Early In-Hospital Mortality following Trainee Doctors' First Day at Work

Background

There is a commonly held assumption that early August is an unsafe period to be admitted to hospital in England, as newly qualified doctors start work in NHS hospitals on the first Wednesday of August. We investigate whether in-hospital mortality is higher in the week following the first Wednesday in August than in the previous week.

Methodology

A retrospective study in England using administrative hospital admissions data. Two retrospective cohorts of all emergency patients admitted on the last Wednesday in July and the first Wednesday in August for 2000 to 2008, each followed up for one week.

Principal Findings

The odds of death for patients admitted on the first Wednesday in August was 6% higher (OR 1.06, 95% CI 1.00 to 1.15, p = 0.05) after controlling for year, gender, age, socio-economic deprivation and co-morbidity. When subdivided into medical, surgical and neoplasm admissions, medical admissions admitted on the first Wednesday in August had an 8% (OR 1.08, 95% CI 1.01 to 1.16, p = 0.03) higher odds of death. In 2007 and 2008, when the system for junior doctors'' job applications changed, patients admitted on Wednesday August 1^st had 8% higher adjusted odds of death than those admitted the previous Wednesday, but this was not statistically significant (OR 1.08, 95% CI 0.95 to 1.23, p = 0.24).

Conclusions

We found evidence that patients admitted on the first Wednesday in August have a higher early death rate in English hospitals compared with patients admitted on the previous Wednesday. This was higher for patients admitted with a medical primary diagnosis.     

Career destinations seven years on among doctors who qualified in the United Kingdom in 1988: postal questionnaire survey

ObjectiveTo report the career choices and career destinations in 1995 of doctors who qualified in the United Kingdom in 1988.DesignPostal questionnaire.SettingUnited Kingdom.SubjectsAll doctors who qualified in the United Kingdom in 1988.ResultsOf the 3724 doctors who were sent questionnaires, eight had died and three declined to participate. Of the remaining 3713 doctors, 2885 (77.7%) replied. 16.9% (608/3593; 95% confidence interval 16.1% to 17.8%) of all 1988 qualifiers from medical schools in Great Britain were not working in the NHS in Great Britain in 1995 compared with 17.0% (624/3674; 16.1% to 17.9%) of the 1983 cohort in 1990. The proportion of doctors working in general practice was lower than in previous cohorts. The percentage of women in general practice (44.3% (528/1192)) substantially exceeded that of men (33.1% (443/1340)). 53% (276/522) of the women in general practice and 20% (98/490) of the women in hospital specialties worked part time.ConclusionsConcerns about recruitment difficulties in general practice are justified. Women are now entering general practice in greater numbers than men. There is no evidence of a greater exodus from the NHS from the 1988 qualifiers than from earlier cohorts.

Key messages

• This study reports the career progress to September 1995 of doctors who qualified in 1988
• Loss from the British NHS, at 16.9% (95% confidence interval, 16.1% to 17.8%), was no greater than among earlier qualifiers at the same time after qualification
• The proportion of doctors working in general practice (38%) was lower than in earlier cohorts studied
• In this generation of doctors, women in general practice now outnumber men
• Fifty three per cent of the women in general practice and 20% of the women in hospital specialties were working on a part time or flexible basis

     

Influence of hospital and clinician workload on survival from colorectal cancer: cohort study

ObjectiveTo determine whether clinician or hospital caseload affects mortality from colorectal cancer.DesignCohort study of cases ascertained between 1990 and 1994 by a region-wide colorectal cancer register.ResultsOf the 3217 new patients registered over the period, 1512 (48%) died before 31 December 1996. Strong predictors of survival both in a logistic regression (fixed follow up) and in a Cox''s proportional hazards model (variable follow up) were Duke''s stage, the degree of tumour differentiation, whether the liver was deemed clear of cancer by the surgeon at operation, and the type of intervention (elective or emergency and curative or palliative intent). In a multilevel model, surgeon’s caseload had no significant effect on mortality at 2 years. Hospital workload, however, had a significant impact on survival. The odds ratio for death within 2 years for cases managed in a hospital with a caseload of between 33 and 46 cases per year, 47 and 54 cases per year, and ⩾55 cases per year (compared to one with ≤23 cases per year) were respectively 1.48 (95% confidence interval 1.03 to 2.13), 1.52 (1.08 to 2.13), and 1.18 (0.83 to 1.68).ConclusionsThere was no detectable caseload effect for surgeons managing colorectal cancer, but survival of patients treated in hospitals with caseloads above 33 cases per year was slightly worse than for those treated in hospitals with fewer caseloads. Imprecise measurement of clinician specific “events rates” and the lack of routinely collected case mix data present major challenges for clinical audit and governance in the years ahead.

