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Objectives: To determine the proportion of avoidable deaths (due to acts of omission and commission) in acute hospital trusts in England and to determine the association with the trust's hospital-wide standardised mortality ratio assessed using the two commonly used methods--the hospital standardised mortality ratio (HSMR) and the summary hospital level mortality indicator (SHMI)., Design: Retrospective case record review of deaths., Setting: 34 English acute hospital trusts (10 in 2009 and 24 in 2012/13) randomly selected from across the spectrum of HSMR., Main Outcome Measures: Avoidable death, defined as those with at least a 50% probability of avoidability in view of trained medical reviewers. Association of avoidable death proportion with the HSMR and the SHMI assessed using regression coefficients, to estimate the increase in avoidable death proportion for a one standard deviation increase in standardised mortality ratio., Participants: 100 randomly selected hospital deaths from each trust., Results: The proportion of avoidable deaths was 3.6% (95% confidence interval 3.0% to 4.3%). It was lower in 2012/13 (3.0%, 2.4% to 3.7%) than in 2009 (5.2%, 3.8% to 6.6%). This difference is subject to several factors, including reviewers' greater awareness in 2012/13 of orders not to resuscitate, patients being perceived as sicker on admission, minor differences in review form questions, and cultural changes that might have discouraged reviewers from criticising other clinicians. There was a small but statistically non-significant association between HSMR and the proportion of avoidable deaths (regression coefficient 0.3, 95% confidence interval -0.2 to 0.7). The regression coefficient was similar for both time periods (0.1 and 0.3). This implies that a difference in HSMR of between 105 and 115 would be associated with an increase of only 0.3% (95% confidence interval -0.2% to 0.7%) in the proportion of avoidable deaths. A similar weak non-significant association was observed for SHMI (regression coefficient 0.3, 95% confidence interval -0.3 to 1.0)., Conclusions: The small proportion of deaths judged to be avoidable means that any metric based on mortality is unlikely to reflect the quality of a hospital. The lack of association between the proportion of avoidable deaths and hospital-wide SMRs partly reflects methodological shortcomings in both metrics. Instead, reviews of individual deaths should focus on identifying ways of improving the quality of care, whereas the use of standardised mortality ratios should be restricted to assessing the quality of care for conditions with high case fatality for which good quality clinical data exist., (© Hogan et al 2015.)

Objective: To compare the cost effectiveness of the three most commonly chosen types of prosthesis for total hip replacement., Design: Lifetime cost effectiveness model with parameters estimated from individual patient data obtained from three large national databases., Setting: English National Health Service., Participants: Adults aged 55 to 84 undergoing primary total hip replacement for osteoarthritis., Interventions: Total hip replacement using either cemented, cementless, or hybrid prostheses., Main Outcome Measures: Cost (£), quality of life (EQ-5D-3L, where 0 represents death and 1 perfect health), quality adjusted life years (QALYs), incremental cost effectiveness ratios, and the probability that each prosthesis type is the most cost effective at alternative thresholds of willingness to pay for a QALY gain., Results: Lifetime costs were generally lowest with cemented prostheses, and postoperative quality of life and lifetime QALYs were highest with hybrid prostheses. For example, in women aged 70 mean costs were £6900 ($11 000; €8200) for cemented prostheses, £7800 for cementless prostheses, and £7500 for hybrid prostheses; mean postoperative EQ-5D scores were 0.78, 0.80, and 0.81, and the corresponding lifetime QALYs were 9.0, 9.2, and 9.3 years. The incremental cost per QALY for hybrid compared with cemented prostheses was £2500. If the threshold willingness to pay for a QALY gain exceeded £10 000, the probability that hybrid prostheses were most cost effective was about 70%. Hybrid prostheses have the highest probability of being the most cost effective in all subgroups, except in women aged 80, where cemented prostheses were most cost effective., Conclusions: Cemented prostheses were the least costly type for total hip replacement, but for most patient groups hybrid prostheses were the most cost effective. Cementless prostheses did not provide sufficient improvement in health outcomes to justify their additional costs.

Routine use of patient reported outcome measures (PROMs) has the potential to help transform healthcare, SAYS NICK BLACK: . Not only can PROMs help patients and clinicians make better decisions, but they can also enable comparisons of providers' performances to stimulate improvements in services.

Objective: To evaluate the impact and cost effectiveness of a programme to transform adult critical care throughout England initiated in late 2000., Design: Evaluation of trends in inputs, processes, and outcomes during 1998-2000 compared with last quarter of 2000-6., Setting: 96 critical care units in England., Participants: 349,817 admissions to critical care units., Interventions: Adoption of key elements of modernisation and increases in capacity. Units were categorised according to when they adopted key elements of modernisation and increases in capacity., Main Outcome Measures: Trends in inputs (beds, costs), processes (transfers between units, discharge practices, length of stay, readmissions), and outcomes (unit and hospital mortality), with adjustment for case mix. Differences in annual costs and quality adjusted life years (QALYs) adjusted for case mix were used to calculate net monetary benefits (valuing a QALY gain at pound20,000 ($33,170, euro22 100)). The incremental net monetary benefits were reported as the difference in net monetary benefits after versus before 2000., Results: In the six years after 2000, the risk of unit mortality adjusted for case mix fell by 11.3% and hospital mortality by 13.4% compared with the steady state in the three preceding years. This was accompanied by substantial reductions both in transfers between units and in unplanned night discharges. The mean annual net monetary benefit increased significantly after 2000 (from pound402 ($667, euro445) to pound1096 ($1810, euro1210)), indicating that the changes were relatively cost effective. The relative contribution of the different initiatives to these improvements is unclear., Conclusion: Substantial improvements in NHS critical care have occurred in England since 2000. While it is unclear which factors were responsible, collectively the interventions represented a highly cost effective use of NHS resources.

