Trends in mortality from pneumonia in the Europe union: a temporal analysis of the European detailed mortality database between 2001 and 2014.

BACKGROUND: Pneumonia is responsible for approximately 230,000 deaths in Europe, annually. Comprehensive and comparable reports on pneumonia mortality trends across the European Union (EU) are lacking. METHODS: A temporal analysis of national mortality statistics to compare trends in pneumonia age-standardised death rates (ASDR) of EU countries between 2001 and 2014 was performed. International Classification of Diseases version 10 (ICD-10) codes were used to extract data from the World Health Organisation European Detailed Mortality Database and trends were analysed using Joinpoint regression. RESULTS: Median pneumonia mortality across the EU for the last recorded observation was 19.8 / 100,000 and 6.9 / 100,000 for males and females, respectively. Mortality was higher in males across all EU countries, most notably in Estonia and Lithuania where the ratio of male to female ASDR was 4.0 and 3.7, respectively. Gender mortality differences were lowest in the UK and Demark with ASDR ratios of 1.1 and 1.5, respectively. Pneumonia mortality across all countries decreased by a median of 31.0% over the observation period. Countries that demonstrated an increase in pneumonia mortality were Poland (males + 33.1%, females + 10.2%), and Lithuania (males + 6.0%). CONCLUSIONS: Mortality from pneumonia is improving in most EU countries, however substantial variation in trends remains between countries and between genders.

Trends in Mortality From Ischemic Heart Disease and Cerebrovascular Disease in Europe: 1980 to 2009.

BACKGROUND: Trends in cardiovascular mortality across Europe demonstrate significant geographical variation, and an understanding of these trends has a central role in global public health. METHODS AND RESULTS: Ischemic heart disease and cerebrovascular disease age-standardized death rates (as per International Classification of Diseases, ninth and tenth revisions) were collated from the World Health Organization mortality database for member states of the European Union. Trends were characterized by using Joinpoint regression analysis. An overall trend for reduction in ischemic heart disease mortality was observed, most pronounced in Western Europe (>60% for the Netherlands, United Kingdom, and Ireland) for both sexes from 1980 to 2009. Eastern European states, Romania, Croatia, and Slovakia, had modest mortality reductions. Most recently (2009), Lithuania had the highest mortality for males and females (318.1/100 000 and 166.1/100 000, respectively), followed by Latvia and Slovakia. France had the lowest mortality: 39.8/100 000 for males and 14.7/100 000 for females. Analysis of cerebrovascular disease mortality revealed that Austria had the largest reduction for both sexes (76.8% males, 76.5% females) from 1980 to 2009. The smallest improvement over this period was seen in Lithuania, Poland, and Cyprus (-5% to +20% approximately). France has the lowest present-day cerebrovascular disease mortality for both males and females (23.9/100 000 and 17.3/100 000, respectively). CONCLUSIONS: There is a growing disparity in cardiovascular mortality between Western and Eastern Europe, for which diverse explanations are discussed. The need for population-wide health promotion and primary prevention policies is emphasized.

Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990-2010: a longitudinal analysis.

BACKGROUND: The global economic crisis has been associated with increased unemployment and reduced public-sector expenditure on health care (PEH). We estimated the effects of changes in unemployment and PEH on cancer mortality, and identified how universal health coverage (UHC) affected these relationships. METHODS: For this longitudinal analysis, we obtained data from the World Bank and WHO (1990-2010). We aggregated mortality data for breast cancer in women, prostate cancer in men, and colorectal cancers in men and women, which are associated with survival rates that exceed 50%, into a treatable cancer class. We likewise aggregated data for lung and pancreatic cancers, which have 5 year survival rates of less than 10%, into an untreatable cancer class. We used multivariable regression analysis, controlling for country-specific demographics and infrastructure, with time-lag analyses and robustness checks to investigate the relationship between unemployment, PEH, and cancer mortality, with and without UHC. We used trend analysis to project mortality rates, on the basis of trends before the sharp unemployment rise that occurred in many countries from 2008 to 2010, and compared them with observed rates. RESULTS: Data were available for 75 countries, representing 2.106 billion people, for the unemployment analysis and for 79 countries, representing 2.156 billion people, for the PEH analysis. Unemployment rises were significantly associated with an increase in all-cancer mortality and all specific cancers except lung cancer in women. By contrast, untreatable cancer mortality was not significantly linked with changes in unemployment. Lag analyses showed significant associations remained 5 years after unemployment increases for the treatable cancer class. Rerunning analyses, while accounting for UHC status, removed the significant associations. All-cancer, treatable cancer, and specific cancer mortalities significantly decreased as PEH increased. Time-series analysis provided an estimate of more than 40,000 excess deaths due to a subset of treatable cancers from 2008 to 2010, on the basis of 2000-07 trends. Most of these deaths were in non-UHC countries. INTERPRETATION: Unemployment increases are associated with rises in cancer mortality; UHC seems to protect against this effect. PEH increases are associated with reduced cancer mortality. Access to health care could underlie these associations. We estimate that the 2008-10 economic crisis was associated with about 260,000 excess cancer-related deaths in the Organisation for Economic Co-operation and Development alone. FUNDING: None.

