Press releases Monday 10 May to Friday 14 May 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) Removal of financial incentives for clinical quality linked to poorer performance (2) Community programme halves fall rate among older people (3) Are enhanced pharmacy services value for money? (4) Low umbilical cord pH at birth linked to death and brain damage (5) New collaboration with Cleveland Clinic offers online medical education credits to BMJ readers
(1) Removal of financial incentives for clinical quality linked to poorer performance
(Research: The impact of removing financial incentives from clinical quality indicators: longitudinal analysis of four Kaiser Permanente indicators)
http://www.bmj.com/cgi/content/abstract/bmj;340/may11_1/c1898
The removal of financial incentives attached to measures of clinical quality is associated with slight drops in performance levels, according to research published on bmj.com today.
Since 2004, UK GPs have received payments based on a range of indicators of clinical quality, eight of which are due to be removed in 2011. While existing research indicates that financial incentives lead to improvements in quality, there are few data on the effect of their removal.
Researchers evaluated the effect of financial incentives in 35 Kaiser Permanente facilities in California, which provided both general and speciality care. They examined quality indicators for diabetes retinopathy screening, cervical cancer screening, glycaemic control for diabetes, and hypertension control.
During the study period - 1997 to 2007 - financial incentives were removed for diabetic retinopathy screening and cervical screening. Over the five years where financial incentives were attached to it, retinopathy screening rates rose from 84.9% to 88.1%. Over the following four years without incentives they fell year on year to 80.5%.
Rates of cervical screening rose slightly over the two initial years when financial incentives were attached, and fell during the five years when they were removed. Incentives were then reattached for two years, and rates began to climb once more.
Diabetes glycaemic control was not incentivised during 1999 and 2000 when levels of achievement were 44.2% and 46.85% respectively. Performance continued to improve following the introduction of incentives in 2001. Hypertension control was incentivised throughout the study period, but data was only available between 2002 and 2007, during which time performance improved.
The researchers point to limitations in the study, for example at Kaiser Permanente, doctors' income is not affected by the incentive, unlike the UK. However, if further research confirms that the removal of financial incentives means performance levels - and potentially patient care - decline, there may be practical implications for policy-makers, clinicians, and patients, they conclude.
Contact:
Helen Lester, Professor of Primary Care, NIHR School for Primary Care Research, Manchester, UK
Email: helen.lester@manchester.ac.uk
(2) Community programme halves fall rate among older people
(Research: Community falls prevention for people who call an emergency ambulance after a fall: randomised controlled trial)
http://www.bmj.com/cgi/content/abstract/bmj;340/may11_1/c2102
(Editorial: Prevention of falls in the community )
http://www.bmj.com/cgi/content/extract/340/may11_1/c2244
A community based falls prevention service reduced the rate of falls among older people by 55%, finds a study published on bmj.com today.
The service also led to increased levels of activities of daily living and reduced fear of falling.
Falls are a common and serious problem in older people. Many people who fall call an emergency ambulance, but are not transported to hospital and are not referred to a falls prevention service. Yet they remain at high risk of falling again.
So a team of researchers in Nottingham set out to evaluate whether falls could be reduced in this high risk group by a community falls prevention service.
The study involved 204 adults aged more than 60 living at home or in residential care who had fallen and called an emergency ambulance but were not taken to hospital.
Participants were given a thorough assessment at the start of the study and then randomly split into two groups. The intervention group received support from community fall teams including strength and balance training, a home hazards assessment and adaptations for the home, and practice in getting up from the floor. They also attended regular group sessions on fall prevention for further strength training and advice.
The control group received no such support and were advised to use existing social and medical services as usual.
All participants completed monthly falls diaries to monitor the rate of falls over 12 months.
The results show a 55% reduction in the rate of falls over the study period (3.5 falls per year in the intervention group compared with 7.7 falls per year in the control group). Results were similar when adjusted for factors such as sex, age, medication use, previous falls and residential status.
