Why many patients shouldn’t be in hospital.

BMJ. 2010;341:c4710

Authors: Patel K

PMID: 20810486 [PubMed - in process]

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Reducing Clostridium difficile infection in acute care by using an improvement collaborative.

BMJ. 2010;341:c3359

Authors: Power M, Wigglesworth N, Donaldson E, Chadwick P, Gillibrand S, Goldmann D

PROBLEM: In 2006, despite a focus on infection control, Salford Royal had the fourth highest rate of Clostridium difficile infection in north west England. DESIGN: Interrupted time series in five collaborative wards (intervention group) and 35 non-collaborative wards (control group). SETTING: University teaching hospital with 850 acute beds. KEY MEASURES FOR IMPROVEMENT: Number of cases of C difficile infection per 1000 occupied bed days. STRATEGIES FOR CHANGE: In February 2007, a newly formed antimicrobial team led the implementation of revised guidelines in all wards and departments. From March to December 2007, five wards participated in an improvement collaborative. Since December 2007, the changes from the collaborative have been collated and implemented throughout the organisation. EFFECTS OF CHANGE: At baseline the non-collaborative wards had 1.15 (95% CI 1.03 to 1.29) cases per 1000 occupied bed days. In August 2007 cases reduced 56% from baseline (0.51, 0.44 to 0.60), which has been maintained since that time. In the collaborative wards, there were 2.60 (2.11 to 3.17) cases per 1000 occupied bed days at baseline. A shift occurred in April 2007 representing a reduction of 73% (0.69, 0.50 to 0.91) from baseline, which has been maintained. LESSONS LEARNT: Careful use of antimicrobial drugs is important in reducing the number of cases of C difficile infection. A collaborative learning model can enable teams to test and implement changes that can accelerate, amplify, and sustain control of C difficile.

PMID: 20659985 [PubMed - in process]

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Postoperative pneumonia in elderly patients receiving acid suppressants: a retrospective cohort analysis.

BMJ. 2010;340:c2608

Authors: Redelmeier DA, McAlister FA, Kandel CE, Lu H, Daneman N

OBJECTIVE: To test whether gastric acid suppressants are associated with an increased risk of postoperative pneumonia in patients undergoing elective surgery. DESIGN: Population-wide retrospective cohort analysis. SETTING: Canadian acute care hospitals between 1 April 1992 and 31 March 2008. Patients Consecutive patients aged >65 years admitted for an elective operation. OUTCOME MEASURE: Postoperative pneumonia recorded in inpatient postoperative notes. RESULTS: A total of 593 265 patients were included, of whom about 21% were taking an acid suppressant (most commonly omeprazole or ranitidine). Overall, 6389 patients developed postoperative pneumonia, with a rate significantly higher for those taking acid suppressants (13 per 1000) than controls (10 per 1000), equivalent to a 30% increase in frequency (odds ratio 1.30 (95% confidence interval 1.23 to 1.38), P<0.001). However, no increase in risk was observed after adjustment for duration of surgery, site of surgery, and other confounders (odds ratio 1.02 (0.96 to 1.09), P=0.48). The general safety of acid suppressants extended to those patients prescribed proton pump inhibitors, experiencing long term treatment, receiving high doses, and undergoing high risk procedures. CONCLUSION: After adjustment for patient and surgical characteristics, acid suppressants are not associated with an increased risk of postoperative pneumonia among elderly patients admitted for elective surgery.

PMID: 20566596 [PubMed - in process]

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Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study.

