Statins in older people

A systematic review, described in Bandolier, examined five large randomised studies with just under 31,000 participants, where statin had been compared with placebo, and published before the end of 1998. Statins used were simvastatin and lovastatin on one each, and pravastatin in three, at various doses.

The main outcome for analysis was major coronary events, which included coronary death, nonfatal myocardial infarction, silent infarction, or resuscitated cardiac arrest, as well as unstable angina in one trial. Participants older than 65 years were included in four of the trials.

Risk was reduced by an average of 32% by statins in participants older than 65 years which was similar to the risk reduction in participants younger than 65 years (31%). A similar degree of risk reduction was seen in studies with high and low rates of previous myocardial infarction.

The number of older people needed to be treated with statins for at least five years to prevent one major coronary event was 23 (95% CI 17 to 33).

What we have here is a lot of information about statins in people older than 65 years. Over 25,000 have been included in well done clinical trials, and nearly half of them were over 70 years. There was a consistency of response over all the studies, irrespective of the statin and dose used, the duration, or the outcomes reported (Figure 1), and whether these older people were younger or older than 70 years.

Ref: web

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National Confidential Enquiries

Dr Peter Simpson is the new chairman of the expanded and renamed National Confidential Enquiry into Patient Outcomes and Deaths (NCEPOD).  The organisation, originally the National Confidential Enquiry into Perioperative Deaths, recently changed its name to reflect a wider remit but kept the same initials (NCEPOD) to ensure continuity in the public mind.

“Doctors know that their work is being looked at by ordinary, practising clinicians, not by ‘the great and the good’ who may be out of touch with day to day clinical practice,” Dr Simpson says.  “Local clinicians feel that they have ownership of the process, in that they can be involved as advisers, and consider that the work the inquiry undertakes is relevant to their clinical practice.”

There is some evidence to indicate that its approach works.  An independent review of the inquiry, carried out in 1998, found that 1700 of 2195 consultants responding said that NCEPOD had influenced their clinical practice in at least one way.

“They considered that the greatest influence had been in the reduction of out of hours surgery, the completion of patients’ clinical notes in greater detail, and the provision of a higher degree of supervision to locums,” Dr Simpson noted.

“Another factor in the organisation’s success has been that its work is based on anonymised data, with no attempt to link events with particular doctors”, said Dr Simpson, who is an anaesthetist at Frenchay Hospital, Bristol.  “We support a blame-free approach as the best way of collecting the information needed to inform changes in practice.”

The watchdog also has teeth.  All hospitals, both NHS and independent, in the areas covered by the inquiry – England, Wales, Northern Ireland, Guernsey, and Jersey – are required to provide data requested by the organisation.  The General Medical Council has stated that taking part in inquiry audits is part of good medical practice, and the NHS requires trusts to take part in their confidential inquiries.

So-called ‘CEPOD’ operating theatres – which are fully resourced to deal with emergency cases – were introduced after an audit showed that emergencies had an adverse effect on elective surgery lists, as cases had to be delayed until the evening, night, or weekend.  Previously, the emergencies were left and were dealt with out of hours.  These specially resourced emergency operating theatres have significantly reduced the number of out of hours operations that take place.

Ref: Web

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Preventable adverse events in hospitals

This BMJ paper looked at adverse events in hospital.

The review of medical records is considered the benchmark for estimating the extent of medical injuries in hospitals.  The limitations of this retrospective method and the assessment of other objectives, such as the impact of risk reduction programmes and organisational and human factors, mean that alternative methods are needed. 

This study compared prospective and cross sectional methods for data collection with review of medical records for assessing rates of adverse events and rates of preventable adverse events in acute care hospitals in France.

The study aimed to compare the effectiveness, reliability, and acceptability of estimating rates of adverse events and rates of preventable adverse events using three methods: cross sectional (data gathered in one day), prospective (data gathered during hospital stay), and retrospective (review of medical records).

This was carried out in 37 wards in seven hospitals (three public, four private) in Southwestern France. 778 patients: medical (n=278), surgical (n=263), and obstetric (n=237) were included.

The main outcome measures were the proportion of cases (patients with at least one adverse event) identified by each method compared with a reference list of cases confirmed by ward staff and the proportion of preventable cases (patients with at least one preventable adverse event).  Secondary outcome measures were inter-rater reliability of screening and identification, perceived workload, and face validity of results.

The prospective and retrospective methods identified similar numbers of medical and surgical cases (70% and 66% of the total, respectively) but the prospective method identified more preventable cases (64% and 40% respectively), had good reliability for identification (k=0.83), represented an acceptable workload, and had higher face validity.  The cross sectional method showed a large number of false positives and identified none of the most serious adverse events.  None of the methods was appropriate for obstetrics.

Overall the prospective method of data collection may be more appropriate for epidemiological studies that aim to convince clinical teams that their errors contribute significantly to adverse events, to study organisational and human factors, and to assess the impact of risk reduction programmes.

Ref: Web

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