The intervention group were also better able to carry out usual daily activities and were less fearful of falling than the control group.
The number of participants admitted to hospital with a fracture, and the number of times an emergency ambulance was called because of a fall were also lower in the intervention group.
The authors believe this reduction to be clinically important and they call for a study of the economic consequences of these findings to be conducted.
In an accompanying editorial, Lindy Clemson, Associate Professor in Ageing at the University of Sydney, says that, although such interventions are successful in trial settings, their uptake in practice has been remarkably slow and inconsistent. She concludes: "Further studies are needed to assess the barriers and facilitators to implementing falls prevention programmes in the community, and how to make these programmes sustainable."
Contacts:
Research: Philippa Logan, Postdoctoral Researcher and Occupational Therapist, School of Community Health Sciences, University of Nottingham, UK
Email: pip.logan@nottingham.ac.uk
Editorial: Lindy Clemson, Associate Professor in Ageing, Faculty of Health Sciences, University of Sydney, NSW, Australia
Email: lindy.clemson@sydney.edu.au
(3) Are enhanced pharmacy services value for money?
(Analysis: Community pharmacy: moving from dispensing to diagnosis and treatment)
http://www.bmj.com/cgi/content/extract/bmj;340/may11_1/c2298
Recent changes to the NHS community pharmacy contract in England and Wales have led to a range of services, like smoking cessation and supervised methadone administration, which were once the reserve of general practitioners but which will now be provided through a private market dominated by large corporations.
But are these enhanced services value for money and what are their implications for patient care? Two public health specialists discuss the issues in a paper published on bmj.com today.
In 2005, the government argued that expanding the range of services provided by private for-profit community pharmacies would increase access and patient choice, reduce general practitioner workload, and lower costs to the NHS. The UK general medical services contract and the pharmacy contract allows a shift of NHS services from general practice to private for-profit community pharmacies in England.
But Elizabeth Richardson and Allyson Pollock from the University of Edinburgh say that a lack of centrally collected data "makes it difficult to draw general conclusions about their effectiveness and efficiency."
"Value for money is also difficult to determine," they add, "because the true costs of providing pharmaceutical services are obscure, especially in relation to premises and staff."
While good evidence supports the provision of some extended services, like smoking cessation and emergency hormone contraception supply, the evidence base on value for money and effectiveness of more complex services - such as opportunistic screening and minor ailment clinics - is limited and more research is needed, they argue.
They point to commercial conflicts of interest which, they say, are at odds "with public health priorities" and could undermine pharmacists' professional role. There is a risk too that, as more services are contracted out from the NHS, the boundaries between public and private funding and provision will also become blurred and difficult and costly to monitor and regulate.
As the health systems of Scotland, England, and Wales diverge it will be important to monitor these market oriented changes and their implications for the NHS and its patients, write Richardson and Pollock.
They conclude: "The absence of national data, central monitoring, and research into these changes means that the effectiveness, equity, efficiency, value for money, and above all the implications for access, safety, and quality of patient care are not known."
Contact:
Allyson Pollock, Centre for International Public Health Policy, University of Edinburgh, Scotland, UK
Email: allyson.pollock@ed.ac.uk
(4) Low umbilical cord pH at birth linked to death and brain damage
(Research: Strength of association between umbilical cord pH and perinatal and long term outcomes: systematic review and meta-analysis)
http://www.bmj.com/cgi/content/abstract/340/may13_1/c1471
(Editorial: Umbilical cord blood gas analysis)
http://www.bmj.com/cgi/content/extract/340/may13_1/c1720
Low umbilical cord blood pH at birth is strongly associated with serious outcomes such as infant death, brain damage and the development of cerebral palsy in childhood, concludes a study published on bmj.com today.
This is the first BMJ research paper to carry a continuing medical education (CME) credit through a new collaboration between the BMJ and Cleveland Clinic (more details below).
The researchers say these findings justify increased surveillance of babies born with a low cord pH and call for further research to explore whether all babies should have their umbilical cord blood tested.
