Christopher Bulstrode

Elective total hip replacement: incidence, emergency readmission rate, and postoperative mortality.

OBJECTIVES--To report the incidence of elective total hip replacement and postoperative mortality, emergency readmission rates, and the demographic factors associated with these rates in a large defined population. DESIGN--Analysis of linked, routine abstracts of hospital inpatient records and death certificates. SETTING--10 hospitals in six districts in Oxford Regional Health Authority covered by the Oxford record linkage study. SUBJECTS--Records for 11,607 total hip replacements performed electively in 1976-85. MAIN OUTCOME MEASURES--Incidence of operation, postoperative mortality, relative mortality ratios, and incidence of emergency readmission. RESULTS--NHS operation rates increased over time from 43 to 58 operations/100,000 population. Variation in operation rates between districts reduced over time. Operation rates were on average 25% higher in women than men. There were 93 deaths (11/1000 operations) within 90 days of the operation and 208 emergency readmissions (28/1000 operations) within 28 days of discharge. Postoperative mortality and emergency readmission rates increased with age. No significant trend with time was found. Mortality in the 90 days after the operation was 2.5-fold higher (1.9 to 3.0) than in the rest of the first postoperative year. This represented an estimated excess of 6.5 (4.2 to 8.8) early postoperative deaths/1000 operations. Most deaths were ascribed to cardiovascular events. Thromboembolic disease was the commonest reason for emergency readmission. CONCLUSIONS--The pronounced increase in operations in districts with initially low rates suggests a trend towards greater equity in the local provision of NHS hip arthroplasty. The early postoperative clusters of deaths attributed to cardiovascular disease and of readmissions for thromboembolic disease suggest that there is scope for investigating ways of reducing the incidence of major adverse postoperative events.

Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study

Abstract Objectives: To determine whether a serious paracetamol overdose in the medical television drama Casualty altered the incidence and nature of general hospital presentations for deliberate self poisoning. Design: Interrupted time series analysis of presentations for self poisoning at accident and emergency departments during three week periods before and after the broadcast. Questionnaire responses collected from self poisoning patients during the same periods. Setting: 49 accident and emergency departments and psychiatric services in United Kingdom collected incidence data; 25 services collected questionnaire data. Subjects: 4403 self poisoning patients; questionnaires completed for 1047. Main outcome measures: Change in presentation rates for self poisoning in the three weeks after the broadcast compared with the three weeks before, use of paracetamol and other drugs for self poisoning, and the nature of overdoses in viewers of the broadcast compared with non-viewers. Results: Presentations for self poisoning increased by 17% (95% confidence interval 7% to 28%) in the week after the broadcast and by 9% (0 to 19%) in the second week. Increases in paracetamol overdoses were more marked than increases in non-paracetamol overdoses. Thirty two patients who presented in the week after the broadcast and were interviewed had seen the episode—20%said that it had influenced their decision to take an overdose, and 17% said it had influenced their choice of drug. The use of paracetamol for overdose doubled among viewers of Casualtyafter the episode (rise of 106%; 28% to 232%). Conclusions: Broadcast of popular television dramas depicting self poisoning may have a short term influence in terms of increases in hospital presentation for overdose and changes in the choice of drug taken. This raises serious questions about the advisability of the media portraying suicidal behaviour.

Workload in trauma and orthopaedic surgery: use of linked statistics to profile a specialty.

We have used linked hospital morbidity statistics to construct a basic profile of the demographic and epidemiological features of trauma and orthopaedic surgery in a defined population. This paper reports on this profile and illustrates trends in the specialty between 1976–86. During this period episode-based inpatient admission rates rose by about 20%. Multiple admissions per person varied with age but did not increase over time. Thus the increase in admission rates in this specialty represented an increase in numbers of people who received treatment. Average length of stay per episode of inpatient care and the total time spent in hospital per person declined over time. New outpatient attendance rates increased by 19% in the 11-year period. The ratio of follow-up outpatient appointments to new appointments fell from 2.68:1 to 2.24:1; the number of inpatient beds fell by about 13% and bed occupancy remained stable at about 80%. We describe some of the major components of clinical workload in the specialty, with emphasis on conditions for which admission rates changed over time, relating the data to numbers of people treated as well as to episodes of care.

NCAA has not been given sufficient tools to identify poorly performing doctors.

EDITOR—The government has announced a new organisation, the National Clinical Assessment Authority (NCAA), which is apparently charged with identifying poorly performing doctors. It is, however, in danger of failing to do its task because it has not been given the tools it needs to achieve this.1 There are three types of regular review needed by any professionals who are entrusted with the safety of patients. The first meeting is for individual professionals. They may want a regular …

The traumas of casualty departments

Trauma care in Britain came in for a battering last week when the BBCs science programme QED screened a drama purporting to show a real life case of medical negligence. Christopher Bulstrode examines the controversy surrounding Cause of Death Mark was just a nice, ordinary lad on a big motorbike that crashed. He was fine when he got to the hospital, apart from a few broken bones, but then things started to go wrong. Within a few days he was in the intensive treatment unit after a cardiac arrest. His brain never recovered, and when they switched off the ventilator the family was left devastated. …