Key messages

• Various benefits have been described for multidisciplinary cancer care, but the precise relation between a surgeon''s or hospital''s caseload and the outcome for the patient is not known
• Any investigation of a caseload effect at the hospital or practitioner level has to simultaneously account for each factor and adjust adequately for case mix
• Surgeon had no significant effect on caseload, but patients treated in hospitals with low caseloads (<33 cases per year) had a slightly better survival at 2 years than those treated in hospitals with a higher caseload
• Defining surgical expertise in terms of volume of activity may be a misdirected and imprecise yardstick for the quality of cancer care; other aspects of the organisation of services may be far more important

     

Confidential inquiry into quality of care before admission to intensive care

Objective: To examine the prevalence, nature, causes, and consequences of suboptimal care before admission to intensive care units, and to suggest possible solutions. Design: Prospective confidential inquiry on the basis of structured interviews and questionnaires. Setting: A large district general hospital and a teaching hospital. Subjects: A cohort of 100 consecutive adult emergency admissions, 50 in each centre. Main outcome measures: Opinions of two external assessors on quality of care especially recognition, investigation, monitoring, and management of abnormalities of airway, breathing, and circulation, and oxygen therapy and monitoring. Results: Assessors agreed that 20 patients were well managed (group 1) and 54 patients received suboptimal care (group 2). Assessors disagreed on quality of management of 26 patients (group 3). The casemix and severity of illness, defined by the acute physiology and chronic health evaluation (APACHE II) score, were similar between centres and the three groups. In groups 1, 2, and 3 intensive care mortalities were 5 (25%), 26 (48%), and 6 (23%) respectively (P=0.04) (group 1 versus group 2, P=0.07). Hospital mortalities were 7 (35%), 30 (56%), and 8 (31%) (P=0.07) and standardised hospital mortality ratios (95% confidence intervals) were 1.23 (0.49 to 2.54), 1.4 (0.94 to 2.0), and 1.26 (0.54 to 2.48) respectively. Admission to intensive care was considered late in 37 (69%) patients in group 2. Overall, a minimum of 4.5% and a maximum of 41% of admissions were considered potentially avoidable. Suboptimal care contributed to morbidity or mortality in most instances. The main causes of suboptimal care were failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice. Conclusions: The management of airway, breathing, and circulation, and oxygen therapy and monitoring in severely ill patients before admission to intensive care units may frequently be suboptimal. Major consequences may include increased morbidity and mortality and requirement for intensive care. Possible solutions include improved teaching, establishment of medical emergency teams, and widespread debate on the structure and process of acute care.

Key messages

• Suboptimal management of oxygen therapy, airway, breathing, circulation, and monitoring before admission to intensive care occurred in over half of a consecutive cohort of acute adult emergency patients. This may be associated with increased morbidity, mortality, and avoidable admissions to intensive care
• At least 39% of acute adult emergency patients were admitted to intensive care late in the clinical course of the illness
• Major causes of suboptimal care included failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice
• A medical emergency team may be useful in responding pre-emptively to the clinical signs of life threatening dysfunction of airway, breathing, and circulation, rather than relying on a cardiac arrest team
• The structure and process of acute care and their importance require major re-evaluation and debate

     

Deprivation and emergency admissions for cancers of colorectum,lung, and breast in south east England: ecological study

Objectives: To examine the relation between deprivation and acute emergency admissions for cancers of the colon, rectum, lung, and breast in south east England. Design: Ecological analysis with data from hospital episode statistics and 1991 census. Setting: North and South Thames Regional Health Authorities (population about 14 million), divided into 10 aggregations of 31 470 census enumeration districts (median population 462). Subjects: 146 639 admissions relating to 76 552 patients aged <100 years on admission, resident in the Thames regions, admitted between 1 April 1992 and 31 March 1995. Results: Residents living in deprived areas were more likely to be admitted as emergencies and has ordinary inpatient admissions and less likely to be admitted as day cases. Adjusted odds of ordinary admissions from the most deprived tenth occurring as emergencies (relative to admissions from the most affluent tenth) were 2.29 (95% confidence interval 2.09 to 2.52) for colorectal cancer, 2.20 (1.99 to 2.43) for lung cancer, and 2.41 (2.17 to 2.67) for female breast cancer; adjusted odds of admissions as day cases were 0.70 (0.64 to 0.76), 0.50 (0.44 to 0.56), and 0.56 (0.50 to 0.62), respectively. Patients from deprived areas with lung or breast cancers were less likely to be recorded as having surgical interventions. Adjusted odds of patients from the most deprived tenth receiving surgery were 0.88 (0.78 to 1.00), 0.58 (0.48 to 0.70), and 0.63 (0.56 to 0.71), respectively. Admissions for colorectal cancer from the most deprived areas were less likely to be to hospitals admitting 100 or more new patients a year; the opposite held true for breast cancer admissions. No association was found for lung cancer admissions. Conclusions: Earlier diagnostic and referral procedures in primary care in deprived areas are required if there are to be significant reductions in mortality from these cancers. A national information strategy is required to ensure the continued availability of population based data on NHS patients and to mandate standardised datasets from the private sector. Rationalisation of acute services, hospital mergers, and plans for bed closures must take into account the increased healthcare needs and inequities in access to treatment and care of residents in areas with high levels of deprivation. Health authorities and primary care groups should re-examine their purchasing intentions, service reviews, and monitoring arrangements in the light of these findings.