Implementation of a teaching programme to improve doctors' awareness of DVLA guidelines: a multicentre study.

INTRODUCTION: Over half of the UK population holds a driver's licence. Driver and Vehicle Licensing Authority (DVLA) guidelines are available for conditions from most specialties. Despite this, no focused training occurs in the undergraduate or postgraduate setting. We evaluate the impact of a teaching programme to improve guideline awareness. METHODS: A 25-point questionnaire was designed using the current DVLA guidelines. Five questions were included for the following fields: neurology, cardiology, drug and alcohol abuse, visual disorders and respiratory. This was distributed to doctors in training at five hospitals. Four weeks later, a single-session teaching programme was implemented. The questionnaire was redistributed. Preintervention and postintervention scores were compared using the Wilcoxon rank sum test. RESULTS: 139 preteaching and 144 post-teaching questionnaires were completed. Implementation of a single-session teaching programme significantly improved the knowledge of DVLA guidelines in all five areas explored. Median scores: neurology, preteaching 40%, post-teaching 100%, p<0.001; cardiology, 0%, 100%, p<0.001; drug and alcohol misuse, 0%, 100%, p<0.001; visual disorders, 40%, 100%, p<0.001; respiratory disorders, 20%, 100%, p<0.001; and overall, 28%, 92%, p<0.001. CONCLUSIONS: Knowledge of DVLA guidelines among our cohort was poor. Implementation of a single-session teaching programme can significantly improve guideline knowledge and awareness, serving as a cost-effective intervention.

Trends in UK regional cancer mortality 1991-2007.

BACKGROUND: Until 1990, there was an upward trend in mortality from breast, lung, prostate, and colon cancers in the United Kingdom. With improvements in cancer treatment there has, in general, been a fall in mortality over the last 20 years. We evaluate regional cancer mortality trends in the United Kingdom between 1991 and 2007. METHODS: We analysed mortality trends for breast, lung, prostate, and colon cancers using data obtained from the EUREG cancer database. We have described changes in age-standardised rates (using European standard population) per 100,000 for cancer mortality and generated trends in mortality for the 11 regions using Joinpoint regression. RESULTS: Across all regions in the United Kingdom there was a downward trend in mortality for the four most common cancers in males and females. Overall, deaths from colon cancer decreased most rapidly and deaths from prostate cancer decreased at the slowest rate. Similar downward trends in mortality were observed across all regions of the United Kingdom with the data for lung cancer exhibiting the greatest variation. CONCLUSIONS: Mortality from the four most common cancers decreased across all regions of the United Kingdom; however, the rate of decline varied between cancer type and in some instances by region.

The influence of volume and experience on individual surgical performance: a systematic review.

OBJECTIVE: To systematically review studies evaluating the influence of surgical experience on individual performance. BACKGROUND: Experience, measured in case volume or years of practice, is recognized as a key driver of individual surgical performance, giving rise to a learning curve. However, this topic has not been reviewed at the cross-specialty level. METHODS: MEDLINE, EMBASE, PsycINFO, AMED, and the Cochrane Database of Systematic Reviews were searched (from inception to February 2013). Two reviewers independently reviewed citations using predetermined inclusion and exclusion criteria. Ninety-one data points per study were extracted. RESULTS: The search strategy yielded 6950 citations. Fifty-seven studies were eligible, including 1,061,913 cases and 35 procedure types, performed by 17,912 surgeons. Forty-five studies monitored case volume, and 6 studies measured experience as both case volume and years of practice. Of these 51 studies, 44 found that increased case volume was associated with significantly improved health outcomes. Several studies noted a plateau phase or maturation in the surgical learning curve. Acquisition of this phase was procedure specific and outcome specific, ranging from 25 to 750 procedures. Twelve studies assessed the impact of years of surgical practice, 11 of which found that increased years of experience was associated with significantly improved health outcomes. Two studies noted a plateau phase, where increases in years of experience were no longer associated with improvements in operative outcomes. Three studies identified performance deterioration after the plateau phase. CONCLUSIONS: Increasing surgical case volume and years of practice are associated with improved performance, in a procedure-specific manner. Performance may deteriorate toward the end of a surgeon's career.