Objectives: To describe the multicentre clinical databases that exist in the United Kingdom, to report on their quality, to explore which organisational and managerial features are associated with high quality, and to make recommendations for improvements., Design: Cross sectional survey, with interviews with database custodians and search of electronic bibliographic database (PubMed)., Studies Reviewed: 105 clinical databases across the United Kingdom., Results: Clinical databases existed in all areas of health care, but their distribution was uneven-cancer and surgery were better covered than mental health and obstetrics. They varied greatly in age, size, growth rate, and geographical areas covered. Their scope (and thus their potential uses) and the quality of the data collected also varied. The latter was not associated with any organisational characteristics. Despite impressive achievements, many faced substantial financial uncertainty. Considerable scope existed for improvements: greater use of nationally approved codes; more support from relevant professional organisations; greater involvement by nurses, allied health professionals, managers, and laypeople in database management teams; and more attention to data security and ensuring patient confidentiality. With some notable exceptions, the audit and research potential of most databases had not been realised: half the databases had each produced only four or fewer peer reviewed research articles., Conclusions: At least one clinical database support unit is needed in the United Kingdom to provide assistance in organisation and management, information technology, epidemiology, and statistics. Without such an initiative, the variable picture of databases reported here is likely to persist and their potential not be realised.

Objectives: To compare general practitioners' perceptions of chronic fatigue syndrome and irritable bowel syndrome and to consider the implications of their perceptions for treatment., Design: Qualitative analysis of transcripts of group discussions., Participants and Setting: A randomly selected sample of 46 general practitioners in England., Results: The participants tended to stereotype patients with chronic fatigue syndrome as having certain undesirable traits. This stereotyping was due to the lack of a precise bodily location; the reclassification of the syndrome over time; transgression of social roles, with patients seen as failing to conform to the work ethic and "sick role" and conflict between doctor and patient over causes and management. These factors led to difficulties for many general practitioners in managing patients with chronic fatigue syndrome. For both conditions many participants would not consider referral for mental health interventions, even though the doctors recognised social and psychological factors, because they were not familiar with the interventions or thought them unavailable or unnecessary., Conclusions: Barriers to the effective clinical management of patients with irritable bowel syndrome and chronic fatigue syndrome are partly due to doctors' beliefs, which result in negative stereotyping of patients with chronic fatigue syndrome and the use of management strategies for both syndromes that may not take into account the best available evidence.

Objective: To determine the effects of training on the quality of peer review., Design: Single blind randomised controlled trial with two intervention groups receiving different types of training plus a control group., Setting and Participants: Reviewers at a general medical journal. Interventions Attendance at a training workshop or reception of a self taught training package focusing on what editors want from reviewers and how to critically appraise randomised controlled trials., Main Outcome Measures: Quality of reviews of three manuscripts sent to reviewers at four to six monthly intervals, evaluated using the validated review quality instrument; number of deliberate major errors identified; time taken to review the manuscripts; proportion recommending rejection of the manuscripts., Results: Reviewers in the self taught group scored higher in review quality after training than did the control group (score 2.85 v 2.56; difference 0.29, 95% confidence interval 0.14 to 0.44; P = 0.001), but the difference was not of editorial significance and was not maintained in the long term. Both intervention groups identified significantly more major errors after training than did the control group (3.14 and 2.96 v 2.13; P < 0.001), and this remained significant after the reviewers' performance at baseline assessment was taken into account. The evidence for benefit of training was no longer apparent on further testing six months after the interventions. Training had no impact on the time taken to review the papers but was associated with an increased likelihood of recommending rejection (92% and 84% v 76%; P = 0.002)., Conclusions: Short training packages have only a slight impact on the quality of peer review. The value of longer interventions needs to be assessed.

Objectives: To determine the strength of evidence for the effectiveness of mental health interventions for patients with three common somatic conditions (chronic fatigue syndrome, irritable bowel syndrome, and chronic back pain). To assess whether results obtained in secondary care can be extrapolated to primary care and suggest how future trials should be designed to provide more rigorous evidence., Design: Systematic review., Data Sources: Five electronic databases, key texts, references in the articles identified, and citations from expert clinicians., Study Selection: Randomised controlled trials including participants with one of the three conditions for which no physical cause could be found. Two reviewers screened sources and independently extracted data and assessed quality., Results: Sixty one studies were identified; 20 were classified as primary care and 41 as secondary care. For some interventions, such as brief psychodynamic interpersonal therapy, little research was identified. However, results of meta-analyses and of randomised controlled trials suggest that cognitive behaviour therapy and behaviour therapy are effective for chronic back pain and chronic fatigue syndrome and that antidepressants are effective for irritable bowel syndrome. Cognitive behaviour therapy and behaviour therapy were effective in both primary and secondary care in patients with back pain, although the evidence is more consistent and the effect size larger for secondary care. Antidepressants seem effective in irritable bowel syndrome in both settings but ineffective in chronic fatigue syndrome., Conclusions: Treatment seems to be more effective in patients in secondary care than in primary care. This may be because secondary care patients have more severe disease, they receive a different treatment regimen, or the intervention is more closely supervised. However, conclusions of effectiveness should be considered in the light of the methodological weaknesses of the studies. Large pragmatic trials are needed of interventions delivered in primary care by appropriately trained primary care staff.