Key messages

• A major reorganisation of cancer services is under way in England and Wales with the aim of improving access to and quality of treatment
• Residents with cancers of the bowel, lung, or breast in deprived areas in the Thames region were more likely to be admitted as emergencies and ordinary inpatients than their counterparts from more affluent areas, and patients with lung or breast cancers from deprived areas were less likely to receive surgical treatment
• Patients with colorectal cancer from the most deprived areas were less likely to be seen at hospitals with a large caseload than were patients from affluent areas; the opposite held true for patients with breast cancer, but no association was found for admissions for lung cancer
• More effective early diagnostic and referral procedures in primary care in deprived areas are required if reductions in mortality are to be achieved
• Hospital mergers and plans for service reconfiguration and bed closures must take into account inequities in access to treatment among residents in deprived areas

     

Cumulative risk adjusted mortality chart for detecting changes in death rate: observational study of heart surgery

Objective: To detect changes in mortality after surgery, with allowance being made for variations in case mix. Design: Observational study of postoperative mortality from January 1992 to August 1995. Setting: Regional cardiothoracic unit. Subjects: 3983 patients aged 16 and over who had open heart operations. Main outcome measures: Preoperative risk factors and postoperative mortality in hospital within 30 days were recorded for all surgical heart operations. Mortality was adjusted for case mix using a preoperative estimate of risk based on additive Parsonnet factors. The number of operations required for statistical power to detect a doubling of mortality was examined, and control limits at a nominal significance level of P=0.01 for detection of an adverse trend were determined. Results: Total mortality of 7.0% was 26% below the Parsonnet predictor (P<0.0001). There was a highly significant variation in annual case mix (Parsonnet scores 8.7-10.6, P<0.0001). There was no significant variation in mortality after adjustment for case mix (odds ratio 1-1.5, P=0.18) with monitoring by calendar year. With continuous monitoring, however, nominal 99% control limits based on 16 expected deaths were crossed on two occasions. Conclusions: Hospital league tables for mortality from heart surgery will be of limited value because year to year differences in death rate can be large (odds ratio 1.5) even when the underlying risk or case mix does not change. Statistical quality control of a single series with adjustment for case mix is the only way to take into account recent performance when informing a patient of the risk of surgery at a particular hospital. If there is an increase in the number of deaths the chances of the next patient surviving surgery can be calculated from the last 16 deaths.

Key messages

• Changes in the patient population affect a hospital’s annual death rate
• Year to year differences in death rate can be large even when there is no change in the underlying risk or case mix
• It takes surprisingly many operations before an increase in death rate can be distinguished from random fluctuation
• A formal inquiry should take place in a hospital if the death rate rises above control limits
• The chances of the next patient surviving surgery should be calculated using the surgeon’s most recent results

     

Career pathways and destinations 18 years on among doctors who qualified in the United Kingdom in 1977: postal questionnaire survey

ObjectiveTo determine the career destinations, by 1995, of doctors who qualified in the United Kingdom in 1977; the relation between their destinations and early career choice; and their intentions regarding retirement age.DesignPostal questionnaire.SettingUnited Kingdom.SubjectsAll (n=3135) medical qualifiers of 1977.ResultsAfter about 12 years the distribution of respondents by type of employment, and, for women, the percentage of doctors in part time rather than full time medical work, had stabilised. Of all 2997 qualifiers from medical schools in Great Britain, 2399 (80.0% (95% confidence interval 79.5% to 80.6%)) were working in medicine in the NHS in Great Britain 18 years after qualifying. Almost half the women (318/656) worked in the NHS part time. Of 1714 doctors in the NHS, 1125 intended to work in the NHS until normal retirement age, 392 did not, and 197 were undecided. Of the 1548 doctors for whom we had sufficient information, career destinations at 18 years matched the choices made at 1, 3, and 5 years in 58.9% (912), 78.2% (1211), and 86.6% (1341) of cases respectively.ConclusionsPlanning for the medical workforce needs to be supported by information about doctors’ career plans, destinations, and whole time equivalent years of work. Postgraduate training needs to take account of doctors’ eventual choice of specialty (and the timing of this choice).

