Performance tables do not make surgeons avoid high risk cases

A new study shows that the introduction of publicly available performance tables in the United Kingdom showing mortality after major cardiac surgery by individual surgeons did not result in fewer procedures being performed on high risk patients, as critics had predicted. The study also shows an association between the introduction of the tables and a decrease in mortality.

The study, published online in the journal Heart, analysed data that were collected prospectively from all NHS centres in northwest England that undertake cardiac surgery. The data covered 25 730 patients undergoing coronary artery bypass grafting for the first time between April 1997 and March 2005. Figures were for 30 different surgeons in four major NHS sites.

The researchers compared surgery carried out before and after individual cardiac surgeons' outcomes became public in 2001, to determine whether some surgeons had become more averse to risk, operating only on patients with a lower risk of complications or death. They also assessed the effect of the introduction of the tables on patients' mortality.

They used the EuroSCORE risk scoring system for patients undergoing cardiac surgery to divide them into low risk, high risk, and very high risk patients. Analysis of data before and after public disclosure of surgeons' performance showed that the number of high risk patients undergoing cardiac surgery rose rather than fell—from 449 (14% of all patients who underwent surgery) before public disclosure to 547 (17%) afterwards. The number of patients at very high risk who underwent surgery also rose slightly, from 41 (1.3%) to 47 (1.4%). The proportion of patients aged over 80 and of those with kidney disease, a recent heart attack, or peripheral vascular disease all increased significantly. In contrast, the number of patients at low risk who underwent surgery fell slightly, from 2694 (85%) before disclosure to 2654 (82%) afterwards.

Observed mortality fell from 2.4% in 1997-8, before disclosure, to 1.8% in 2004-5—even though the expected mortality (based on EuroSCORE) rose from 3.0 to 3.5, indicating that more complicated cases or more elderly people were being taken on. Overall, the ratio of observed to expected mortality decreased from 0.8 to 0.5.

Cardiac surgery is currently the only area of medicine in the UK for which data on individual surgeons are disclosed. This followed a public inquiry into the deaths of children undergoing cardiac surgery at Bristol Royal Infirmary in 2001, which recommended making individual heart surgeons' performance public.

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Diet and Obesity in Childhood

Controversial information exists on the contribution of several dietary factors for overweight development in childhood, but there is no doubt that obesity prevalence is increasing. A recent review looked at the most up-to-date information in order to clarify the evidence-based dietary aspects influencing obesity development in children and adolescents.

Longitudinal studies are the preferred method for analysing the relationship between dietary factors and obesity development. With the exception of infants, there are no conclusive associations between energy intake or diet composition and later overweight development in children.

Among formula or mixed-fed infants, the increase in energy intake has been associated with an increased risk of being overweight during childhood. Breastfeeding seems to be a protective factor for later obesity development. In terms of food intake, longitudinal studies have only found a clear and positive association between obesity development and sugar-sweetened beverage consumption; this is not the case with snacking, fast food or food portion sizes.

Cross-sectional studies have found correlations between being overweight in childhood and buying lunch at school, eating supper while watching television or without family supervision, consuming less energy at breakfast or more at dinner, and missing breakfast.

Overall, results from longitudinal studies must be taken into account in order to design preventive strategies to counteract the increased prevalence of obesity and its consequences in children. Lack of breastfeeding, high early energy intake and high intake of sugar-sweetened beverages seem to be the main dietary factors contributing to obesity development.

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NICE guidance assessing children with fever

The National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Women and Children’s Health have (May 2007) issued a guideline on assessing and managing children with fever.

This is the first guideline to provide all healthcare professionals, including GPs, nurses, pharmacists and paediatricians with a practical tool to assess the symptoms of a child with fever and advise them on how they should be cared for within the appropriate setting.

Feverish illness is very common in young children, with between 20% and 40% of parents seeking healthcare for such an illness each year. Most fevers will settle by themselves but a few are caused by serious infections such as meningitis or pneumonia and infections remain the leading cause of death in children under the age of 5 years.

The guideline recommends that:

• Children with feverish illness should be assessed for the presence or absence of symptoms and signs that can be used to predict the risk of serious illness using the traffic light system tool.

• Children with any ‘red’ features (those who are at high risk) should be urgently assessed by a healthcare professional in a face-to-face setting.

• Parental perception of a fever should be considered valid and taken seriously by healthcare professionals.

• If symptoms suggest the child is not at a high risk and can be cared for at home, the parent or carer should be provided with a safety net of information which can include, verbal and/or written information on warning symptoms, direct access to other out-of-hours healthcare professionals and follow up appointments if required.

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