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Babies given paracetamol are twice as likely to develop asthma by the age of six, the Daily Express has reported. The Daily Mirror also reported on the study, suggesting the brand Calpol, which contains paracetamol, could “boost” the risk of asthma.

The news is based on research that found that use of paracetamol before the age of 15 months was associated with a higher risk of children being predisposed to allergies at the age of six, as defined by skin prick tests. It also found that at the age of six, greater paracetamol use in the past year was linked to a greater chance of wheeze or asthma symptoms during the period.

While this study has found a number of associations, parents should not be concerned by this research or assume that paracetamol or Calpol may give their children asthma. This study has only found associations between paracetamol and asthma symptoms in a cross-sectional analysis, meaning that it has not established any cause-and-effect relationship between the two. As it stands, it may be the case that children with symptoms such as wheezing, a potential sign of asthma, were given paracetamol due to their existing symptoms. The study has a number of further limitations that mean its results need further verification, ideally through good quality clinical research.

Paracetamol is currently advised as safe to use for pain and fever in babies from the age of three months and, in certain circumstances, in babies between two and three months. It is important to follow instructions about doses.

 

Where did the story come from?

The study was carried out by researchers from the University of Otago, the University of Canterbury and Christchurch Hospital, all in New Zealand. It was funded by the Health Research Council of New Zealand and the David and Cassie Anderson Bequest (Wellington). The study was published in the peer-reviewed journal Clinical and Experimental Allergy.

The headline in the Daily Express, suggesting that paracetamol can double the risk of asthma for babies, is misleading since the study did not prove that paracetamol use caused asthma, merely that the two factors were associated. Furthermore, early paracetamol use was associated with an increased risk of atopy – a predisposition to allergy rather than allergy itself – as defined in a skin prick test.

However, the Express did include comments from the study’s lead author stating that more research is needed and from independent experts who say that the benefits of using paracetamol currently outweigh the potential risks. The Daily Mirror’s headline suggesting that childhood asthma may be “boosted by Calpol” is perhaps confusing. Calpol is only one brand name for paracetamol.

 

What kind of research was this?

This was a prospective cohort study that set out to investigate any possible association between paracetamol use in babies up to 15 months and the risk of asthma and allergic disease at 5-6 years. Cohort studies can follow large groups of people for several years and are often used to look at possible links between an exposure (in this case, paracetamol use) and health outcomes (allergy and asthma). However, on their own they cannot prove causation. Prospective cohort studies track people forward in time and their results are more reliable than retrospective studies.

Researchers also used a cross-sectional analysis to look at possible association between paracetamol use at six years and the incidence of reported wheeze and asthma. A cross-sectional analysis is less reliable than a cohort study, since it looks at two factors simultaneously. It is possible, for example, that in this case, children with wheeze might be more likely to take paracetamol rather than vice versa.

The researchers point out that other studies have shown “positive associations” between paracetamol use and asthma but, so far, the potential role of paracetamol is unclear.

 

What did the research involve?

Between 1997 and 2001, researchers randomly recruited 1,105 pregnant women for their study from two centres in New Zealand. The women were given questionnaires at recruitment and then regularly until the children were six years old. At three months, 15 months and six years of age participating children were assessed at the research centres, but at other times nurses conducted questionnaires on their mothers by phone. During assessments mothers were asked about the prevalence of symptoms of wheeze, hayfever, rhinitis and eczema, asthma and rash using questions that had been validated in international research.

When the children were six years old, researchers used skin prick tests to assess their sensitivity to certain allergens including rye grass, cow’s milk, and cat, dog and horse hair. Blood samples were also collected and analysed for the presence of IgE antibodies, which are associated with allergy.

At three and 15 months, one of the centres (Christchurch) also asked mothers about paracetamol use. This was not possible in the other centre (Wellington), which had started the study before the development of the paracetamol hypothesis. Both centres collected information on paracetamol use in children at six years. Mothers were asked to choose one of five categories, depending on how often the painkiller was used.

The researchers used standard statistical techniques to analyse associations between paracetamol use at 15 months and atopy at six years. Atopy is defined as a predisposition to allergy, but does not mean allergy is necessarily present. They also analysed associations between how often paracetamol was used at six years and the presence of wheeze and asthma in the previous 12 months.

The figures were adjusted for other factors (called confounders) that might have affected results, including number of chest infections and the use of antibiotics.

 

What were the basic results?

They found that at the Christchurch centre (which assessed infant paracetamol use), babies who had been given paracetamol before the age of 15 months were more than three times as likely to be predisposed to allergy (atopy) at six years (adjusted odds ratio 3.61, 95% CI 1.33 to 9.77), as defined by skin prick tests. There was no association between paracetamol use at 15 months and presence of allergy-associated IgE antibodies.

