Faculty Peer Reviewed
Our cousins across the Atlantic are feeling the economic sting: in Great Britain they will be implementing market-style changes to their health care system and moving away from a system of complete central control. As reported in the New England Journal of Medicine, the British government is instituting financial incentives to improve healthcare for all British citizens through payment reform, shifting control of hospitals to local communities, and giving patients a greater role in decisions about their care. Seventy percent of the National Health Service (NHS) budget will now be controlled by established groups of general practitioners. GPs in England will be the gatekeepers for specialist care. Groups of primary care physicians will form commissioning groups and oversee budgets from which they buy specialist care for their patients; these groups will be held accountable to a national board. Also, more emphasis will be placed on the NHS in terms of healthcare outcomes and availability, and this will complement newly increased patient autonomy in the choice of both primary and specialist physicians. In addition, the control of many public health services will be transferred from national to local government. Coverage will still be universal.
A recent article in Radiology describes the alarming increase in computed tomography (CT) scans in children visiting emergency departments. The researchers used the National Hospital Ambulatory Medical Care Survey (NHAMCS) public-use dataset to describe the trends in CT scanning of pediatric patients from 1995 to 2008. Authors found that the use of CT in children visiting the ED had an annual growth rate of 12.8% during this period. By 2008, a CT was done in 1.7 million of 27.9 million pediatric visits to emergency departments. These trends were comparable to the adult population, and the growth of the use of CT was explained by the increasing frequency of CT use, as the number of visits to EDs stayed relatively constant throughout the study period. Of note, authors also found that the majority (89.4%) of these CT scans occurred at non-pediatric-focused facilities. The cost of these CT scans is concerning, but what is more alarming are the potential adverse effects of ionizing radiation on children, especially when conducted at non-pediatric facilities which may not have proper pediatric protocols implemented in all scans.
Moving now from the cost of healthcare to inpatient management, a new trial was just published in the New England Journal of Medicine on dalteparin and deep vein thrombosis (DVT) outcomes. The primary endpoint of the Prophylaxis for Thromboembolism in Critical Care Trial (PROTECT) looked at the effect of dalteparin versus unfractionated heparin in preventing proximal DVTs in critically ill patients. The multinational trial at 67 ICUs compared patients receiving either subcutaneous dalteparin at a dose of 5000 IU once daily (n=1873) or unfractionated heparin at a dose of 5000 IU twice daily (n=1873), with ultrasonography performed 2 days after admission and then twice weekly, with a mean length of stay of 7 days. Results demonstrated no significant difference in the primary endpoint of development of a proximal DVT in the group assigned to receive dalteparin (96 patients–5.1%) versus 103 patients (5.8%) receiving unfractionated heparin, but pulmonary embolism developed in significantly fewer patients in the dalteparin group (24 patients–1.3%) than in those assigned to receive unfractionated heparin (43 patients–2.3%). The rates of other venous thromboses, major bleeding, and death were similar in the 2 groups. Yet, before we start implementing dalteparin in all of our critically ill patients, cost-benefit analysis should be performed.
As Clinical Correlations tries to cover all aspects of medicine, we’ll move on to outpatient and preventive medicine. In a recent article published in the American Journal of Cardiology, Rahilly-Tierney and colleagues looked at 652 males enrolled in the VA Normative Aging Study (a longitudinal study of aging in 2280 men living in the greater Boston area, with enrollment beginning in 1961) who had greater than one HDL cholesterol level measured from 1979 through 1999, to see if HDL cholesterol levels were associated with survival to age 85. In their analysis, other cofactors associated with longevity were included and controlled for, including smoking, hypertension, alcohol use, body-mass index, LDL cholesterol, coronary artery disease, and cerebrovascular disease. Authors observed that with each 10 mg/dL increment in HDL cholesterol levels there was an independently associated 14% decrease in risk of mortality before 85 years of age. They also found the hazard ratio of mortality at age 85 to be 0.72 for patients with an initial HDL cholesterol level of greater than 50 mg/dL. These patients with higher initial HDL levels were also significantly less likely to be smokers or have hypertension, CVD, or CAD. Although it is not earth-shattering news that healthier lifestyles can lead to longevity, at least now we can give our patients real numbers as a motivating factor to lead healthier lives!
Dr. Tzimas is a 2nd year resident at NYU Langone Medical Center
Peer reviewed by Michael Tanner, section editor, Clinical Correlations
Image courtesy of Wikimedia Commons
1. Roland M, Rosen R. English NHS embarks on controversial and risky market-style reforms in health care. N Engl J Med. 2011;364(14):1360-1366. Available from: http://www.nejm.org/search?q=roland+and+Rosen
2. Larson DB, Johnson LW, Schnell BM, Goske MJ, Salisbury SR, Forman HP. Rising use of CT in child visits to the emergency department in the United States, 1995–2008. Radiology. 2011 April. [Epub ahead of print.] Available from: http://radiology.rsna.org/content/early/2011/03/15/radiol.11101939.full
3. PROTECT Investigators for the Canadian Critical Care Trials Group and the Australian and New Zealand Intensive Care Society Clinical Trials Group, Cook D, Meade M, Guyatt G, et al. Dalteparin versus unfractionated heparin in critically ill patients. N Engl J Med. 2011;364(14):1305-1314. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa1014475
4. Rahilly-Tierney CR, Spiro A 3rd, Vokonas P, Gaziano JM. Relation between high-density lipoprotein cholesterol and survival to age 85 years in men (from the VA Normative Aging Study). Am J Cardiol. 2011; 107(8):1173-1177. Available from: http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6T10-523RYHH-F-1&_cdi=4876&_user=30681&_pii=S0002914910027190&_origin=gateway&_coverDate=04%2F15%2F2011&_sk=998929991&view=c&wchp=dGLzVlb-kzk&md5=820577041b805841f7f47da447444307&ie=/sdarticle.pdf