Key messages

• A large scale national study in the United Kingdom followed doctors from qualification to mid-career and beyond
• Most doctors had made their choice of eventual career—at least in terms of broadly defined specialty—within 5 years of qualifying
• Eighteen years on, 80% of the doctors were working in the NHS and nearly half of women doctors were working part time
• Almost a quarter of NHS doctors planned to retire early

     

Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey

AimTo compare perinatal morbidity and mortality for babies delivered in water with rates for babies delivered conventionally (not in water).DesignSurveillance study (of all consultant paediatricians) and postal survey (of all NHS maternity units).SettingBritish Isles (surveillance study); England and Wales (postal survey).SubjectsBabies born in the British Isles between April 1994 and March 1996 who died perinatally or were admitted for special care within 48 hours of birth after delivery in water or after labour in water followed by conventional delivery (surveillance study); babies delivered in water in England and Wales in the same period (postal survey).Results4032 deliveries (0.6% of all deliveries) in England and Wales occurred in water. Perinatal mortality was 1.2/1000 (95% confidence interval 0.4 to 2.9) live births; 8.4/1000 (5.8 to 11.8) live births were admitted for special care. No deaths were directly attributable to delivery in water, but 2 admissions were for water aspiration. UK reports of mortality and special care admission rates for babies of women considered to be at low risk of complications during delivery who delivered conventionally ranged from 0.8/1000 (0.2 to 4.2) to 4.6/1000 (0.1 to 25) live births and from 9.2 (1.1 to 33) to 64/1000 (58 to 70) live births respectively. Compared with regional data for low risk, spontaneous, normal vaginal deliveries at term, the relative risk for perinatal mortality associated with delivery in water was 0.9 (99% confidence interval 0.2 to 3.6).ConclusionsPerinatal mortality is not substantially higher among babies delivered in water than among those born to low risk women who delivered conventionally. The data are compatible with a small increase or decrease in perinatal mortality for babies delivered in water.

Key messages

• Data on adverse effects of delivery in water have been limited
• Perinatal mortality and risk of admission for special care is similar for babies delivered in water and for low risk deliveries that do not take place in water
• The risk of perinatal mortality for babies delivered in water is similar to the risk for babies born by normal vaginal delivery to women at low risk of adverse outcome
• Delivery in water may have caused water aspiration in two babies and contributed to snapped umbilical cord in five

     

β Blockade after myocardial infarction: systematic review and meta regression analysis

ObjectivesTo assess the effectiveness of β blockers in short term treatment for acute myocardial infarction and in longer term secondary prevention; to examine predictive factors that may influence outcome and therefore choice of drug; and to examine the clinical importance of the results in the light of current treatment.DesignSystematic review of randomised controlled trials.SettingRandomised controlled trials.SubjectsPatients with acute or past myocardial infarction.Interventionβ Blockers compared with control.Mainoutcome measures All cause mortality and non-fatal reinfarction.ResultsOverall, 5477 of 54 234 patients (10.1%) randomised to β blockers or control died. We identified a 23% reduction in the odds of death in long term trials (95% confidence interval 15% to 31%), but only a 4% reduction in the odds of death in short term trials (−8% to 15%). Meta regression in long term trials did not identify a significant reduction in effectiveness in drugs with cardioselectivity but did identify a near significant trend towards decreased benefit in drugs with intrinsic sympathomimetic activity. Most evidence is available for propranolol, timolol, and metoprolol. In long term trials, the number needed to treat for 2 years to avoid a death is 42, which compares favourably with other treatments for patients with acute or past myocardial infarction.Conclusionsβ Blockers are effective in long term secondary prevention after myocardial infarction, but they are underused in such cases and lead to avoidable mortality and morbidity.

Key messages

• The first randomised trials of β blockade in secondary prevention after myocardial infarction were published in the 1960s
• β blockers were once heralded as a major advance, but their use for secondary prevention has declined in recent years
• Firm evidence shows that long term β blockade remains an effective and well tolerated treatment that reduces mortality and morbidity in unselected patients after myocardial infarction
• The benefits from β blockade compare favourably with other drug treatments for this patient group
• Most evidence is for propranolol, timolol, and metoprolol, whereas atenolol, which is commonly used, is inadequately evaluated for long term use

     

Evaluation of Pneumonia Severity and Acute Physiology Scores to Predict ICU Admission and Mortality in Patients Hospitalized for Influenza

Background

The demand for inpatient medical services increases during influenza season. A scoring system capable of identifying influenza patients at low risk death or ICU admission could help clinicians make hospital admission decisions.

Methods

Hospitalized patients with laboratory confirmed influenza were identified over 3 influenza seasons at 25 Ontario hospitals. Each patient was assigned a score for 6 pneumonia severity and 2 sepsis scores using the first data available following their registration in the emergency room. In-hospital mortality and ICU admission were the outcomes. Score performance was assessed using the area under the receiver operating characteristic curve (AUC) and the sensitivity and specificity for identifying low risk patients (risk of outcome <5%).