BMJ. 2010;340:c3111

Authors: Greenhalgh T, Stramer K, Bratan T, Byrne E, Russell J, Potts HW

OBJECTIVE: To evaluate a national programme to develop and implement centrally stored electronic summaries of patients’ medical records. DESIGN: Mixed-method, multilevel case study. SETTING: English National Health Service 2007-10. The summary care record (SCR) was introduced as part of the National Programme for Information Technology. This evaluation of the SCR considered it in the context of national policy and its frontline implementation and use in three districts. Participants and methods Quantitative data (cumulative records created nationally plus a dataset of 416 325 encounters in participating primary care out-of-hours and walk-in centres) were analysed statistically. Qualitative data (140 interviews including policy makers, managers, clinicians, and software suppliers; 2000 pages of ethnographic field notes including observation of 214 clinical consultations; and 3000 pages of documents) were analysed thematically and interpretively. RESULTS: Creating individual SCRs and supporting their adoption and use was a complex, technically challenging, and labour intensive process that occurred more slowly than planned. By early 2010, 1.5 million such records had been created. In participating primary care out-of-hours and walk-in centres, an SCR was accessed in 4% of all encounters and in 21% of encounters where one was available; these figures were rising in some but not all sites. The main determinant of SCR access was the identity of the clinician: individual clinicians accessed available SCRs between 0 and 84% of the time. When accessed, an SCR seemed to support better quality care and increase clinician confidence in some encounters. There was no direct evidence of improved safety, but findings were consistent with a rare but important positive impact on preventing medication errors. SCRs sometimes contained incomplete or inaccurate data, but clinicians drew judiciously on these data along with other sources. SCR use was not associated with shorter consultations or reduction in onward referral. Successful introduction of SCRs depended on interaction between multiple stakeholders from different worlds (clinical, political, technical, commercial) with different values, priorities, and ways of working. The programme’s fortunes seemed to turn on the ability of change agents to bridge these different institutional worlds, align their conflicting logics, and mobilise implementation effort. CONCLUSIONS: Benefits of centrally stored electronic summary records seem more subtle and contingent than many stakeholders anticipated, and clinicians may not access them. Complex interdependencies, inherent tensions, and high implementation workload should be expected when they are introduced on a national scale.

PMID: 20554687 [PubMed - in process]

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Related Articles

Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis.

BMJ. 2010;340:c2096

Authors: Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD

OBJECTIVE: To systematically review the literature and, where appropriate, meta-analyse studies investigating subsequent antibiotic resistance in individuals prescribed antibiotics in primary care. DESIGN: Systematic review with meta-analysis. DATA SOURCES: Observational and experimental studies identified through Medline, Embase, and Cochrane searches. Review methods Electronic searches using MeSH terms and text words identified 4373 papers. Two independent reviewers assessed quality of eligible studies and extracted data. Meta-analyses were conducted for studies presenting similar outcomes. RESULTS: The review included 24 studies; 22 involved patients with symptomatic infection and two involved healthy volunteers; 19 were observational studies (of which two were prospective) and five were randomised trials. In five studies of urinary tract bacteria (14 348 participants), the pooled odds ratio (OR) for resistance was 2.5 (95% confidence interval 2.1 to 2.9) within 2 months of antibiotic treatment and 1.33 (1.2 to 1.5) within 12 months. In seven studies of respiratory tract bacteria (2605 participants), pooled ORs were 2.4 (1.4 to 3.9) and 2.4 (1.3 to 4.5) for the same periods, respectively. Studies reporting the quantity of antibiotic prescribed found that longer duration and multiple courses were associated with higher rates of resistance. Studies comparing the potential for different antibiotics to induce resistance showed no consistent effects. Only one prospective study reported changes in resistance over a long period; pooled ORs fell from 12.2 (6.8 to 22.1) at 1 week to 6.1 (2.8 to 13.4) at 1 month, 3.6 (2.2 to 6.0) at 2 months, and 2.2 (1.3 to 3.6) at 6 months. CONCLUSIONS: Individuals prescribed an antibiotic in primary care for a respiratory or urinary infection develop bacterial resistance to that antibiotic. The effect is greatest in the month immediately after treatment but may persist for up to 12 months. This effect not only increases the population carriage of organisms resistant to first line antibiotics, but also creates the conditions for increased use of second line antibiotics in the community.

PMID: 20483949 [PubMed - indexed for MEDLINE]

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Some doctors left in charge of 400 patients at night, study shows.

BMJ. 2010;340:c2206

Authors: O’Dowd A

PMID: 20410176 [PubMed - in process]

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Potential of an age adjusted D-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients: a retrospective analysis of three large cohorts.

BMJ. 2010;340:c1475

Authors: Douma RA, le Gal G, Söhne M, Righini M, Kamphuisen PW, Perrier A, Kruip MJ, Bounameaux H, Büller HR, Roy PM

OBJECTIVES: In older patients, the the D-dimer test for pulmonary embolism has reduced specificity and is therefore less useful. In this study a new, age dependent cut-off value for the test was devised and its usefulness with older patients assessed. DESIGN: Retrospective multicentre cohort study. SETTING: General and teaching hospitals in Belgium, France, the Netherlands, and Switzerland. Patients 5132 consecutive patients with clinically suspected pulmonary embolism. INTERVENTION: Development of a new D-dimer cut-off point in patients aged >50 years in a derivation set (data from two multicentre cohort studies), based on receiver operating characteristics (ROC) curves. This cut-off value was then validated with two independent validation datasets. MAIN OUTCOME MEASURES: The proportion of patients in the validation cohorts with a negative D-dimer test, the proportion in whom pulmonary embolism could be excluded, and the false negative rates. RESULTS: The new D-dimer cut-off value was defined as (patient's agex10) mug/l in patients aged >50. In 1331 patients in the derivation set with an "unlikely" score from clinical probability assessment, pulmonary embolism could be excluded in 42% with the new cut-off value versus 36% with the old cut-off value (<500 mug/l). In the two validation sets, the increase in the proportion of patients with a D-dimer below the new cut-off value compared with the old value was 5% and 6%. This absolute increase was largest among patients aged >70 years, ranging from 13% to 16% in the three datasets. The failure rates (all ages) were 0.2% (95% CI 0% to 1.0%) in the derivation set and 0.6% (0.3% to 1.3%) and 0.3% (0.1% to 1.1%) in the two validation sets. CONCLUSIONS: The age adjusted D-dimer cut-off point, combined with clinical probability, greatly increased the proportion of older patients in whom pulmonary embolism could be safely excluded.