In both centres, there was a trend for higher reported paracetamol use in children between five and six years and greater risk of wheeze and asthma; however, not all relationships were statistically significant.

• The children of mothers who reported using the medicine 3-10 times between the ages of five and six years were 1.83 times more likely (95% CI 1.04 to 3.23) to have wheeze than children of mothers using it twice or less over the year. The relationship with asthma was, however, not significant (adjusted odds ratio 1.63, 95% CI 0.92 to 2.89).
• The children of mothers who reported using the medicine more than 10 times between the ages of five and six years were more than twice as likely to have wheeze (adjusted odds ratio 2.30, 1.28 to 4.16) or asthma (adjusted odds ratio 2.16, 1.19 to 3.92) compared with children of mothers using it twice or less over the year.
• Reported frequency of paracetamol use between five and six years was not associated with atopy, as defined by skin prick tests.

How did the researchers interpret the results?
The researchers say their findings suggest that paracetamol has a role in the development of atopy and the maintenance of asthma symptoms. Randomised controlled trials are needed to determine if the association is causal before recommendations for clinical practice can be made, they say.

 

Conclusion

While this research has found associations between paracetamol use and asthmatic symptoms, parents should not automatically assume that paracetamol itself causes asthma.

While this might initially seem logical, the results were from a cross sectional analysis: children who had reportedly been given more paracetamol between five and six years were more likely to have wheeze and asthma symptoms during that same time period than children who were given less. This analysis cannot show that paracetamol played a role in the development of asthma or wheeze since, it is possible that children with these conditions took more paracetamol.  In short, we cannot confidently assume a simple cause-and-effect relationship between the two factors, and news reports of this research should not be a cause of concern.

Other factors further complicate the issue, such as testing for predisposition to allergy (atopy) rather than allergy itself.

Further points to note:

• The researchers relied on parental reports of both use of paracetamol and the prevalence of symptoms such as asthma and wheeze. This could affect the reliability of the results, particularly as asthma is notoriously difficult to diagnose in young children and can have variable presentation. Often a night-time cough is the only symptom. Likewise, wheeze can occur with an acute chest infection and does not necessarily mean the person has asthma. The fact that the researchers adjusted their findings for reports of infection is, however, a strength.
• Only one of the centres, which enrolled about half the participants, collected information about paracetamol use before 15 months. In addition, nearly 90% of these children had reportedly been given paracetamol by 15 months. This decreases the reliability of the results and gives a smaller comparison group of children who had not been given paracetamol.
• Both centres seemed to have a high drop-out rate. For example, of 553 participants recruited in one centre, only 469 (84.8%) had data available at 15 months and six years and only 391 (70.7%) were given skin prick tests. This decreases the reliability of the results, particularly those suggesting an association between paracetamol and atopy.

Current advice is that paracetamol use in babies and children is safe, provided the dosage instructions are correctly followed. Paracetamol should never be taken with other products containing paracetamol. When buying over-the-counter painkillers and other products, always check the information on the patient leaflet.

Another painkiller, aspirin, should never be given to anyone under 16 except on specialist advice. It can cause a condition called Reye’s syndrome in this age group, which can be fatal.

Links To The Headlines

Giving children paracetamol linked to asthma: research. The Daily Telegraph, November 30 2010

Paracetamol can double the risk of asthma for babies. Daily Express, November 30 2010

Kid asthma ‘boosted by’ Calpol use. Daily Mirror, November 30 2010

Links To Science

Wickens K, Beasley R, Town I et al. The effects of early and late paracetamol exposure on asthma and atopy: a birth cohort. Clinical & Experimental Allergy, [First published online] SEP 29 2010

 

The BBC reports that “scientists have identified a gene which may play a role in a common defect affecting the genitalia of baby boys”. The condition in question is called hypospadias, where the open end of the urethral tube is not in its normal position at the tip of the penis, but is instead positioned somewhere along the underside of the penis or scrotum.

This research identified variations in a gene called DGKK, which are associated with an increased risk of one form of hypospadias. It also demonstrated that a gene that was suspected of being involved was active in the tissue of the penis, and that the gene was less active in males carrying one of the variants. One of the strengths of this study is that it confirmed its findings in more than one sample.

As the authors of this research say, there are probably many different risk factors for hypospadias, and this may include both genetic and environmental factors. Further research will be needed to confirm and investigate the role of the DGKK gene in this condition, and to identify other risk factors.

 

Where did the story come from?

The study was carried out by researchers from Radboud University Nijmegen Medical Centre and other research institutions in the Netherlands, Sweden, USA and the UK. It was funded by the Radboud University Nijmegen Medical Centre and the Urology Foundation 1973 in the Netherlands. The study was published in the peer-reviewed scientific journal Nature Genetics.

