This week in the BMJ
Volume 327, Number 7406, Issue of 12 Jul 2003Lobectomy mortality is a poor measure of surgical performance
Lobectomy mortality is a poor measure of surgical performance
Mortality from lobectomy for primary lung cancer is a poor means of measuring surgeons' performance. Treasure and colleagues (p 73) analysed the mortality data for lung cancer surgery that thoracic surgeons are obliged to report for standards monitoring. Data from the Society of Cardiothoracic Surgeons of Great Britain and Ireland show a wide range of surgical volume, which reflects the widespread mixed practice of cardiothoracic surgery in the United Kingdom. They found no significant relation between in-hospital mortality and the number of operations performed by the surgeon. The data are not risk adjusted; the authors argue that the most likely effect of these data is to reduce the number of cancer operations by encouraging surgeons to avoid high risk cases.
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Extracorporeal shock wave therapy fails to help plantar fasciitis
Extracorporeal shock wave therapy works no better than placebo for plantar fasciitis. In a randomised, blinded, multicentre trial with 272 patients in Germany, Haake and colleagues (p 75) found no benefit from extracorporeal shock wave therapy versus placebo for treating chronic plantar fasciitis. At 12 weeks' follow up, the success rate of the shock wave therapy was 34%, compared with 30% with placebo. Improvement rates were similar after three months and one year in both groups.
Homeless people are more likely to die early
Homeless people staying in hostels, particularly young women, are more likely than the general population to die early. Nordentoft and Wandall-Holm (p 81) studied two samples of homeless people staying in hostels in Copenhagen in 1991. Ten years later they found that homeless people were four times more likely to die early than people in the general Danish population. Mortality was especially high in homeless people aged 15 to 34 years. Predictors of early death were short stay in the hostel; adverse childhood experiences, particularly the death of the father; and misuse of alcohol and sedatives.
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Joint teleconsultations are likely to increase costs to the NHS
Virtual outreach consultations cost more than standard outpatient appointments. In an economic evaluation that was conducted alongside a randomised controlled trial, Jacklin and colleagues (p 84) found that the costs to the NHS of a virtual outreach consultation were £100 ($166; €145) more than for a conventional outpatient appointment. Patients preferred virtual outreach consultations and these made an average saving of £8, but the authors did not find evidence of improved health status at six months. The authors contend that there is little economic justification for the widespread adoption of virtual outreach services in the NHS, but the cost effectiveness of such services could be improved by better selection of patients and by improvements in technology.
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Women need full information for breast screening decisions
The value of routine mammography is debated, but women must be the ones to make informed choices about the screening examination. Thornton and colleagues (p 101) argue that the focus of the debate in the media and among scientists on the efficacy of mammography misses the point. Women must be empowered to make individual decisions about screening, which the authors say are essentially value judgments. This can be facilitated by providing women with full information on harms and benefits, and doing so in a way that is understandable. The authors state that unless women are able to make true informed choices, support and funding for routine mammography will continue to be questioned.
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Evidence based interventions can prevent fractures in elderly people
Fractures among elderly people represent an important and preventable public health problem. In a clinical review on the topic, Woolf and Akesson (p 89) state that prevention of fractures involves reducing falls, minimising the morbidity associated with falls, and maximising bone strength at all ages. Pharmacological treatment is most cost effective for people at high risk: women, people over 75 years old, and elderly patients with osteoporosis or previous falls. Frailty and comorbidity are also associated with risk of fractures. The authors outline a selective case finding approach to help clinicians recognise and treat elderly patients at risk.
