What distinguishes top-performing hospitals.....

In recent years, public reporting of hospitals' performance is becoming increasingly common in America to improve patient outcomes and accountability. Many hospitals have made substantial efforts in quality improvement including investing in high-tech equipments and systems, but disparities still persist between the highest and lowest performing hospitals in patient mortality rates.

According to a new study, conducted by Yale Global Health Leadership Institute at Yale University, published in the Annals of Internal Medicine, between 2005 and 2007, the 30-day mortality rates for Medicare heart attack patients ranged from 11.4%-14% among the high performers and 17.9%- 20% among the low.

Earlier studies suggested that the high mortality rates in low-performing hospitals could have been caused by factors such as hospital location, bed size, for-profit status, nurse staffing ratio and patient population, eg black, elderly. However, the Yale researchers found that these factors accounted for a small percentage of the variation between the high and low peforming hospitals.

They compared the characteristics of 11 hospitals ranking the top or bottom 5% measured by the 30-day mortality rates for acute myocardial infarction (AMI). They interviewed 158 key staff who were involved with AMI care at the hospitals and found few differences in protocols and processes used in treating heart attacks, but what differentiated the high performers from the low was how they did things - a shared organisational culture that focused on communication and support to improve patient care.

They found that high-performing hospitals were characterised by the followings :
- staff shared organisational values and goals of providing high quality care
- senior management involvement and commitment to high quality care

- broad staff presence and expertise in clinical decision making
- strong communication and coordination across disciplines and departments resulting in seamless transitions in care
- used adverse events and feedback as opportunities for problem solving that focused on nonpunitive learning

The study concluded that protocols and processes are not sufficient for achieving high performace in AMI care but "long-term investment and concerted efforts to create an organisational culture that supports full engagement in quality, strong communication and coordination .... problem solving and learning across the organisation" may be required.

Source: What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates? A Qualitative Study. Annals of Internal Medicine. March 14, 2011 vol. 154 no. 6 384-390 ( f/t via Athens)

Metformin still best first-line type 2 diabetes drug

According to a new review published online in Annals of Internal Medicine, there are numerous regimes of diabetes medications to treat type 2 diabetes in the US. Many of these patients need to take multiple medications to control their blood sugar levels, but they have side effects - hypoglycemia ( low blood sugar levels) is the the most common serious side effect, others include nausea or diarrhea.

Researchers at Johns Hopkins reviewed 166 studies that examined the efficacy of 6 classes of diabetes drugs. They found that most of the medications lowered blood sugar levels by a similar amount and that combination of 2 drugs improved blood sugar control, but no combination was shown to have significant benefits over another. The study found that metformin, an older drug approved in 1995 in the US, was consistently associated with fewer side effects and is cheaper than most newer drugs. Reserachers suggested metformin is probably the best first-line therapy for type 2 diabetes.

The study noted that 95 of the 166 studies reported drug company support, many of them were not long enough to study the side effects. The study leader said longer-term reserach into their impact on long-term outcome is needed .

Siurce: Comparative Effectiveness and Safety of Medications for Type 2 Diabetes: An Update Including New Drugs and 2-Drug Combinations. Annals of Internal Medicine, First published online on March 14, 2011 ( free f/t article)

Tamoxifen saves lives and costs

Research has shown that tamoxifen (Nolvadex) can protect against breast cancer but can have side effects including hot flashes, weight gain, abnormal menstrual periods and nausea.


To investigate those women who can most benefit from tamoxifen as a cancer preventive drug, US researchers analysed 4 randomised, placebo-controlled trials and assessed the effects that tamoxifen would have on breast cancer risk 10 years after the treatment.


Investigators used a mathematical model and found that in post-menopausal women under 55 who have an increased risk of developing breast cancer, the benefits of using tamoxifen to prevent cancer are sufficiently outweigh its side effects, it also saves costs.


Source: Cost-effectiveness of chemoprevention of breast cancer using tamoxifen in a postmenopausal US population. Cancer, 2011; published online 14 March 2011

Mediterranean diet reduces metabolic syndrome

Many studies have found that the Mediterranean diet reduces heart disease, but a new review, published in the Journal of the American College of Cardiology, examined the effects of the Mediterrean diet on the risk factors of cardiovascular diseases.

The researchers reviewed and analysed the results of 50 studies in the English language with more than 500,000 participants, they also evaluated the quality of each study. They found that eating the Mediterranean diet reduced the development of the metabolic syndrome as well as all the individual components such as high blood pressure, high blood sugar, high blood fat, low levels of good cholesterol and large waist circumference - these are the risk factors often precede the development of cardiovascular diseases.

They concluded that thier findings have considerable public health importance but noted several limitations in the study, eg the considerable heterogeneity among the studies which could affect the results - only 8 studies addressed the effects on all the metabolic syndrome risk factors, of which 2 were RCTs, 2 cohort studies and 4 cross-sectional studies.

Source: Kastorini CM, Milionis HJ, Esposito K et al. The Effect of Mediterranean Diet on Metabolic Syndrome and its Components: A Meta-Analysis of 50 Studies and 534,906 Individuals. Journal of the American College of Cardiology, 2011; 57:1299-1313

Current fever management in children is challenged

A new clinical report prepared by the American Academy of Pediatrics (AAP) and published in Pediatrics highlights the need to educate patients and families about fever in children.


It is not a new research but an expert commentary with the aim to challenge current practice on fever management in children, ie fever reduction.

They said that fever is a physiological mechanism in fighting infection, there is no evidence that fever causes long-term neurological complications. The report emphasizes improving the child’s overall comfort rather than concentrating in normalizing the body temperature.


Paracetamol and ibuprofen are the most commonly used antipyretics, but there are adverse effects and toxicity. The report said that it is critical to administer a safe dosage of these drugs and the correct dosage is based on the child's weight. However, many parents do not understand dosing instructions resulting in potential inaccurate or overdosing.


The authors call for better information for parents and concluded that in fever management, fever reduction should not be the primary aim but parents and healthcare professionals should be more vigilant for signs of serious illnesses.


Source: Sullivan JE, Farrar HC and the Section on Clinical Pharmacology and Clinical Report. Fever and Antipyretic Use in Children. Pediatrics 2011 , published online Feb 28

UK-trained doctors from ethnic minority groups underperform academically

A third of all UK medical students and junior doctors come from ethnic groups. In 2009, 36% of newly qualified doctors and 52% of all other NHS doctors were from these groups. A new study conducted by UCL researchers found that UK-trained medical students and doctors from ethnic minority groups underpeformed academically compared with their white counterparts. They systematically analysed 22 reports involving about 24,000 UK- trained medical students and doctors from different ethnic groups and found that the odds of failure in non-white candidates was 2.5 times higher than the white candidates. They said that ethnic differences in academic performance are widespread across different medical schools, different types of exams and in both undergraduate and postgraduate assessments. It was persistent for 30 years and "cannot be dismissed as atypical or local problems". They called for further research into the causes to ensure that all future doctors are assessed fairly. In an accompanying editorial, the author said that soultions will be found through critically appraising assessment methods, curricula and interactions with students.

What do you think may have caused the ethnic differences in attainment and how can they be resolved?

Source: Ethnicity and academic performance in UK trained doctors and medical students: systematic review and meta-analysis. BMJ 2011; 342:d901 ( free access) Editorial - Ethnicity and academic performance in the UK. BMJ 2011; 342:d709 ( free access)