BBC News covers this study well.

 

What kind of research was this?

Hypospadias is a birth defect that affects the penis. In hypospadias the open end of the urethral tube is not at the tip of the penis as it would normally be, and instead is somewhere along the underside of the penis or scrotum. It is reported to affect about one in 750 births in Europe, and the condition is usually treated by surgery in early childhood.

The causes of hypospadias are not clear, but boys with a male relative with the condition are at increased risk, so genetic factors are thought to play a role. This “familial clustering” is found in hypospadias where the urethral opening is positioned somewhere between the middle and front end of the penis (called anterior or middle hypospadias), but not in those where the opening is further up towards the base of the penis or scrotum. Because of this genetic connection, the researchers decided to look at anterior or middle hypospadias only.

The current study was a genome-wide association study looking for common genetic variants that might be associated with an increased risk of anterior or middle hypospadias. This is an appropriate study design for addressing this question.

 

What did the research involve?

The researchers compared the DNA of 436 males with anterior or middle hypospadias (cases) and 494 unaffected males (controls). All of the males were of European descent to avoid ethnic differences affecting the results. The researchers looked at just over 900,000 single letter variations across the DNA, to identify variants that were more or less common in the cases than controls.

The 10 variants that had the strongest association with hypospadias and that were near genes were then assessed separately to verify the association. This second assessment was in 133 Dutch males with hypospadias and their parents, and 266 Swedish males with hypospadias and 402 controls.

The researchers then examined the genetic variants that showed the strongest link with the risk of hypospadias in all three samples, and assessed how much of the risk in the population could be attributed to these variants. They also identified the genes that contained these variants or lay near to these variants and tested whether the genes were active in samples from the foreskins of 14 males with hypospadias and 10 males without the condition. The activity of the genes were compared between males with and without the condition, and also between males with and without the risk variants, to see whether these variants were associated with different levels of activity of the genes.

 

What were the basic results?

The researchers identified two variants in a gene called DGKK that were associated with an increased risk of hypospadias in all of the samples tested. The DGKK gene lies on the X chromosome, and plays a role in signalling within the cells. In the first sample of European males and in the Swedish sample, cases were about twice as likely to carry the variants as controls. In the Dutch sample, cases were almost four times as likely to carry the variants as controls. The researchers calculated that the identified variants could account for about 30% of the risk of hypospadias in the Dutch and Swedish populations.

The researchers found that the DGKK gene was similarly active in the foreskin tissue in cases and controls. The DGKK gene was less active in the foreskin tissue in males carrying one of the variants associated with hypospadias risk, called rs1934179.

 

How did the researchers interpret the results?

The researchers conclude that they have identified a new area of DNA associated with the risk of anterior or middle hypospadias. They suggest that the DGKK gene might be responsible for this increase in risk, and that it could also be important in other similar conditions.

 

Conclusion

This study has identified genetic variants associated with an increased risk of the penile birth defect hypospadias. It also demonstrated that a gene that was suspected of being involved was active in the tissue of the penis, and that the gene’s activity was lower in males with  one of the variants. One of the strengths of this study is that it confirmed its findings in more than one sample. Ideally, these findings will also be confirmed by other research in more hypospadias samples.

It is important to note that the variants identified in this study are common variants, and only increase the risk of hypospadias, rather than guarantee that it will occur.

As the authors of the research report, there are probably many different risk factors for hypospadias, and this may include both genetic and environmental factors. Further research will be needed to confirm and investigate the role of the DGKK gene in this condition, and to identify other risk factors.

Links To The Headlines

Clue found to penis birth defect. BBC News, November 29 2010

Links To Science

van der Zanden LFM, van Rooij IALM, Feitz WFJ, et al. Common variants in DGKK are strongly associated with risk of hypospadias. Nature Genetics 2010, Published online: November 28

A gene therapy technique designed to ease the memory problems of Alzheimer’s disease has been tested in rats, BBC News has reported. The website says that scientists took rats bred to have an Alzheimer’s-like condition and improved their memory problems by increasing levels of a chemical that helps brain cells signal to each other.

The laboratory study in question has detailed some of the complex pathways that underpin the nerve cell damage that is linked with Alzheimer’s disease. The researchers found that the protein deposits commonly found in the brain of people with the disease specifically affect the passage of nerve impulses through some brain cells. This, they discovered, is because the protein deposits interfere with a chemical that affects some important receptors in the brain.

This is a new line of research that may one day reveal a target for human treatment, but for now its direct relevance to human health is unclear. While the research has successfully tested a new ‘treatment’ in rats, it is not yet clear how they will be affected in the long term or how the treatment might translate to one that will be safe for use in humans.

 

Where did the story come from?

