This week in the BMJ

Volume 327, Number 7406, Issue of 12 Jul 2003

Lobectomy mortality is a poor measure of surgical performance
Extracorporeal shock wave therapy fails to help plantar fasciitis
Homeless people are more likely to die early
Joint teleconsultations are likely to increase costs to the NHS
Women need full information for breast screening decisions
Evidence based interventions can prevent fractures in elderly people

Lobectomy mortality is a poor measure of surgical performance

Mortality from lobectomy for primary lung cancer is a poor meansof measuring surgeons' performance. Treasure and colleagues (p 73) analysed the mortality data for lung cancer surgerythat thoracic surgeons are obliged to report for standardsmonitoring. Data from the Society of Cardiothoracic Surgeonsof Great Britain and Ireland show a wide range of surgical volume, which reflects the widespread mixed practice of cardiothoracicsurgery in the United Kingdom. They found no significant relationbetween in-hospital mortality and the number of operationsperformed by the surgeon. The data are not risk adjusted; theauthors argue that the most likely effect of these data isto reduce the number of cancer operations by encouraging surgeonsto avoid high risk cases.

Extracorporeal shock wave therapy fails to help plantar fasciitis

Extracorporeal shock wave therapy works no better than placebofor plantar fasciitis. In a randomised, blinded, multicentretrial with 272 patients in Germany, Haake and colleagues (p 75)found no benefit from extracorporeal shock wave therapyversus placebo for treating chronic plantar fasciitis. At 12weeks' follow up, the success rate of the shock wave therapywas 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. Nordentoftand Wandall-Holm (p 81) studied two samples of homeless peoplestaying in hostels in Copenhagen in 1991. Ten years later theyfound that homeless people were four times more likely to dieearly than people in the general Danish population. Mortalitywas especially high in homeless people aged 15 to 34 years.Predictors of early death were short stay in the hostel; adversechildhood experiences, particularly the death of the father;and misuse of alcohol and sedatives.

Credit: FRANCIS DEAN/REX

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 alongsidea randomised controlled trial, Jacklin and colleagues (p 84)found that the costs to the NHS of a virtual outreach consultationwere £100 ($166; €145) more than for a conventionaloutpatient appointment. Patients preferred virtual outreachconsultations and these made an average saving of £8,but the authors did not find evidence of improved health statusat six months. The authors contend that there is little economicjustification for the widespread adoption of virtual outreachservices in the NHS, but the cost effectiveness of such servicescould be improved by better selection of patients and by improvementsin technology.

Credit: DENNIS COOK/AP

Women need full information for breast screening decisions

The value of routine mammography is debated, but women mustbe the ones to make informed choices about the screening examination.Thornton and colleagues (p 101) argue that the focus of thedebate in the media and among scientists on the efficacy of mammography misses the point. Women must be empowered to makeindividual decisions about screening, which the authors sayare essentially value judgments. This can be facilitated byproviding women with full information on harms and benefits,and doing so in a way that is understandable. The authors statethat unless women are able to make true informed choices, supportand funding for routine mammography will continue to be questioned.

Credit: JESSE/SPL

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, Woolfand Akesson (p 89) state that prevention of fractures involvesreducing falls, minimising the morbidity associated with falls,and maximising bone strength at all ages. Pharmacological treatmentis most cost effective for people at high risk: women, peopleover 75 years old, and elderly patients with osteoporosis or previous falls. Frailty and comorbidity are also associatedwith risk of fractures. The authors outline a selective casefinding approach to help clinicians recognise and treat elderlypatients at risk.