Many people receive suboptimal care after myocardial infarction, research showsBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2655 (Published 11 May 2016) Cite this as: BMJ 2016;353:i2655
All rapid responses
I had to see and experience a "Minor injury and out of hours GP" clinic. Serves a large city and some small towns and villages nearby. A Sunday morning.
There were a dozen children, adults of various ages and dsabilities. An old gentleman had a disabled lady holding on to him.
The staff were courteous and busy.
I learnt that although pus was taken out for culture and sensitivity, the specimen would not be sent to the bacteriology laboratory till Monday.
Two points arise.
Does a large hospital serving the district not provide bacteriology services on weekends?
If it does not, does this not increase morbidity and mortality?
Why do the Commissioners not provide a service for the children, staffed by paediatric doctors and paediatric nurses?
I ask: do the local members of parliament conduct unannounced visits to the local health facilities? I mean general practices, clinics, hospitals?
If not, why not?
I ask: does the local director of public health visit such facilities, unannounced? Or, does he/she just look at at statistical print outs. Are the bipeds in his parish ever considered as people? Or, just numbers?
Competing interests: Elderly patient.
I read the article by Jacqui Wise titled "Many people receive suboptimal care after myocardial infarction, research shows” in last week’s BMJ issue, with great interest. It has highlighted a very important topic and demonstrated the major impact suboptimal care has had on patient healthcare. Only a small percentage of patients were receiving interventions for which they were eligible.
Most patients did not receive dietary or smoking cessation advice after suffering an NSTEMI, despite these being simple yet effective interventions. Any member of the healthcare team could help make these interventions, as the patient will be in contact with the team during their hospital stay as well as after discharge. Making the healthcare team aware of these shortcomings and the development of a consistent approach to delivering such lifestyle advice could help with improvement.
It was interesting to also see that some patients were not receiving pharmacological therapy for secondary prevention of a myocardial infarction, such as aspirin and statins, as recommended by the National Institute for Health and Care Excellence. I had recently undertaken a re-audit of secondary prevention of myocardial infarctions in post-MI patients after they had had coronary artery bypass graft surgery, in a hospital I had a placement at. Some of the recommendations from this audit were that there could be electronic prompts on discharge forms to remind the healthcare team to prescribe these drugs. This may be of potential use on a wider scale as well.
In conclusion, as suggested by the article, it is good that these problems have been identified so solutions can be devised. It would also be valuable to investigate further about what other reasons there may be for these shortcomings. This will enable appropriate methods of dealing with these issues, to be identified, and hopefully result in the improvement of the care patients receive.
Competing interests: No competing interests
This paper is about the heart. Prof Javaid's response is about bones. Bariatric surgeons talk about the need for more bariatric surgery. Prof Modi, a paediatrician, talks about the lack of proper care for children. Others have mentioned blocked beds.
Is it not obvious that:
There are not enough bed
There are not enough staff (of every category)
There are not enough funds for the running expenses
There are not enough doctors, nurses, therapists in the so-called community to care for patients when discharged home or in to residential homes.
The fact that successive governments have spent billions on building new hospitals via PFIs, and on the obscenity called computerisation, is no fault of the patients.
Competing interests: Elderly patient
Secondary prevention after heart attack is important, but we are missing opportunities for secondary prevention in another very important area.
Every year half a million older adults present to the NHS with fractures of the wrist, hip or vertebrae. Patients with such fragility fractures are at high risk of further fractures. Evidence based secondary prevention interventions with medication and non-pharmacological measures (e.g. strength and balance training) could prevent 46,000 recurrent fractures in these patients including 20,000 hip fractures, within the subsequent 5 years.
Our recent audit, commissioned by the Healthcare Quality Improvement Partnership and managed by the Royal College of Physicians, of services to support this secondary prevention(1) illustrated many opportunities for quality improvement. The majority of acute hospitals in England and Wales do not have such services and many services that exist are inadequately resourced to provide for their local population needs. As a result 70% of patients with fragility fractures will receive inadequate clinical care and unfortunately many of these will go on to suffer a further fracture that could have been prevented. This causes unnecessary pain and disability for individuals, exposes those who suffer hip fracture to a high mortality risk and puts additional strain on already over stretched NHS services.
With a growing elderly population adequate provision of secondary prevention services is much better for patients and much more cost effective, both core for the future for the NHS.
1. The Royal College of Physicians. Fracture Liaison Service (FLS) Database facilities audit. FLS breakpoint: opportunities for improving patient care following a fragility fracture. London: Royal College of Physicians, 2016.
Competing interests: MK Javaid has in last five years received honoraria, travel and/or subsistence expenses from: Amgen, Eli Lilly, Medtronic, Norvartis, Proctor and Gamble, Servier, Shire, Internis, Consilient Health, Stirling Anglia Pharmaceuticals, Mereo Biopharma, Optasia