The study was carried out by researchers in San Francisco and was funded by the US National Institutes of Health. It was published in the peer-reviewed scientific journal Nature.

BBC News discusses the context and methods of this research well, and quotes relevant experts who have commented on what this study adds to this field.

 

What kind of research was this?

This was animal and laboratory research investigating the complex processes that underpin the decline in brain cell function that is associated with Alzheimer’s disease. The learning and memory deficits that accompany Alzheimer’s have been associated with fibre deposits in the brain called ‘amyloid-beta oligomers’. Mutant rats with high levels of these oligomers also have reduced levels of other key substances required for brain signalling (the passing of messages along nerves). In particular, there is evidence that a particular pathway called NMDA signalling is reduced. The NMDA pathway relies on an enzyme called EphB2, and when levels of this enzyme are reduced signalling through this pathway is dysfunctional.

In this study, the researchers were investigating whether amyloid-beta oligomers interfere with NMDA signalling, and specifically whether they affect levels of the EphB2 enzyme in rat brains.

 

What did the research involve?

There were several complex steps in this research. The researchers investigated the effect of oligomer fibres on EphB2 and then the effects of EphB2 depletion on cells, specifically on the signalling of brain cells in rats.

Researchers first investigated whether amyloid-beta oligomers could bind with EphB2 and the exact site at which the molecules bound. Having established this, they measured the levels of EphB2 in mutant rat brains at 2 months and 3-4 months of age to see at what age changes in EphB2 affected rats with an Alzheimer’s-like condition. They conducted further experiments on cultures of rat brain cells to determine exactly what effect the oligomers were having on the levels of EphB2 in the cells, and to identify any substances that might block this depletion.

The researchers then took rats that had an Alzheimer’s-like disease and attempted to ‘treat’ them using a gene therapy. To do this they used a virus vector to provide the rats with a gene that would increase their EphB2 levels. Behavioural experiments were conducted in Alzheimer’s rats treated with this gene to see whether it could improve their cognition.

 

What were the basic results?

The researchers found that the EphB2 enzyme could bind with the amyloid-beta oligomer fibres associated with Alzheimer’s disease. In rats with an Alzheimer’s-like disease, levels of EphB2 were lower than in control rats at 3-4 months, but not at 2 months. Treating cultured brain cells of normal rats with amyloid-beta oligomers for three days led their levels of EphB2 to become depleted. This depletion was found to be occurring within a structure in the cell called the proteasome.

The researchers also showed that a lack of EphB2 in the cell affected the NMDA signalling pathway, specifically reducing the way that signals passed through synapses along these nerve cells. This was because depletion of the EphB2 enzyme impaired the cell receptors involved in NMDA.

In live rats with an Alzheimer’s-like condition, the introduction of a gene to increase EphB2 levels performed as intended. These treated rats did not show the expected problems within their brain cells, which were now able to conduct impulses as normal. Testing showed the strength of the synapses involved in NMDA signals had been restored.

Rats treated to restore EphB2 levels also performed better on some behavioural tests – those involving spatial and nonspatial learning and memory. There was no improvement in tasks relating to other areas of the brain.

 

How did the researchers interpret the results?

The researchers conclude that depletion of EphB2 is important in “amyloid-b-induced neuronal dysfunction” and that increasing EphB2 levels or function could be beneficial in Alzheimer’s disease.

 

Conclusion

This is another well-conducted and well-described study conducted in rat cells in the laboratory. It is a complex study using methods that are appropriate in this field. That said, it is difficult to see the direct relevance of this research to humans. As with all animal research, it paves the way for similar research into human cells, and the findings of such future studies will have greater relevance for human Alzheimer’s. There are a number of ethical and technical issues associated with gene therapy in humans and a possible area for future research may be whether levels of EphB2 could be raised through other means.

One notable issue raised by the researchers is that this study has identified the involvement of EphB2 in only certain regions of the brain. Further research will be needed to determine whether the enzyme is also linked to the effects of Alzheimer’s seen in other parts of the brain. They say that if this is the case then EphB2 may be a target for drug treatments.

Links To The Headlines

Gene therapy ‘memory boost hope’. BBC News, November 29 2010

Links To Science

Cissé M, Halabisky B, Harris J et al. Reversing EphB2 depletion rescues cognitive functions in Alzheimer model. Published online, November 28 2010

“Scientists have managed to reverse the ageing process in a ‘landmark’ study,” reported the Daily Express. The newspaper said that research has shown that targeting the telomerase enzyme proved it is possible to protect body tissue from degenerating.

This research is well-executed and has been described by experts in the field as an important, if not landmark, study. It found that restoring the activity of this enzyme, which protects cells against the damage that occurs as they age, can restore the function of ageing organs in mice.