PMID: 20354012 [PubMed - in process]

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Association between industry affiliation and position on cardiovascular risk with rosiglitazone: cross sectional systematic review.

BMJ. 2010;340:c1344

Authors: Wang AT, McCoy CP, Murad MH, Montori VM

OBJECTIVE: To explore a possible link between authors’ financial conflicts of interest and their position on the association of rosiglitazone with increased risk of myocardial infarction in patients with diabetes. DATA SOURCES: On 10 April 2009, we searched Web of Science and Scopus for articles citing and commenting on either of two index publications that contributed key data to the controversy (a meta-analysis of small trials and a subsequent large trial). Data selection Articles had to comment on rosiglitazone and the risk of myocardial infarction. Guidelines, meta-analyses, reviews, clinical trials, letters, commentaries, and editorials were included. DATA EXTRACTION: For each article, we sought information about the authors’ financial conflicts of interest in the report itself and elsewhere (that is, in all publications within two years of the original publication and online). Two reviewers blinded to the authors’ financial relationships independently classified each article as presenting a favourable (that is, rosiglitazone does not increase the risk of myocardial infarction), neutral, or unfavourable view on the risk of myocardial infarction with rosiglitazone and on recommendations on the use of the drug. RESULTS: Of the 202 included articles, 108 (53%) had a conflict of interest statement. Ninety authors (45%) had financial conflicts of interest. Authors who had a favourable view of the risk of myocardial infarction with rosiglitazone were more likely to have financial conflicts of interest with manufacturers of antihyperglycaemic agents in general, and with rosiglitazone manufacturers in particular, than authors who had an unfavourable view (rate ratio 3.38, 95% CI 2.26 to 5.06 and 4.29, 2.63 to 7.02, respectively). There was likewise a strong association between favourable recommendations on the use of rosiglitazone and financial conflicts of interest (3.36, 1.94 to 5.83). These links persisted when articles rather than authors were used as the unit of analysis (4.69, 2.84 to 7.72), when the analysis was restricted to opinion articles (6.29, 2.15 to 18.38) or to articles in which the rosiglitazone controversy was the main focus (6.50, 2.56 to 16.53), and both in articles published before and after the Food and Drug Administration issued a safety warning for rosiglitazone (3.43, 0.99 to 11.82 and 4.95, 2.87 to 8.53, respectively). CONCLUSIONS: Disclosure rates for financial conflicts of interest were unexpectedly low, and there was a clear and strong link between the orientation of authors’ expressed views on the rosiglitazone controversy and their financial conflicts of interest with pharmaceutical companies. Although these findings do not necessarily indicate a causal link between the position taken on the cardiac risk of rosiglitazone in patients with diabetes and the authors’ financial conflicts of interest, they underscore the need for further changes in disclosure procedures in order for the scientific record to be trusted.

PMID: 20299696 [PubMed - in process]

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Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study.

BMJ. 2010;340:c309

Authors: Pronovost PJ, Goeschel CA, Colantuoni E, Watson S, Lubomski LH, Berenholtz SM, Thompson DA, Sinopoli DJ, Cosgrove S, Sexton JB, Marsteller JA, Hyzy RC, Welsh R, Posa P, Schumacher K, Needham D