Results

The cohort consisted of 607 adult patients. Mean age was 76 years, 12% of patients died (71/607) and 9% required ICU care (55/607). None of the scores examined demonstrated good discriminatory ability (AUC≥0.80). The Pneumonia Severity Index (AUC 0.78, 95% CI 0.72–0.83) and the Mortality in Emergency Department Sepsis score (AUC 0.77, 95% 0.71–0.83) demonstrated fair predictive ability (AUC≥0.70) for in-hospital mortality. The best predictor of ICU admission was SMART-COP (AUC 0.73, 95% CI 0.67–0.79). All other scores were poor predictors (AUC <0.70) of either outcome. If patients classified as low risk for in-hospital mortality using the PSI were discharged, 35% of admissions would have been avoided.

Conclusions

None of the scores studied were good predictors of in-hospital mortality or ICU admission. The PSI and MEDS score were fair predictors of death and if these results are validated, their use could reduce influenza admission rates significantly.     

Retrospective analysis of census data on general practitioners who qualified in South Asia: who will replace them as they retire?

ObjectivesTo determine the number and geographical distribution of general practitioners in the NHS who qualified medically in South Asia and to project their numbers as they retire.DesignRetrospective analysis of yearly data and projection of future trends.SettingEngland and Wales.SubjectsGeneral practitioners who qualified medically in the countries of Bangladesh, India, Pakistan, and Sri Lanka and who were practising in the NHS on 1 October 1992.Results4192 of 25 333 (16.5%) of all unrestricted general practitioners practising full time on 1 October 1992 qualified in South Asian medical schools. The proportion varied by health authority from 0.007% to 56.5%. Roughly two thirds who were practising in 1992 will have retired by 2007; in some health authorities this will represent a loss of one in four general practitioners. The practices that these doctors will leave seem to be in relatively deprived areas as measured by deprivation payments and a health authority measure of population need.ConclusionMany general practitioners who qualified in South Asian medical schools will retire within the next decade. The impact will vary greatly by health authority. Those health authorities with the greatest number of such doctors are in some of the most deprived areas in the United Kingdom and have experienced the most difficulty in filling vacancies. Various responses will be required by workforce planners to mitigate the impact of these retirements.

Key messages

• Currently, one in six general practitioners practising full time in the NHS qualified medically in a South Asian medical school; two thirds are likely to retire by 2007
• It is unlikely that doctors who qualify in South Asia will be a source of general practice recruitment in the future
• The posts from which South Asian qualifiers are retiring may be more difficult to fill because they are often in practices in areas of higher need
• There is extreme variation in the proportion of total general practitioners who are South Asian qualifiers; flexibility for policy responses should be maintained

     

Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey

Background

There is a growing recognition that the provision of surgical services in low-income countries is inadequate to the need. While constrained health budgets and health worker shortages have been blamed for the low rates of surgery, there has been little empirical data on the providers of surgery and cost of surgical services in Africa. This study described the range of providers of surgical care and anesthesia and estimated the resources dedicated to surgery at district hospitals in three African countries.

Methods and Findings

We conducted a retrospective cross-sectional survey of data from eight district hospitals in Mozambique, Tanzania, and Uganda. There were no specialist surgeons or anesthetists in any of the hospitals. Most of the health workers were nurses (77.5%), followed by mid-level providers (MLPs) not trained to provide surgical care (7.8%), and MLPs trained to perform surgical procedures (3.8%). There were one to six medical doctors per hospital (4.2% of clinical staff). Most major surgical procedures were performed by doctors (54.6%), however over one-third (35.9%) were done by MLPs. Anesthesia was mainly provided by nurses (39.4%). Most of the hospital expenditure was related to staffing. Of the total operating costs, only 7% to 14% was allocated to surgical care, the majority of which was for obstetric surgery. These costs represent a per capita expenditure on surgery ranging from US$0.05 to US$0.14 between the eight hospitals.

Conclusion

African countries have adopted different policies to ensure the provision of surgical care in their respective district hospitals. Overall, the surgical output per capita was very low, reflecting low staffing ratios and limited expenditures for surgery. We found that most surgical and anesthesia services in the three countries in the study were provided by generalist doctors, MLPs, and nurses. Although more information is needed to estimate unmet need for surgery, increasing the funds allocated to surgery, and, in the absence of trained doctors and surgeons, formalizing the training of MLPs appears to be a pragmatic and cost-effective way to make basic surgical services available in underserved areas. Please see later in the article for the Editors'' Summary     

Fatal opioid overdoses during and shortly after hospital admissions in England: A case-crossover study