However, this is research in mice and there is some debate over how applicable these findings are to humans. At present, it should be considered as proof-of-principle that activating telomerase in this way can restore function to cells. More research will probably follow into the effects of artificial induction of telomerase activity. It too soon to describe this as the ‘secret of youth’ and the researchers themselves say that there is more to ageing than the process investigated here.

 

Where did the story come from?

The study was carried out by researchers from Harvard Medical School in Boston. Funds were provided by the National Cancer Institute and the Belter Foundation. The study was published in the peer-reviewed medical journal Nature.

The research is reported accurately by The Guardian. The Express article may give the impression that a practical application of this research is closer than it actually is, only mentioning that the study is in mice towards the latter end of the article.

 

What kind of research was this?

This research investigated the ageing process in the laboratory. The researchers were interested in whether restoring the activity of a particular enzyme would affect the age-related decline in the condition of the organs of mice that had been engineered to age prematurely.

Ageing involves many complex cellular processes that drive age-related organ decline and the increased risk of disease. One of these processes involves damage to DNA that can lead to cell death. The DNA damage occurs through the normal course of cell division over a lifetime. At the end of each chromosome is a section of DNA called a telomere. The telomeres protect the DNA from deteriorating. When cells divide, the DNA replicates and each time it replicates, the telomeres at the end of the DNA strands get shorter. When the telomeres get too short, the cell detects this as damage to the DNA and cell death or failure to repair can follow.

Research has shown that an enzyme called telomerase can prevent the telomeres from shortening and may even elongate them. This enzyme is active in many cancer tumours, in which it enables the cancer cells to continue growing. It is a potential target for anti-cancer drugs. Telomerase is not usually active in normal body cells in humans, but the theory is that if it were, the ageing processes involving telomere shortening could be prevented or even reversed.

In this study, the researchers investigated the effects of activating telomerase in genetically modified mice with damaged telomeres and increased DNA damage. They also carried out some of the experiments on the mice cells in culture.

 

What did the research involve?

Genetically modified mice with no telomerase activity were bred. Researchers tested whether these mice showed premature ageing as would be expected as they lacked the enzyme needed to prevent or slow down telomere shortening. They cultured some of the mutant mice cells (fibroblasts) for four weeks in an environment that reactivated telomerase. Live mice were treated with the telomerase activator too, and the researchers investigated what effect this had on their organs and survival.

The researchers were particularly interested in the effects on brain health (because ageing in humans involves changes to cognition) and on smell (ageing in humans often means “a reduced ability in odour identification and discrimination”). Towards this end, they investigated the effects of inducing telomerase activity in neural stem cells (the cells that produce other brain cells) of these mutant mice and on cells specifically linked with the sense of smell.

 

What were the basic results?

The genetically modified mice had significantly reduced survival (44 weeks compared to the 87 weeks that normal mice are expected to live) and many of their organs were damaged. When the researchers exposed mouse cells in culture to telomerase, an increase in telomere length was observed. Live mice treated with telomerase also displayed growth in telomere length, and also had improved organ health, particularly in the fast-growing cells such as those in the intestines, the testes and the liver. After four weeks of treatment, the mouse survival improved.

In further experiments, mouse neural stem cells that were treated with a telomerase activator had a restored ability to produce brain cells (i.e. neurogenic capacity). Further detailed analyses of the brain cells showed that telomerase activation restored several of the cell features to normal. Olfactory and neural cells that generally had shorter telomeres and were dysfunctional before treatment had their function partially restored afterwards.

 

How did the researchers interpret the results?

The researchers say that their mouse model has demonstrated the effects of telomerase reactivation in adult cells and different organs, and that it can restore the length of telomeres and reduce DNA damage in mice. They speculate that this may mean that the organs retain some healthy stem cells that can be reactivated to reproduce normal cells. They conclude that their findings warrant further study, saying that “…this unprecedented reversal of age-related decline in the central nervous system and other organs vital to adult mammalian health justify exploration of telomere rejuvenation strategies for age-associated diseases.”

 

Conclusion

This is well-executed laboratory research in animals and has been described by experts in the field as an important, if not a landmark, study. However, this is research in mice and there is some debate over whether these findings can be applied to humans. At present, it should be considered as proof-of-principle that activating telomerase, an enzyme known to prevent the shortening of telomeres that has been linked to cell damage and ageing, can restore function to cells.

The findings help to explain further some of the complex cellular activities that occur as cells age.
More research will probably follow into the effects of artificial induction of telomerase activity. It is too soon to describe this as the “secret of youth”, as the Express does. The researchers themselves acknowledge that there is more to ageing than the process investigated here.

