Brian Hurwitz

Explaining differences in English hospital death rates using routinely collected data

Objectives: To ascertain hospital inpatient mortality in England and to determine which factors best explain variation in standardised hospital death ratios. Design: Weighted linear regression analysis of routinely collected data over four years, with hospital standardised mortality ratios as the dependent variable. Setting: England. Subjects:Eight million discharges from NHS hospitals when the primary diagnosis was one of the diagnoses accounting for 80% of inpatient deaths. Main outcome measures: Hospital standardised mortality ratios and predictors of variations in these ratios. Results: The four year crude death rates varied across hospitals from 3.4% to 13.6% (average for England 8.5%), and standardised hospital mortality ratios ranged from 53 to 137 (average for England 100). The percentage of cases that were emergency admissions (60% of total hospital admissions) was the best predictor of this variation in mortality, with the ratio of hospital doctors to beds and general practitioners to head of population the next best predictors. When analyses were restricted to emergency admissions (which covered 93% of all patient deaths analysed) number of doctors per bed was the best predictor. Conclusion: Analysis of hospital episode statistics reveals wide variation in standardised hospital mortality ratios in England. The percentage of total admissions classified as emergencies is the most powerful predictor of variation in mortality. The ratios of doctors to head of population served, both in hospital and in general practice, seem to be critical determinants of standardised hospital death rates; the higher these ratios, the lower the death rates in both cases.

Narrative Research in Health and Illness

© 2004 by BMA. All rights reserved. This comprehensive book celebrates the coming of age of narrative in health care. It uses narrative to go beyond the patients story and address social, cultural, ethical, psychological, organizational and linguistic issues. This book has been written to help health professionals and social scientists to use narrative more effectively in their everyday work and writing. The book is split into three, comprehensive sections; Narratives, Counter-narratives and Meta-narratives.

Interventions in primary care to reduce medication related adverse events and hospital admissions: systematic review and meta-analysis

Objective: To identify and evaluate studies of interventions in primary care aimed at reducing medication related adverse events that result in morbidity, hospital admission, and/or mortality. Methods: Fourteen electronic databases were systematically searched for published and unpublished data. Bibliographies of retrieved papers were searched and experts and first authors contacted in an attempt to locate additional studies. There were no restrictions on language of publication. All interventions applied in primary care settings which aimed to improve patient safety by reducing adverse events resulting from medication overuse or misuse were considered. Randomised controlled trials, controlled trials, controlled before and after studies, and interrupted time series studies were eligible for inclusion. Study quality assessment and data extraction were undertaken using the Cochrane Effective Practice and Organisation of Care data collection checklist and template. Meta-analysis was performed using a random effects model. Results: 159 studies were initially identified, of which 38 satisfied our inclusion criteria. These were categorised as follows: 17 pharmacist-led interventions (of which 15 reported hospital admissions as an outcome); eight interventions led by other primary healthcare professionals that reported preventable drug related morbidity as an outcome; and 13 complex interventions that included a component of medication review aimed at reducing falls in the elderly (the outcome being falls). Meta-analysis found that pharmacist-led interventions are effective at reducing hospital admissions (OR 0.64 (95% CI 0.43 to 0.96)), but restricting analysis to the randomised controlled trials failed to demonstrate significant benefit (OR 0.92 (95% CI 0.81 to 1.05)). Pooling the results of studies in the other categories did not demonstrate any significant effect. Conclusions: There is relatively weak evidence to indicate that pharmacist-led medication reviews are effective in reducing hospital admissions. There is currently no evidence for the effectiveness of other interventions which aim at reducing admissions or preventable drug related morbidity. More randomised controlled trials of primary care based pharmacist-led interventions are needed to decide whether or not this intervention is effective in reducing hospital admissions.