OBJECTIVES: To evaluate the extent to which intensive care units participating in the initial Keystone ICU project sustained reductions in rates of catheter related bloodstream infections. Design Collaborative cohort study to implement and evaluate interventions to improve patients’ safety. SETTING: Intensive care units predominantly in Michigan, USA. INTERVENTION: Conceptual model aimed at improving clinicians’ use of five evidence based recommendations to reduce rates of catheter related bloodstream infections rates, with measurement and feedback of infection rates. During the sustainability period, intensive care unit teams were instructed to integrate this intervention into staff orientation, collect monthly data from hospital infection control staff, and report infection rates to appropriate stakeholders. MAIN OUTCOME MEASURES: Quarterly rate of catheter related bloodstream infections per 1000 catheter days during the sustainability period (19-36 months after implementation of the intervention). RESULTS: Ninety (87%) of the original 103 intensive care units participated, reporting 1532 intensive care unit months of data and 300 310 catheter days during the sustainability period. The mean and median rates of catheter related bloodstream infection decreased from 7.7 and 2.7 (interquartile range 0.6-4.8) at baseline to 1.3 and 0 (0-2.4) at 16-18 months and to 1.1 and 0 (0.0-1.2) at 34-36 months post-implementation. Multilevel regression analysis showed that incidence rate ratios decreased from 0.68 (95% confidence interval 0.53 to 0.88) at 0-3 months to 0.38 (0.26 to 0.56) at 16-18 months and 0.34 (0.24-0.48) at 34-36 months post-implementation. During the sustainability period, the mean bloodstream infection rate did not significantly change from the initial 18 month post-implementation period (-1%, 95% confidence interval -9% to 7%). CONCLUSIONS: The reduced rates of catheter related bloodstream infection achieved in the initial 18 month post-implementation period were sustained for an additional 18 months as participating intensive care units integrated the intervention into practice. Broad use of this intervention with achievement of similar results could substantially reduce the morbidity and costs associated with catheter related bloodstream infections.

PMID: 20133365 [PubMed - in process]

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Non-invasive cardiac stress testing before elective major non-cardiac surgery: population based cohort study.

BMJ. 2010;340:b5526

Authors: Wijeysundera DN, Beattie WS, Austin PC, Hux JE, Laupacis A

OBJECTIVE: To determine the association of non-invasive cardiac stress testing before elective intermediate to high risk non-cardiac surgery with survival and hospital stay. DESIGN: Population based retrospective cohort study. SETTING: Acute care hospitals in Ontario, Canada, between 1 April 1994 and 31 March 2004. PARTICIPANTS: Patients aged 40 years or older who underwent specific elective intermediate to high risk non-cardiac surgical procedures. INTERVENTIONS: Non-invasive cardiac stress testing performed within six months before surgery. MAIN OUTCOME MEASURES: Postoperative one year survival and length of stay in hospital. RESULTS: Of the 271 082 patients in the entire cohort, 23 991 (8.9%) underwent stress testing. After propensity score methods were used to reduce important differences between patients who did or did not undergo preoperative stress testing and assemble a matched cohort (n=46 120), testing was associated with improved one year survival (hazard ratio (HR) 0.92, 95% CI 0.86 to 0.99; P=0.03) and reduced mean hospital stay (difference -0.24 days, 95% CI -0.07 to -0.43; P<0.001). In an analysis of subgroups defined by Revised Cardiac Risk Index (RCRI) class, testing was associated with harm in low risk patients (RCRI 0 points: HR 1.35, 95% CI 1.05 to 1.74), but with benefit in patients who were at intermediate risk (RCRI 1-2 points: 0.92, 95% CI 0.85 to 0.99) or high risk (RCRI 3-6 points: 0.80, 95% CI 0.67 to 0.97). CONCLUSIONS: Preoperative non-invasive cardiac stress testing is associated with improved one year survival and length of hospital stay in patients undergoing elective intermediate to high risk non-cardiac surgery. These benefits principally apply to patients with risk factors for perioperative cardiac complications.

PMID: 20110306 [PubMed - in process]

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Neuraminidase inhibitors for preventing and treating influenza in healthy adults: systematic review and meta-analysis.