Incidence of prostate and urological cancers in England by ethnic group, 2001-2007: a descriptive study.

BACKGROUND: The aetiology of urological cancers is poorly understood and variations in incidence by ethnic group may provide insights into the relative importance of genetic and environmental risk factors. Our objective was to compare the incidence of four urological cancers (kidney, bladder, prostate and testicular) among six 'non-White' ethnic groups in England (Indian, Pakistani, Bangladeshi, Black African, Black Caribbean and Chinese) to each other and to Whites. METHODS: We obtained Information on ethnicity for all urological cancer registrations from 2001 to 2007 (n = 329,524) by linkage to the Hospital Episodes Statistics database. We calculated incidence rate ratios adjusted for age, sex and income, comparing the six ethnic groups (and combined 'South Asian' and 'Black' groups) to Whites and to each other. RESULTS: There were significant differences in the incidence of all four cancers between the ethnic groups (all p < 0.001). In general, 'non-White' groups had a lower incidence of urological cancers compared to Whites, except prostate cancer, which displayed a higher incidence in Blacks. (IRR 2.55) There was strong evidence of differences in risk between Indians, Pakistanis and Bangladeshis for kidney, bladder and prostate cancer (p < 0.001), and between Black Africans and Black Caribbeans for all four cancers (p < 0.001). CONCLUSIONS: The risk of urological cancers in England varies greatly by ethnicity, including within groups that have traditionally been analysed together (South Asians and Blacks). In general, these differences are not readily explained by known risk factors, although the very high incidence of prostate cancer in both black Africans and Caribbeans suggests increased genetic susceptibility. g.

The impact of feedback of surgical outcome data on surgical performance: a systematic review.

BACKGROUND: Increasing patient demands, costs and emphasis on safety have led to performance tracking of individual surgeons. Several methods of using these data, including feedback have been proposed. Our aim was to systematically review the impact of feedback of outcome data to surgeons on their performance. STUDY DESIGN: MEDLINE, Embase, PsycINFO, AMED and the Cochrane Database of Systematic Reviews (from their inception to February 2013) were searched. Two reviewers independently reviewed citations using predetermined inclusion and exclusion criteria. Forty two data-points per study were extracted. RESULTS: The search strategy yielded 1,531 citations. Seven studies were eligible comprising 18,632 cases or procedures by 52 surgeons. Overall, feedback was found to be a powerful method for improving surgical outcomes or indicators of surgical performance, including reductions in hospital mortality after CABG of 24% (P = 0.001), decreases of stroke and mortality following carotid endarterectomy from 5.2 to 2.3%, improved ovarian cancer resection from 77 to 85% (P = 0.157) and reductions in wound infection rates from 14 to 10.3%. Improvements in performance occurred in concert with reduced costs: for hepaticojejunostomy, implementation of feedback was associated with a decrease in overall hospital costs from $24,446 to $20,240 (P < 0.01). Similarly, total cost of carotid endarterectomy and following management decreased from $13,344 to $9548. CONCLUSIONS: The available literature suggests that feedback can improve surgical performance and outcomes; however, given the heterogeneity and limited number of studies, in addition to their non-randomised nature, it is difficult to draw clear conclusions from the literature with regard to the efficacy of feedback and the specific nuances required to optimise the impact of feedback. There is a clear need for more rigorous studies to determine how feedback of outcome data may impact performance, and whether this low-cost intervention has potential to benefit surgical practice.

Unemployment, public-sector health-care spending and breast cancer mortality in the European Union: 1990-2009.