Legal and political considerations of clinical practice guidelines

In the 4th century BC, Plato explored the difference between skills grounded in practical expertise and those based solely on following instructions or obeying rules. Using the clinician as his model, he set up a thought experiment: doctors would be stripped of their clinical freedom—“no longer allowed unchecked authority”—but would form themselves into councils to determine majority views about how to practise medicine in all situations.1 Platos notion of codifying the majority decisions of panels (composed of clinical and non-clinical members) and publishing their work in order to influence (Plato says to dictate) “the ways in which the treatment of the sick is practised”1 prefigures many of the impulses which animate the clinical guidelines movement today. In Platos view, important hallmarks of expertise include flexible responsiveness and “improvisatory ability”—an approach to practice endangered, he believed, by use of guidelines.1 However effective health care by guideline turned out to be—and Plato was prepared to concede its potential—it remained in his view a debased form of practice, firstly because guidelines presuppose an average patient rather than the particular patient whom a doctor is endeavouring to treat, and secondly because the knowledge and analysis that go into the creation of guidelines are not rooted in the mental processes of clinicians, but in the minds of guideline developers distant from the consultation. Similar concerns trouble present day clinicians (box). #### Summary points Clinical guidelines cannot offer doctors thoughtproof mechanisms for improving medical care However well linked to evidence, clinical guidelines need to be interpreted sensibly and applied with discretion Under UK common law, minimum acceptable standards of clinical care derive from responsible customary practice, not from guidelines If clinicians implement faulty guidelines it is they, rather than the authors of such guidelines, who are likely to increase their liability in negligence The NHS Executive …

Ethnic variations in UK asthma frequency, morbidity, and health-service use: a systematic review and meta-analysis

BACKGROUND The frequency of asthma varies between countries, and may also vary between ethnic groups in more geographically confined areas. We sought evidence of such ethnic variations in the UK for asthma frequency, morbidity, and health-services use, and to understand possible reasons for any differences. METHODS We searched MEDLINE, EMBASE, CINAHL, PSYCHInfo, PREMEDLINE, HEALTHSTAR, Cambridge Register of Conference Abstracts, the Dissertation and Thesis Database, and the National Registry of Research. Additionally, we searched the bibliographies of reports identified and websites of health authorities, and contacted experts in this discipline. Our main outcomes were comparisons of asthma rate, morbidity, and health-services use. We did meta-analyses using random-effects models. FINDINGS 13 studies contained relevant data. All prevalence studies were of children and showed that south Asian children had a lower frequency of symptoms suggestive of asthma compared with black and white children (pooled rate of history of wheeze in the previous 12 months: south Asians 9.6% [95%CI 8.0-11.2%], black people 16.2% [12.8-19.6%], white people 14.6% [11.5-17.8%]). The pooled frequency of clinician-diagnosed asthma in children followed a similar pattern (south Asians 7.6% [3.7-11.4%], black people 15.0% [3.5-26.5%], white people 10.6% [4.6-16.7%]. However, relative to white people, the risk of admission for asthma in children and adults was higher for south Asians (odds ratio 2.9 [2.4-3.4]) and black people (2.1 [1.8-2.5]). INTERPRETATION The differences in admission are not explained by differences in asthma frequency between groups; they could relate to ethnic variations in asthma severity, differences in health-seeking behaviour, or difficulties in accessing high-quality primary care services.

Donors' attitudes towards body donation for dissection

We report a survey in the UK of potential whole-body donors for dissection. 218 people (age range 19-97 years) answered a postal questionnaire, giving information about themselves, their reasons for donation, attitudes towards the dead body, funeral preferences and medical giving and receiving. In addition to altruism, motives included the wish to avoid funeral ceremonies, to avoid waste, and in a few cases, to evade the expense of a funeral. 44% understood that their bodies would be used as teaching material, 42% for experiments. Whilst 69% believed in one or more supernatural phenomena, only 39% said they were religious. 69% requested cremation after dissection; 2% wanted to be buried. The notion of money incentives to promote donation was overwhelmingly rejected.