Links To The Headlines

Secret of youth: doctors find a way to reverse ageing. Daily Express, November 29 2010

Harvard scientists reverse the ageing process in mice – now for humans. The Guardian, November 29 2010

Links To Science

Telomerase reverses ageing process. Nature News 2010

Jaskelioff M, Muller FL, Paik J-H, et al. Telomerase reactivation reverses tissue degeneration in aged telomerase-deficient mice. Nature 2010

“Nineteen hospital trusts are today exposed as having alarmingly high death rates in a major report that also reveals how hundreds of people are dying needlessly because of substandard NHS care”, reported The Observer.

The newspaper story is based on the annual hospital guide, published today by Dr Foster Intelligence, an independently run health information firm which is part owned by the Department of Health.

The guide is an annual publication that seeks to measure hospital performance in England with a growing series of comparative indicators. These indicators are constructed in partnership with Imperial College London. They are based on NHS hospital data and are free of political bias.

The Health Secretary, Dr Andrew Lansley, welcomed the report, writing a commentary in The Observer detailing the steps that are being taken to increase transparency and improve hospital safety and performance:

“We need a cultural shift in the NHS: from a culture responsive mainly to orders from the top down to one responsive to patients, in which patient safety is put first.”

 

What are the main areas of hospital performance covered by the hospital guide?

The guide is broken down into three main parts:

• an analysis of hospital performance based on different measures of mortality
• a detailed look at hospital performance in three major areas of care: stroke, orthopaedics and urology
• an analysis of patient safety in terms of adherence to best practice, infection control and adverse incidents including accidents

There are also new analyses of efficiency, measured by hospital readmission rates and patient experience, measured by patient survey.

 

What are the main conclusions of the guide?

The guide contains both positive and negative findings. Under the heading ‘Good news’ it reports that:

• Deaths in hospitals continue to fall, dropping 7% between 2008/09 and 2009/10 in crude terms.
• The gap between the hospitals with the highest and lowest Hospital Standard Mortality Ratios (HSMRs) has narrowed, with eight fewer hospital trusts’ HSMRs above the expected range.
• Safety standards have improved, with higher rates of compliance with safety alerts and better reporting of errors.
• Four hospital trusts – Airedale, Royal Free Hampstead, Ipswich Hospital and East Kent Hospitals – are given accolades for exceptional performance.

 Under ‘Areas of concern’, the guide reports that:

• Variations in mortality ratios persist, with 19 hospital trusts having high HSMRs.
• Four trusts have high ratios for the ‘deaths after surgery’ indicator. This means patients who, following surgery, developed another problem such as internal bleeding, and subsequently died. Two of these trusts – University Hospitals Birmingham Foundation Trust and Hull and East Yorkshire Hospitals Trust – also have high HSMRs.
• Rates of emergency readmissions vary widely between hospital trusts, as do revisions and manipulations following common orthopaedic operations, where three trusts – Frimley Park Hospital NHS Trust, Northumbria Healthcare NHS Foundation Trust and Guy’s and St Thomas’ NHS Foundation Trust – have high rates.
• Over 27,000 potential medical mistakes (or adverse events) were recorded in hospital data. Dr Foster says that this is almost certainly an undercount due to inconsistent recording.
• Standards in the treatment of life-threatening conditions such as stroke and broken hips vary widely, with many trusts falling short of best practice.

The hospital guide also makes a call for more data to be made available, noting that there is information ‘we cannot tell you but would like to know’. It highlights a need for better recording of patients developing life-threatening blood clots following treatment, more information about community and primary care services, and better measurement of outcomes in private hospitals providing NHS care, among other things.

 

What does the guide say about hospital mortality?

It says that Hospital Standard Mortality Rates (HSMRs) are decreasing (i.e. improving) across the NHS in England. Only 19 of the 147 hospital trusts now have ‘significantly high’ HMSRs, compared to 27 in last year’s guide, and 26 trusts have HSMRs that are ‘significantly low’, down from 32 a year ago.

‘The overall improvement suggests greater consistency across trusts, both in terms of data recording and perhaps in the quality of care,’ it says.

The use of HSMRs to measure hospital performance has proved controversial in recent years, with experts pointing out that the measure is ‘imperfect’ and warning that it should not be used to construct simplistic league tables of best and worst hospitals.

Nevertheless, they should not be ignored. Earlier this year, the Department of Health stated: ‘A high HSMR is a trigger to ask hard questions. Good hospitals monitor their HSMRs actively and seek to understand where performance may be falling short, and action should not stop until the clinical leaders and the board at the hospital are satisfied that the issues have been effectively dealt with.’

In a bid to construct a better picture of hospital mortality, the hospital guide published a second mortality indicator measuring deaths after surgery for the first time this year. This looked at surgical patients who had a secondary diagnosis such as internal bleeding, pneumonia or a blood clot, and subsequently died.