For some time, doctors have thought there might be a link between umbilical artery pH and adverse outcomes. This stems from the fact that, if a baby is deprived of adequate oxygen during labour (hypoxia), the pH of blood in the umbilical cord drops. Hypoxia is the most common cause of brain damage and premature or very small babies are at most risk.
But so far, the evidence for such a link has been inconsistent. Current guidelines also question whether umbilical artery pH can accurately predict infant death or the development of cerebral palsy.
So a team of researchers based in Birmingham analysed the results of 51 studies, involving almost half a million babies, to evaluate the strength of the association. Study quality was variable, but this did not seem to influence the overall results.
They found that low arterial umbilical cord pH had a strong and consistent association with infant death and brain damage as well as cerebral palsy in childhood.
Based on these findings, they call for increased surveillance of babies born with a low arterial cord pH, and for further research to explore the cost effectiveness of doing this test in all babies.
In an accompanying editorial, James Neilson, Professor of Obstetrics and Gynaecology at the University of Liverpool, says that, given the findings of this study, "we should aim to reduce the number of babies born with a low cord pH, without increasing unnecessary obstetric intervention." He hopes that this can be achieved by more hands-on input to labour ward care by fully trained obstetric specialists and the use of computerised intelligent systems to guide decision making by obstetricians and midwives.
In the meantime, he supports current recommendations that umbilical cord blood should only be tested when there has been concern about the baby either in labour or immediately following birth.
Contacts:
Research: Gemma Malin, Academic department of Obstetrics and Gynaecology, Birmingham Women's Hospital, Edgbaston, Birmingham, UK
Email: g.l.malin@bham.ac.uk
Editorial: James Neilson, Professor of Obstetrics and Gynaecology, University of Liverpool, Liverpool, UK
Email: jneilson@liv.ac.uk
(5) New collaboration with Cleveland Clinic offers online medical education credits to BMJ readers
(Editorial: Continuing medical education for BMJ readers)
http://www.bmj.com/cgi/content/extract/340/may13_1/c2410
The BMJ has joined forces with the Cleveland Clinic in the US to offer certified continuing medical education (CME) credits to all of its readers.
Both parties have long histories of involvement in the education of doctors. The BMJ publishes articles that help doctors make better decisions, while the Cleveland Clinic's Center for Continuing Education has emerged as one of world's largest academic providers of continuing medical education.
This collaboration will therefore benefit doctors and other health professionals around the world.
The programme will start with modules linked to BMJ research articles, chosen for their focus on important and clinically relevant questions, and whose findings are applicable to a wide cross section of readers.
"Because these are open access, this allows us to make CME activities available to all doctors and other health professionals wherever they are in the world and whether or not they subscribe to the BMJ," explains Steven Kawczak, Associate Director at the Cleveland Clinic Centre for Continuing Education. "In time we plan to extend CME credits to other content on bmj.com, including clinical reviews, practice articles, and editorials."
The Cleveland Clinic's CME accreditation will ensure that BMJ CME meets demanding standards of effective educational planning and design as well as independence from commercial interests.
Readers will be able to claim credit toward the American Medical Association Physician's Recognition Award (AMA PRA Category 1 Credit™) for each module they pass. This involves reading the research article online and completing a set of multiple choice questions hosted on BMJ Learning (http://www.bmjlearning.com).
Once readers have achieved an 80% pass on the test, they can claim their credit and the Cleveland Clinic will provide them with a CME certificate. If they fail the test initially, they can retake it until they pass. The Cleveland Clinic will also maintain a record of which modules readers have completed.
"We hope you will try this new approach to online continuing medical education and that you will give us your feedback, so that we too can continue to improve on what we provide," say Steven Kawczak and Kirsten Patrick, Assistant Editor at the BMJ.
Contact:
Kirsten Patrick, Assistant Editor, BMJ, London, UK
Email: kpatrick@bmj.com
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Email: edickinson@bma.org.uk
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