BACKGROUND: The global economic crisis has been associated with increased unemployment, reduced health-care spending and adverse health outcomes. Insights into the impact of economic variations on cancer mortality, however, remain limited. METHODS: We used multivariate regression analysis to assess how changes in unemployment and public-sector expenditure on health care (PSEH) varied with female breast cancer mortality in the 27 European Union member states from 1990 to 2009. We then determined how the association with unemployment was modified by PSEH. Country-specific differences in infrastructure and demographic structure were controlled for, and 1-, 3-, 5- and 10-year lag analyses were conducted. Several robustness checks were also implemented. RESULTS: Unemployment was associated with an increase in breast cancer mortality [P < 0.0001, coefficient (R) = 0.1829, 95% confidence interval (CI) 0.0978-0.2680]. Lag analysis showed a continued increase in breast cancer mortality at 1, 3, 5 and 10 years after unemployment rises (P < 0.05). Controlling for PSEH removed this association (P = 0.063, R = 0.080, 95% CI -0.004 to 0.163). PSEH increases were associated with significant decreases in breast cancer mortality (P < 0.0001, R = -1.28, 95% CI -1.67 to -0.877). The association between unemployment and breast cancer mortality remained in all robustness checks. CONCLUSION: Rises in unemployment are associated with significant short- and long-term increases in breast cancer mortality, while increases in PSEH are associated with reductions in breast cancer mortality. Initiatives that bolster employment and maintain total health-care expenditure may help minimize increases in breast cancer mortality during economic crises.

Systematic review of perioperative outcomes following laparoscopic abdominal aortic aneurysm repair.

OBJECTIVE: To collate information available in the literature regarding perioperative outcomes following elective laparoscopic abdominal aortic aneurysm repair. MATERIALS AND METHODS: Electronic databases were searched and a systematic review was performed. In total, 1256 abstracts were screened, from which 10 studies were included for analysis. Perioperative and technical outcomes were analysed. RESULTS: In the totally laparoscopic repair of infra-renal aneurysms (n = 302), 30-day mortality ranged between 0% and 6% and in the laparoscopic-assisted cases (n = 547) ranged between 0% and 7%. Of the former group, 5-30% of cases were converted to open repair, with 6% reintervention rate, whereas there was a 5-10% conversion and 3% reintervention rate in the latter group. CONCLUSIONS: The outcomes from selected patients in selected centres demonstrate that elective laparoscopic repair of aortic aneurysms is feasible and comparable in safety to open repair; it remains unclear, however, whether there are substantial advantages of this method compared with open and endovascular repair.

Distant peer-tutoring of clinical skills, using tablets with instructional videos and Skype: A pilot study in the UK and Malaysia.

OBJECTIVES: To assess the feasibility and impact of using low-cost Android tablets to deliver video tutorials and remote online peer-tutoring for clinical skills between two countries. METHODS: Nine junior medical students from Malaysia were paired with five senior medical students from the UK, who played the role of peer-tutors. Students from Malaysia were given a low-cost Android tablet from which they could access instructional video tutorials. At the end of each week, the peer-tutors would observe their peer-learners as they performed a clinical examination. Tutors would then provide individual feedback using a videoconferencing tool. Outcomes were assessed using Observed Structured Clinical Examination (OSCE) scores, post-study questionnaires and semi-structured interviews with participants. RESULTS: Peer-learners reported an increased confidence in clinical examination of 8.4 (±1.0) on a 10-point scale and all nine said they would recommend the scheme to their peers. Both peer-tutors and peer-learners were able to establish a strong rapport over video, rating it as 8.4 (±0.6) and 8.4 (±0.9), respectively. Peer-learners' rated the sound and video quality of the tablet as 7.0 (±1.1) but were less satisfied with the screen resolution of the tablet, rating this as 4.0 (±1.5). CONCLUSION: This preliminary pilot study presents an innovative, low cost approach to international medical education with significant potential for future development.

Building effective clinical teams in healthcare.

PURPOSE: This article aims to review teamwork and the creation of effective teams within healthcare. DESIGN/METHODOLOGY/APPROACH: By combining research material found in management, psychology and health services research the article explores the drivers increasing the importance of teamwork, reviews the current knowledge base on how to build a team and focuses on some of the barriers to effective team performance. FINDINGS: The simultaneous inflation of healthcare costs and necessity to improve quality of care has generated a demand for novel solutions in policy, strategy, commissioning and provider organisations. A critical, but commonly undervalued means by which quality can be improved is through structured, formalised incentivisation and development of teams, and the ability of individuals to work collectively and in collaboration. Several factors appear to contribute to the development of successful teams, including effective communication, comprehensive decision making, safety awareness and the ability to resolve conflict. Not only is strong leadership important if teams are to function effectively but the concept and importance of followership is also vital. RESEARCH LIMITATIONS/IMPLICATIONS: Building effective clinical teams is difficult. The research in this area is currently limited, as is the authors' understanding of the different requirements faced by those working in different areas of the health and social care environment. ORIGINALITY/VALUE: This article provides a starting place for those interested in leading and developing teams of clinicians.