The guide reports that there is wide variation between hospitals on this new measure. It says four hospital trusts – Hull and East Yorkshire Hospitals NHS Trust; The Newcastle upon Tyne Hospitals NHS Foundation Trust; University Hospitals Birmingham NHS Foundation Trust; and University Hospital of North Staffordshire NHS Trust – have ‘significantly high’ ratios. Two trusts – Chelsea and Westminster Hospital NHS Foundation Trust and Winchester and Eastleigh Healthcare NHS Trust – have ‘significantly low’ death after surgery results.

‘This measure uses a very different approach from the HSMR, so trusts that have high ratios on both measures – University Hospitals Birmingham NHS Foundation Trust and Hull and East Yorkshire Hospitals Trust – will want to understand the possible causes,’ says Dr Foster.

The Observer reports that sources from the Care Quality Commission have said that they have no concerns about University Hospitals Birmingham on either account or North Staffs on deaths after surgery.

The chief executive of Hull and East Yorkshire, Phil Morley, said, "We are confident that we are providing safe care of a high quality to our patients".

The hospital guide also notes, that the focus on mortality ratios in recent years has caused some trusts to revisit how they ‘code’ or report patient deaths. This has resulted in some trusts increasing the number of deaths they identify as occurring in ‘palliative care’. This in turn improves the trusts’ mortality ratio because death is the expected outcome.

In the interests of transparency, Dr Foster now publishes the percentage of deaths coded as palliative care for each hospital trust. These range from less than 1% in some trusts to over 40% in others. Basingstoke and North Hampshire NHS Foundation Trust reports 45.5% of deaths as palliative care and Medway NHS Foundation Trust reports 44.5% of deaths in this way.

Two other trusts – Pennine Acute Hospitals Trust and Royal Bolton Hospital NHS Foundation Trust – are noted in the guide as having been in the ‘higher than expected’ HSMR category for the past six years.

 

What does the guide say about hospital safety?

Overall, safety standards have improved. Dr Foster says a key way of improving safety is to accurately measure and monitor the way in which it is being addressed. Hospitals were rated on a range of aspects of patient safety in 2009. A comparison with this year’s results shows:

• Higher rates of compliance with safety alerts compared to 2009. However, three trusts still fall short on the immediacy of their compliance, including Southend University Hospital NHS Foundation Trust, St George’s Healthcare NHS Trust, and the Western Sussex Hospitals NHS Trust.
• An increase in the number of hospitals routinely screening for and treating patients admitted to hospital for infections, along with a special ‘antibiotic pharmacist’ on staff, from 86% last year to 97% this year.
• Better reporting of patient safety incidents. Though the average number of incidents has increased (from 5% to 5.7%), this is a ‘positive sign’ because it shows ‘awareness of errors and near-misses and a culture of freedom to report’.
• More hospitals using ‘track and trigger’ systems, which are regular observations by nurses designed to pick up deterioration in a patient’s condition (79% of trusts compared to 64% last year).

Dr Foster says there is room for improvement in how data is recorded. It lists the available figures for several types of avoidable harm, such as pulmonary embolisms and post-operative sepsis, which it cannot put into context due to the lack of complete data.

It identifies the same problem regarding data on the rate of medical mistakes (or adverse events) that happen in hospitals. The guide says again, that trusts with higher rates of incidents also tend to have more complete records about their patients.

The prevention of blood clots also features highly. The report says that all patients admitted to hospital now must be risk assessed for the risk of venous thromboembolism (VTE, of which DVT [deep vein thrombosis] is a common type). However, trusts gave varying responses when asked ‘What percentage of patients are risk-assessed for VTE on admission?’ Most trusts were able to report how many patients were risk-assessed, but 15 responded that they were either not assessing patients for VTE or were unable to provide the information.

A spokesperson for the Department of Health said:
“We accept that VTE is underreported, and are taking steps to change that position.

“At a national level, DH are enabling the NHS to improve accuracy of reporting incidence of hospital acquired VTE.”

 

What does the guide say about stroke care?

Stroke is the third most common cause of death in the UK, costing the economy an estimated £8 billion a year. Dr Foster says there have been measurable improvements in the way the NHS deals with strokes but still notes ‘a worrying level of variation in care’.

The report identifies six best performing and eight worst performing trusts based on an analysis of six key indicators:

• the proportion of patients having a brain scan on the same or next day: this ranged from 87% to 42%, with North Middlesex University Hospital NHS Trust having the highest rate
• the proportion of patients given ‘clot busting’ drugs (thrombolysis) within 24 hours: Rates varied from 0.2% to 17%
• the proportion of stroke admissions that lead to pneumonia due to swallowing problems: rates varied from 2% to 12%
• the proportion of patients return home from hospital within 56 days: rates varied from 55% to 85%
• the rate of emergency readmissions: this varied from 44% below average to 58% above
• standardised mortality ratio for stroke (a measure that can highlight preventable deaths): rates varied from 34% below average to 66% above average

 

What does the guide say about orthopaedic care?