BackgroundHospital patients who use illicit opioids such as heroin may use drugs during an admission or leave the hospital in order to use drugs. There have been reports of patients found dead from drug poisoning on the hospital premises or shortly after leaving the hospital. This study examines whether hospital admission and discharge are associated with increased risk of opioid-related death.Methods and findingsWe conducted a case-crossover study of opioid-related deaths in England. Our study included 13,609 deaths between January 1, 2010 and December 31, 2019 among individuals aged 18 to 64. For each death, we sampled 5 control days from the period 730 to 28 days before death. We used data from the national Hospital Episode Statistics database to determine the time proximity of deaths and control days to hospital admissions. We estimated the association between hospital admission and opioid-related death using conditional logistic regression, with a reference category of time neither admitted to the hospital nor within 14 days of discharge. A total of 236/13,609 deaths (1.7%) occurred following drug use while admitted to the hospital. The risk during hospital admissions was similar or lower than periods neither admitted to the hospital nor recently discharged, with odds ratios 1.03 (95% CI 0.87 to 1.21; p = 0.75) for the first 14 days of an admission and 0.41 (95% CI 0.30 to 0.56; p < 0.001) for days 15 onwards. 1,088/13,609 deaths (8.0%) occurred in the 14 days after discharge. The risk of opioid-related death increased in this period, with odds ratios of 4.39 (95% CI 3.75 to 5.14; p < 0.001) on days 1 to 2 after discharge and 2.09 (95% CI 1.92 to 2.28; p < 0.001) on days 3 to 14. 11,629/13,609 deaths (85.5%) did not occur close to a hospital admission, and the remaining 656/13,609 deaths (4.8%) occurred in hospital following admission due to drug poisoning. Risk was greater for patients discharged from psychiatric admissions, those who left the hospital against medical advice, and those leaving the hospital after admissions of 7 days or more. The main limitation of the method is that it does not control for time-varying health or drug use within individuals; therefore, hospital admissions coinciding with high-risk periods may in part explain the results.ConclusionsDischarge from the hospital is associated with an acute increase in the risk of opioid-related death, and 1 in 14 opioid-related deaths in England happens in the 2 weeks after the hospital discharge. This supports interventions that prevent early discharge and improve linkage with community drug treatment and harm reduction services.

In a case-crossover study, Dan Lewer and coauthors investigate factors associated with fatal opioid overdoses during and shortly after hospital admissions in England.     

Emerging tobacco hazards in China: 2. Early mortality results from a prospective study

ObjectiveTo monitor the evolving epidemic of mortality from tobacco in China following the large increase in male cigarette use in recent decades.DesignProspective study of smoking and mortality starting with 224 500 interviewees who should eventually be followed for some decades.Setting45 nationally representative small urban or rural areas distributed across China.SubjectsMale population aged 40 or over in 1991, of whom about 80% were interviewed about smoking, drinking, and medical history.Results74% were smokers (73% current, only 1% former), but few of this generation would have smoked substantial numbers of cigarettes since early adult life. Overall mortality is increased among smokers (risk ratio 1.19; 95% confidence interval 1.13 to 1.25, P<0.0001). Almost all the increased mortality involved neoplastic, respiratory, or vascular disease. The overall risk ratios currently associated with smoking are less extreme in rural areas (1.26, 1.12, or 1.02 respectively for smokers who started before age 20, at 20-24, or at older ages) than in urban areas (1.73, 1.40, or 1.16 respectively).ConclusionThis prospective study and the accompanying retrospective study show that by 1990 smoking was already causing about 12% of Chinese male mortality in middle age. This proportion is predicted to rise to about 33% by 2030. Long term continuation of the prospective study (with periodic resurveys) can monitor the evolution of this epidemic.

Key messages

• In recent years most young men in China have become persistent cigarette smokers, starting at about age 20; this will cause high mortality in middle age and old age
• Currently, however, most middle aged and older smokers (particularly in rural areas) have not persistently used substantial daily numbers of cigarettes ever since they were young adults, so their current tobacco attributed mortality is more limited
• Nationally representative retrospective and prospective studies now show that in about 1990 “only” about 12% of adult male deaths in middle age were caused by smoking
• Continuation of the present prospective study will monitor the growth of the epidemic of tobacco related deaths in China over the next few decades

     

Downsizing of acute inpatient beds associated with private finance initiative: Scotland's case study

ObjectivesTo evaluate whether the projected 24% reduction in acute bed numbers in Lothian hospitals, which formed part of the private finance initiative (PFI) plans for the replacement Royal Infirmary of Edinburgh, is being compensated for by improvements in efficiency and greater use of community facilities, and to ascertain whether there is an independent PFI effect by comparing clinical activity and performance in acute specialties in Lothian hospitals with other NHS hospitals in Scotland.DesignComparison of projected and actual trends in acute bed capacity and inpatient and day case admissions in the first five years (1995-6 to 2000-1) of Lothian Health Board''s integrated healthcare plan. Population study of trends in bed rate, hospital activity, length of stay, and throughput in Lothian hospitals compared with the rest of Scotland from 1990-1 to 2000-1.ResultsBy 2000-1, rates for inpatient admission in all acute, medical, surgical, and intensive therapy specialties in Lothian hospitals were respectively 20%, 6%, 28%, and 38% below those in the rest of Scotland. Day case rates in all acute and acute surgical specialties were 13% and 33% lower. The proportion of delayed discharges in staffed acute and post-acute NHS beds in Lothian hospitals exceeded the Scottish average (15% and 12% respectively; P<0.001).ConclusionThe planning targets and increase in clinical activity in acute specialties in Lothian hospitals associated with PFI had not been achieved by 2000-1. The effect on clinical activity has been a steeper decline in the number of acute beds and rates of admission in Lothian hospitals compared with the rest of Scotland between 1995-6 and 2000-1.