Narrative and the practice of medicine

1Clinicians spend their lives in the midst of narrative: listening to story fragments, interpreting word sequences, observing gesture, deciphering symptoms, ascribing causes, and suggesting treatments. We are creatures, says the writer Italo Calvino, “possessed of an ocean of words”, who offer ourselves to each other as links in stories that go on and on. 2 Clinical practice is predicated upon recognising and responding to such links—whether symptom, sign, expression, mood, behaviour pattern, or feeling. What is narrative? A narrative is a pattern of events placed in an order of sorts, involving a succession of occurrences or recounted experiences from which a chronological sequence may be inferred. Temporal succession alone cannot make a story, but what has been termed the principle of “and then” coupled with a notion of causality which gives meaning to phrases such as “that’s why” and “therefore” underpins a narrative coherence to events recounted. 3

How does evidence based guidance influence determinations of medical negligence

> “Any doctor not fulfilling the standards and quality of care in the appropriate treatment that are set out in these Clinical Guidelines, will have this taken into account if, for any reason, consideration of their performance in this clinical area is undertaken.” Department of Health, 1999.1 Evidence based guidance arguably offers the most trustworthy advice available to clinicians concerning medical management. Their authoritative status may explain why clinical guidelines are sometimes prefaced with vague warnings that link guideline compliance with accountability. But how authoritative can guidelines actually be, and does evidence based guidance entirely supplant clinical discretion? The legal status of evidence based guidance is examined, including whether guidelines from the National Institute for Clinical Excellence (NICE) should be understood to carry special importance in helping courts to decide whether or not allegations of negligence should be upheld. Evidence is a generic notion of great importance to many practices and enquiries. Cardinal to spying, journalism, historical and scientific research, and the practice of medicine, semantically the term bundles together two approaches to supporting belief, perception, and understanding. Whether evidence refers to marks or indications conspicuous to an observer, to reasoning and judgment about such indications, or to analysis of data arising from experiments, evidence leads on to and supports hypotheses and conclusions, however provisional and conditional. Evidence—and the more recently minted compound term “evidence based”—refers to reliable observational, inferential, or experimental information forming part of the grounds for upholding or rejecting claims or beliefs. Evidence based medicine (EBM) has not developed a new concept of evidence2; its major contribution lies in the emphasis it places on a hierarchy of evidential reliability, in which conclusions related to evidence from controlled experiments are accorded greater credibility than conclusions grounded in other sorts of evidence. Since studies underpinning most medical …

House dust mite avoidance measures for perennial allergic rhinitis: an updated Cochrane systematic review.

To cite this article: Nurmatov U, van Schayck CP, Hurwitz B, Sheikh A. House dust mite avoidance measures for perennial allergic rhinitis: an updated Cochrane systematic review. Allergy 2012; 67: 158–165.

Swearing to care: the resurgence in medical oaths

We are witnessing a resurgence of professional interest in medical oaths and codes of conduct. In the United Kingdom the General Medical Council has reissued its professional code and, together with the BMA, the royal colleges, and other organisations, has published a document on the “core values” of medical practice.1 2 There has been discussion of the role of oath taking at the end of medical training, and the BMA has drafted a new Hippocratic Oath on behalf of the World Medical Association (see third box).3 4 5 6 7 8 9 10 11 The American Medical Association has this year commemorated the 150th anniversary of its 1847 Code of Ethics with an extensive debate on the relevance of oaths and codes to modern practice.12 13 14 #### Declaration of Geneva “At the time of being admitted as a Member of my Profession: I solemnly pledge myself to consecrate my life to the service of humanity; I will give to my teachers the respect and gratitude which is their due; I will practice my profession with conscience and dignity; The health of those in my care will be my first consideration; I will respect the secrets that are confided in me, even after the patient has died; I will maintain by all the means in my power, the honour and the noble traditions of my profession; My colleagues will be my sisters and brothers; I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, or social standing to intervene between my duty and my patient; I will maintain the utmost respect for human life from its beginning, even under threat, and I will not use my specialist knowledge contrary to the laws of humanity; I make these promises solemnly, freely, and …