Hip and knee replacements, as well as hip fractures, are a major expense for the NHS. The guide analyses some key indicators of the quality of care in these cases:

• The percentage of patients readmitted to hospital within 28 days of a hip or knee replacement
  Most hospitals performed as expected. However, for hip replacements, two trusts had high rates – Leeds Teaching Hospitals NHS Trust (75% above average) and Newcastle upon Tyne Hospitals NHS Foundation Trust (63% above average). Two trusts had low rates – Northern Devon Healthcare NHS Trust (67% below average) and Royal Devon and Exeter NHS Foundation Trust (35% below average).
• The number of patients requiring revision of a knee or hip replacement
  Hip replacement revision rates varied from 0 to 3.5 % for knees, rates varied from 0 to 2.1%. Sixteen trusts performed particularly well on this indicator, while three had high rates.
• Standardised mortality ratio for hip fractures
  Hip fractures are the most common reason for orthopaedic admission and about 10% of people with a hip fracture die within a month. All trusts performed as well as expected and Cambridge University Hospitals NHS Foundation Trust performed particularly well, with a mortality ratio 46% below average.
• Hip fractures operated on within two days.
  Operating straight away increases a patient’s chances of survival. However, Dr Foster found only 21% of trusts had rates of delayed surgery that were significantly low. The percentage operated on within two days varied from 34% to 94%.

Dr Foster identified six trusts as the best performers across its orthopaedic indicators and singled out Leeds Teaching Hospitals NHS Trust as the worst performer.

 

What does the guide say about care in urology?

Surgery for urological cancers should ideally be performed in large hospitals where these procedures are carried out more frequently. NICE guidelines state that pelvic urological cancer surgery should only take place in units where more than 50 procedures are carried out each year.

The guide identifies 19 trusts that carried out high numbers of prostate and bladder cancer operation between 2007 and 2010. It also identifies eight trusts performing high numbers of keyhole prostate operations, which enable quicker surgery and recovery.

Overall, the guide notes that more operations are being performed for prostate cancer, more of these operations are taking place in large hospitals and more keyhole procedures are being carried out.

There is a similar trend towards performing cystectomy (removal of the bladder) in large units. In 2006/07 large trusts performed only 21% of cystectomies but by 2009/10 this had risen to 63%.

The guide notes that operations to treat benign urological conditions are performed in a wider range of units than for cancer with varying quality. Dr Foster looked at the need for repeat surgery following one such procedure, transurethral resection of the prostate (TURP), as an indicator of care quality. The report lists 13 trusts that perform best on this indicator and three that perform worst.

 

Should I worry about the findings in the hospital guide?

No, the guide shows that overall things are improving. Although there are some trusts that are poor performing relative to the average, the vast majority are in the ‘as expected’ range and there are many batting well above average.

The key is to compare hospitals before making an appointment with a specialist and then to make use of your right to choosing which hospital you go to. For more on hospital choice go here.

 

How can I compare hospitals myself?

NHS Choices’ Find and choose hospitals function allows you to compare hospitals on a wide and growing range of measures, including:

• overall quality of service (judged by the regulator)
• mortality rates
• waiting times
• infection rates
• food quality
• parking facilities
• disabled access

NHS Choices also allows patients to record their views on NHS services they have used. Users can leave comments about a hospital and say whether they would recommend it to a friend. They can also rate it on the following:

• Cleanliness
• How well staff work together
• Whether they are treated with dignity and respect
• Whether they were involved in decisions about their care
• Whether the hospital offers same-sex accommodation

You can view these comments and ratings for any hospital using NHS Choices’ Find and choose services function.

Find more information about your right to choose where you are treated on our page about choosing a hospital.

The hospital guide is published in full on the Dr Foster website.

Links To The Headlines

Exposed: the hospitals whose high death rates are failing the NHS. The Observer, November 28 2010

Andrew Lansley: An open, transparent NHS is a safer NHS. The Observer, November 28 2010

The ‘catalogue of errors’ that cost this father his life. The Observer, November 28 2010

NHS death rates better – but some trusts still too high. BBC News, November 28 2010

Alarm over ‘high nhs death rates’. Daily Star, November 28 2010

Death rates at 19 hospitals ‘alarmingly high’ says report. The Daily Telegraph, November 28 2010

Alarmingly high death rates at 19 NHS hospital trusts, influential report reveals. Daily Mail, November 28 2010

Links To Science

The 2010 Dr Foster hospital guide [downloadable pdf].