BMJ. 2009;339:b5106

Authors: Jefferson T, Jones M, Doshi P, Del Mar C

OBJECTIVES: To update a 2005 Cochrane review that assessed the effects of neuraminidase inhibitors in preventing or ameliorating the symptoms of influenza, the transmission of influenza, and complications from influenza in healthy adults, and to estimate the frequency of adverse effects. Search strategy An updated search of the Cochrane central register of controlled trials (Cochrane Library 2009, issue 2), which contains the Acute Respiratory Infections Group’s specialised register, Medline (1950-Aug 2009), Embase (1980-Aug 2009), and post-marketing pharmacovigilance data and comparative safety cohorts. Selection criteria Randomised placebo controlled studies of neuraminidase inhibitors in otherwise healthy adults exposed to naturally occurring influenza. MAIN OUTCOME MEASURES: Duration and incidence of symptoms; incidence of lower respiratory tract infections, or their proxies; and adverse events. DATA EXTRACTION: Two reviewers applied inclusion criteria, assessed trial quality, and extracted data. Data analysis Comparisons were structured into prophylaxis, treatment, and adverse events, with further subdivision by outcome and dose. RESULTS: 20 trials were included: four on prophylaxis, 12 on treatment, and four on postexposure prophylaxis. For prophylaxis, neuraminidase inhibitors had no effect against influenza-like illness or asymptomatic influenza. The efficacy of oral oseltamivir against symptomatic laboratory confirmed influenza was 61% (risk ratio 0.39, 95% confidence interval 0.18 to 0.85) at 75 mg daily and 73% (0.27, 0.11 to 0.67) at 150 mg daily. Inhaled zanamivir 10 mg daily was 62% efficacious (0.38, 0.17 to 0.85). Oseltamivir for postexposure prophylaxis had an efficacy of 58% (95% confidence interval 15% to 79%) and 84% (49% to 95%) in two trials of households. Zanamivir performed similarly. The hazard ratios for time to alleviation of influenza-like illness symptoms were in favour of treatment: 1.20 (95% confidence interval 1.06 to 1.35) for oseltamivir and 1.24 (1.13 to 1.36) for zanamivir. Eight unpublished studies on complications were ineligible and therefore excluded. The remaining evidence suggests oseltamivir did not reduce influenza related lower respiratory tract complications (risk ratio 0.55, 95% confidence interval 0.22 to 1.35). From trial evidence, oseltamivir induced nausea (odds ratio 1.79, 95% confidence interval 1.10 to 2.93). Evidence of rarer adverse events from pharmacovigilance was of poor quality or possibly under-reported. CONCLUSION: Neuraminidase inhibitors have modest effectiveness against the symptoms of influenza in otherwise healthy adults. The drugs are effective postexposure against laboratory confirmed influenza, but this is a small component of influenza-like illness, so for this outcome neuraminidase inhibitors are not effective. Neuraminidase inhibitors might be regarded as optional for reducing the symptoms of seasonal influenza. Paucity of good data has undermined previous findings for oseltamivir’s prevention of complications from influenza. Independent randomised trials to resolve these uncertainties are needed.

PMID: 19995812 [PubMed - indexed for MEDLINE]

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Lying obliquely–a clinical sign of cognitive impairment: cross sectional observational study.

BMJ. 2009;339:b5273

Authors: Kraft P, Gadeholt O, Wieser MJ, Jennings J, Classen J

OBJECTIVE: To determine if failure to spontaneously orient the body along the longitudinal axis of a hospital bed when asked to lie down is associated with cognitive impairment in older patients. DESIGN: Cross sectional observational study. SETTING: Neurology department of a university hospital in Germany. PARTICIPANTS: Convenience sample of 110 older (>or=60 years) inpatients with neurological conditions and 23 staff neurologists. MAIN OUTCOME MEASURES: The main outcome measure was the association between the angle of the body axis and the results of three cognitive screening tests (mini-mental state examination, DemTect, and clock drawing test). Staff doctors were shown photographs of a model taken at a natural viewing able to determine their subjective perspective of what constitutes oblique. RESULTS: 110 neurological inpatients (mean age 70.9 (SD 6.8) years) were included after exclusions. Evidence of cognitive impairment was found in 34, with scores indicating dementia in eight, according to the mini-mental state examination, and in 11 according to the DemTect. Across all patients, the mean angular deviation of the body axis from the longitudinal axis of the bed (range 0-23 degrees ) correlated linearly with the mini-mental state examination (r=-0.480), DemTect (r=-0.527), and the clock drawing test (r=-0.552) scores (P<0.001 for all), even after removing age as a covariate. Overall, 90% of staff neurologists considered a minimal body angle of 7 degrees to be oblique. Angular deviation of at least 7 degrees predicted cognitive impairment according to the three different tests, with specificities between 89% and 96% and sensitivities between 27% and 50%. CONCLUSION: Clinicians might suspect cognitive impairment in mobile older inpatients with neurological disorders who spontaneously position themselves obliquely when asked to lie on a bed.

PMID: 20015907 [PubMed - indexed for MEDLINE]

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Investigating suspected bone infection in the diabetic foot.

BMJ. 2009;339:b4690

Authors: Teh J, Berendt T, Lipsky BA

PMID: 19965936 [PubMed - in process]

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Hepatocellular carcinoma for the non-specialist.

BMJ. 2009;339:b5039

Authors: Kumagi T, Hiasa Y, Hirschfield GM

PMID: 19965932 [PubMed - in process]

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Fall in swine flu cases may not signal an end of the epidemic, warns Professor Donaldson.

BMJ. 2009;339:b5329

Authors: Mashta O

PMID: 19969608 [PubMed - in process]

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