What is already known on this topic

The full business cases for the 15 first wave private finance initiative (PFI) hospitals in England and Scotland projected reductions in acute beds of about 30% in the five years before the opening of the new replacement hospitalsThe new PFI Royal Infirmary of Edinburgh, which will fully open in 2003, is the cornerstone of Lothian Health Board''s healthcare plan for its acute hospitals

What this study adds

Compared with other Scottish NHS hospitals, service delivery has been reduced across Lothian associated with PFI developmentThe planning targets and increase in clinical activity in acute specialties in Lothian hospitals had not been achieved by 2000-1There is evidence of an independent “PFI effect” on hospital downsizing and bed reductions, which in Lothian has resulted in severe capacity constraints across all acute specialties with a need for immediate expansion in acute and community provisionFurther hospital and community service downsizing may be required to meet the financial deficit, which is principally due to the high costs of PFI     

Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery

ObjectivesTo determine whether preoperative optimisation of oxygen delivery improves outcome after major elective surgery, and to determine whether the inotropes, adrenaline and dopexamine, used to enhance oxygen delivery influence outcome.DesignRandomised controlled trial with double blinding between inotrope groups.SettingYork District Hospital, England.Subjects138 patients undergoing major elective surgery who were at risk of developing postoperative complications either because of the surgery or the presence of coexistent medical conditions.InterventionsPatients were randomised into three groups. Two groups received invasive haemodynamic monitoring, fluid, and either adrenaline or dopexamine to increase oxygen delivery. Inotropic support was continued during surgery and for at least 12 hours afterwards. The third group (control) received routine perioperative care.ResultsOverall, 3/92 (3%) preoptimised patients died compared with 8/46 controls (17%) (P=0.007). There were no differences in mortality between the treatment groups, but 14/46 (30%) patients in the dopexamine group developed complications compared with 24/46 (52%) patients in the adrenaline group (difference 22%, 95% confidence interval 2% to 41%) and 28 patients (61%) in the control group (31%, 11% to 50%). The use of dopexamine was associated with a decreased length of stay in hospital.ConclusionRoutine preoperative optimisation of patients undergoing major elective surgery would be a significant and cost effective improvement in perioperative care.

Key messages

• Major elective surgery in UK general hospitals still carries significant mortality and morbidity
• Preoperative administration of fluid and inotropes, guided by invasive monitoring, can significantly reduce mortality, morbidity, and length of hospital stay
• The choice of inotrope may influence the extent of improvements in outcome
• Routine preoperative optimisation would require initial investment in high dependency care facilities but is likely to be cost effective by reducing complications and length of hospital stay

     

Increasing Short-Stay Unplanned Hospital Admissions among Children in England; Time Trends Analysis ’97–‘06

Background

Timely care by general practitioners in the community keeps children out of hospital and provides better continuity of care. Yet in the UK, access to primary care has diminished since 2004 when changes in general practitioners'' contracts enabled them to ‘opt out’ of providing out-of-hours care and since then unplanned pediatric hospital admission rates have escalated, particularly through emergency departments. We hypothesised that any increase in isolated short stay admissions for childhood illness might reflect failure to manage these cases in the community over a 10 year period spanning these changes.

Methods and Findings

We conducted a population based time trends study of major causes of hospital admission in children <10 years using the Hospital Episode Statistics database, which records all admissions to all NHS hospitals in England using ICD10 codes. Outcomes measures were total and isolated short stay unplanned hospital admissions (lasting less than 2 days without readmission within 28 days) from 1997 to 2006. Over the period annual unplanned admission rates in children aged <10 years rose by 22% (from 73.6/1000 to 89.5/1000 child years) with larger increases of 41% in isolated short stay admissions (from 42.7/1000 to 60.2/1000 child years). There was a smaller fall of 12% in admissions with length of stay of >2 days. By 2006, 67.3% of all unplanned admissions were isolated short stays <2 days. The increases in admission rates were greater for common non-infectious than infectious causes of admissions.

Conclusions

Short stay unplanned hospital admission rates in young children in England have increased substantially in recent years and are not accounted for by reductions in length of in-hospital stay. The majority are isolated short stay admissions for minor illness episodes that could be better managed by primary care in the community and may be evidence of a failure of primary care services.     

