Thursday, 7 November 2013

Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia Bismark MM, Spittal MJ, Gurrin LC, et al. BMJ Qual Saf 2013;22: 532–540.

Can we identify doctors who are at risk of having formal complaints made against them? This Australian study suggests that there are risk factors that can be identified, mainly on the basis of how many complaints you have received before. Over an 11 year period 18,907 formal complaints were made against doctors in Australia. 3% of doctors account for 49% of complaints, and 1% account for 25%, showing that a few doctors are at risk of serial complaints.
Luckily for us, whilst 47% of complaints are against GPs and 14% against surgeons, only 4% are against anaesthetists.
Most complaints relate to treatment, diagnosis and medications, but importantly nearly 25% relate to communication (15% to attitude or manner, 6% to information given and 3% to consent).
79% of complaints are against male doctors.
In terms of recurrence, if more than 2 complaints have been made, there is a 57% chance of a further complaint within 2 years, rising to 79% for 5 complaints, and a 97% chance of a new complaint within a year for someone who has had 10 or more previous complaints.
Across the board we are most at risk of having a formal complaint made against us within 6 months of a previous complaint.
by SW

Risk of Major Adverse Cardiac Events Following Noncardiac Surgery in Patients with Coronary Stents. JAMA October 2013

This article looks at the risk factors for adverse cardiac events in patients who have had a coronary stent within 2 years prior to undergoing non-cardiac surgery. Its findings question the current guideline recommendation of delaying elective non-cardiac surgery for 1 year after drug eluting stent placement and 6 weeks after bare metal stent placement. Over 25,000 operations occurring 6 weeks or more after stent placement were included in this study. The investigators found that the 3 most important risks for a Major Adverse Cardiac Event (MACE) occurring in these patients are emergency surgery, history of myocardial infarction in the last 6 months and advanced cardiac disease. Stent type and timing of surgery after 6 months did not seem to be significantly associated with increased MACE, nor did cessation of anti-platelet therapy. Well designed studies are needed on this subject to help guide management of these patients.

Asymptomatic Aortic Stenosis in the Elderly. A Clinical Review. JAMA October 2013

Aortic stenosis is the most common form of valvular heart disease. So how should we approach the patient who presents to preadmission with severe aortic stenosis? If they are asymptomatic and have a normal left ventricular ejection fraction then it is unlikely they will require a valve replacement. An exercise test will be useful in those with uncertain symptomatology. This is an informative review on the subject.

Tuesday, 5 November 2013

Neuroaxial block, death and serious cardiovascular morbidity in the POISE trial. BJA Sept 2013

This post hoc analysis of the POISE trial has discovered an association between epidural combined with GA (versus GA alone) and increased risk of adverse cardiovascular outcomes in patients at high risk of cardiovascular morbidity. The most notable increased risk was shown with thoracic epidurals. Rather than change practice, this article highlights the need for more studies to help guide the patient population that will benefit most from a neuraxial block and those who we may actually harm. An accompanying editorial discusses the limitation of the methodology of propensity-score matching used in the analysis.