
http://www.bmj.com/cgi/content/full/340/apr19_2/c1594
(Editorial: Diagnosing serious bacterial infection in young febrile children)
http://www.bmj.com/cgi/content/full/340/apr19_2/c2062

A computerised diagnostic model outperforms clinical judgement for the diagnosis of fever in young children, and may improve early treatment, finds a study published on bmj.com today.

Fever (or febrile illness) is a common symptom in children, especially in those under five years of age, but it can be difficult to diagnose the correct cause. Yet physicians need to be able to distinguish minor viral illnesses from serious bacterial infections such as pneumonia, urinary tract infection and meningitis.

Current diagnostic processes and clinical scoring systems are often inadequate, so there is a real need for an accurate acute clinical decision making tool that takes into account all the signs and symptoms associated with serious causes of febrile illness.

So a team of researchers in Australia set out to develop and test a computerised model to distinguish serious bacterial infections from self limiting non-bacterial illnesses.

The study involved over 15,000 healthy children under five years of age presenting to the emergency department of a large children's hospital over a two-year period with a febrile illness (a body temperature of 38ºC or more in the previous 24 hours).

A standard clinical evaluation was performed by physicians and serious bacterial infections were confirmed or excluded using standard tests and follow up. The signs and symptoms noted by the physicians were then combined in a diagnostic model and the results were compared.

The data show that urinary tract infection, pneumonia and bacteraemia (bacteria in the blood) occur in about 7% of young children with a fever, but only 70-80% of these children are prescribed antibiotics on initial consultation and 20% of children without an identified bacterial infection are probably over-treated with antibiotics.

The performance of the diagnostic model for each infection was acceptable or better than physician evaluation.

The authors point out that almost all (95%) of these children had the appropriate tests, and that some doctors routinely delay giving antibiotics until test results are known, so this may help to explain the initial under-treatment. However, about two thirds of children who were not treated were subsequently prescribed antibiotics.

They conclude: "By combining routinely collected clinical information into a statistical model, we have demonstrated that a clinical diagnostic model may improve the care of children presenting with fever who have suspected serious bacterial illness."

"This study reinforces the importance of measuring vital signs and assessing a child's overall state of illness," say general practitioners Matthew Thompson and Anne Van den Bruel in an accompanying editorial. But, they caution that, "before widespread implementation, we will need to have evidence showing the effect of using such a model on patient management and outcomes."

Contact:
Research: Jonathan Craig, senior staff specialist, The Children's Hospital at Westmead and University of Sydney, Australia
Email: jonc@health.usyd.edu.au

Editorial: Matthew Thompson (via University of Oxford press office)
Email: press.office@admin.ox.ac.uk

(4) Men from deprived areas less likely to be treated for prostate cancer
(Research: Population based time trends and socioeconomic variation in use of radiotherapy and radical surgery for prostate cancer in a UK region: continuous survey)
http://www.bmj.com/cgi/doi/10.1136/bmj.c1928
(Editorial: Prostate cancer and deprivation)
http://www.bmj.com/cgi/content/full/340/apr21_4/c2043

Men living in deprived areas are far less likely to be treated with the most common types of radical treatment for prostate cancer than those in more affluent places, says a study published on bmj.com today.

A large scale study carried out by researchers from Cambridge found that patients from the most deprived areas are 26% less likely to have radiotherapy than men from the most affluent areas and 52% less likely to have radical surgery.

Prostate cancer is the most common malignancy in men and its incidence has been increasing, particularly since the late 1980s and early 1990s.

It is 20-40% more likely to happen and be noted in the most affluent areas and survival rates are also increasing to around 80% in that same socioeconomic group. It is thought this is partly due to less deprived men agreeing to prostate specific antigen (PSA) screening tests.

The researchers, led by Georgios Lyratzopoulos at the University of Cambridge, studied data on 35,171 men (aged 51 and over) between 1995 and 2006.

More detailed information about the stage of their disease was available for 15,916 men over a nine-year period from 1998 to 2006.

The men were all diagnosed with prostate cancer during this period and the researchers sought to find out what variation existed in how the cancer was managed between patients of different socioeconomic status.

The proportion of patients treated by surgery increased significantly over time from 2.9% during 1995-7 to 8.4% during 2004-6. Use of radiotherapy for patients remained stable at around 25% throughout the study period.

The researchers found that either radiotherapy or surgery was used more often in the most affluent people.

Radiotherapy was used for the most affluent people in 28.5% of cases, compared with 21% of people from the most deprived areas – a 26% difference. Similarly, surgery was used for 8.4% of the better off people, compared with just 4% of the worse off patients - a 52% difference.

This pattern persisted even when factors such as age, hospital of diagnosis and disease stage were taken into consideration.

The researchers say the causes and impact on survival of such differences between socioeconomic groups remain uncertain, and call for further research to help explain the socioeconomic differences in treatment.

In an accompanying editorial, researchers in Finland suggest that, when discussing treatment decisions, "better educated patients may process information more easily and doctor-patient communication may be more effective or fluent when doctor and patient have similar social backgrounds."

Because the reasons for these socioeconomic disparities are unclear and the best way to reduce them is unknown, future studies should investigate the contribution of various prognostic factors to differences in survival, they conclude.

Contacts:
Research: Georgios Lyratzopoulos, Senior Clinical Research Associate, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, UK
Email: gl290@medschl.cam.ac.uk
Editorial: Kari Tikkinen, Urology Resident, Department of Urology and Clinical Research Institute HUCH Ltd, Helsinki University Central Hospital, Helsinki, Finland
Email: kari.tikkinen@fimnet.fi

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Email: edickinson@bma.org.uk

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