Prevalence of anxiety and depressive illness and help seeking behaviour in African Caribbeans and white Europeans: two phase general population survey

ObjectiveTo determine the prevalence of common mental disorders (anxiety and depression) and help seeking behaviour in African Caribbeans and white Europeans.DesignTwo phase survey in a general population sample. The first phase comprised screening with the 12 item general health questionnaire; the second phase was standardised psychiatric assessment and interview about help seeking.SettingPeople registered with four general practices in central Manchester.ParticipantsOf 1467 people randomly selected from family health services authority lists, 864 were still resident. 337 African Caribbeans and 275 white Europeans completed the screening phase (response rate 71%); 127 African Caribbeans and 103 white Europeans were interviewed in the second phase.Results13% of African Caribbeans (95% confidence interval 10% to 16%) and 14% (10% to 18%) of white Europeans had one or more disorder. Anxiety disorders were significantly less common among African Caribbeans (3% (1% to 5%) v 9% (6% to 12%) in white Europeans). Depressive disorders were significantly more common among African Caribbean women than white women (difference 8% (1% to 15%)). Medical help seeking was similar in the two groups, but African Caribbeans with mental disorders were more likely to seek additional help from non-medical sources (12/29 v 5/29, P=0.082).ConclusionsIn an inner city setting the prevalence of common mental disorders is similar in these two ethnic groups.

Key messages

• Most studies of ethnic differences in mental health focus on psychotic illness rather than common mental disorders
• In this inner city study the prevalence of anxiety and depression was similar in African Caribbeans and white Europeans
• Anxiety disorders were less common, and depression more common, in African Caribbeans than white Europeans
• Improved recognition and treatment of non-psychotic disorders are necessary, taking into account patients’ views of their illnesses

     

Annual league tables of mortality in neonatal intensive care units: longitudinal study

Objective: To assess whether crude league tables of mortality and league tables of risk adjusted mortality accurately reflect the performance of hospitals. Design: Longitudinal study of mortality occurring in hospital. Setting: 9 neonatal intensive care units in the United Kingdom. Subjects: 2671 very low birth weight or preterm infants admitted to neonatal intensive care units between 1988 and 1994. Main outcome measures: Crude hospital mortality and hospital mortality adjusted using the clinical risk index for babies (CRIB) score. Results: Hospitals had wide and overlapping confidence intervals when ranked by mortality in annual league tables; this made it impossible to discriminate between hospitals reliably. In most years there was no significant difference between hospitals, only random variation. The apparent performance of individual hospitals fluctuated substantially from year to year. Conclusions: Annual league tables are not reliable indicators of performance or best practice; they do not reflect consistent differences between hospitals. Any action prompted by the annual league tables would have been equally likely to have been beneficial, detrimental, or irrelevant. Mortality should be compared between groups of hospitals using specific criteria—such as differences in the volume of patients, staffing policy, training of staff, or aspects of clinical practice—after adjusting for risk. This will produce more reliable estimates with narrower confidence intervals, and more reliable and rapid conclusions.

Key messages

• League tables are being used increasingly to evaluate hospital performance in the United Kingdom
• In annual league tables the rankings of nine neonatal intensive care units in different hospitals had wide and overlapping confidence intervals and their rankings fluctuated substantially over six years
• Annual league tables of hospital mortality were inherently unreliable for comparing hospital performance or for indicating best practices
• The UK government’s commitment to using annual league tables of outcomes such as mortality to monitor services and the spread of best practices should be reconsidered
• Prospective studies of risk adjusted outcome in hospitals grouped according to specific characteristics would provide better information and be a better use of resources

     

Reporting on quality of life in randomised controlled trials: bibliographic study

ObjectivesTo examine the frequency and quality of reporting on quality of life in randomised controlled trials.DesignSearch of the Cochrane Controlled Trials Register 1980 to 1997 to identify trials from all disciplines, from oncology, and from cardiovascular medicine that reported on quality of life. Assessment of abstracts from articles published from 1993 to 1996. Assessment of a sample of full reports with a standardised instrument.ResultsDuring 1980-97 reporting on quality of life increased from 0.63% to 4.2% for trials from all disciplines, from 1.5% to 8.2% for cancer trials, and from 0.34% to 3.6% for cardiovascular trials. Of 364 abstracts, 65% reported on drug interventions. Of a sample of 67 full reports, authors of 48 (72%) used 62 established quality of life instruments. In 15 reports (22%) authors developed their own measures, and in 2 (3%) methods were unclear. Response rates were given in 38 (57%), and complete reporting on all items and scales occurred in 31 (46%).ConclusionsLess than 5% of all randomised controlled trials reported on quality of life, and this proportion was below 10% even for cancer trials. A plethora of instruments was used in different studies, and the reporting of methods and results was often inadequate. Standards for the measurement and reporting of quality of life in clinical trials research need to be developed.

Key messages

• We examined the reporting on quality of life in randomised controlled trials listed in the Cochrane Controlled Trials Register
• Although reporting on quality of life increased over time, fewer than 5% of trials overall and fewer than 10% of cancer trials included quality of life in 1997
• Among 67 articles selected at random for detailed examination, a wide range of established and self developed measures of quality of life were used
• Only about half of trials gave response rates, and less than half reported on all items and scales used
• Standards for assessing and reporting quality of life in clinical research trials need to be developed