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Director & Co-Directors' Blog
Are electronic patient records a medico-legal timebomb?
Litigation lawyers used to chase ambulances; soon they may be trawling patient records.
Electronic records can be an uncompromising record of when care departed from clinical guidelines. Once upon a time the Bolam test - acting in accordance with a body of medical opinion – was sufficient to define the required standard of care. But after 1997, the Bolitho case modified this to allow that a body of medical opinion could be challenged as irrational.[1] More recently, clinical guidelines have begun to inform the required standard of care.[2]
Now both the Medical Defence Union (MDU) and the Medical Protection Society (MPS) advise that doctors must be prepared to justify decisions and actions that depart from nationally recognised guidelines.[3] [4] Alongside this, the General Medical Council regard it as a professional responsibility to be familiar with guidelines.[5] So if a doctor departs from clinical guidelines without recording a reason and their patient suffers a foreseeable adverse outcome as a result, there is a basis for a medical negligence claim.
Do electronic patient records have implications for this? Quite possibly. By retrieving historical records it is relatively easy to identify if a patient who suffered an adverse outcome was previously treated in accordance with guidelines. We can get an idea of the scale of this by looking at an example.
Anticoagulants halve the risk of stroke in atrial fibrillation, and guidelines recommend anticoagulant use in most patients with atrial fibrillation.[6] But in the UK half are untreated.[7] By contrast, 87% are treated in Germany and 92% in Switzerland.[8] [9] So it is not a question of contraindications. There are about 100,000 strokes a year in the UK, with about 80,000 ischaemic strokes.[10] Data from Sweden – with a similar undertreatment problem – indicates that about 29% of these will have atrial fibrillation.[11] So the UK has roughly 23,000 strokes a year in atrial fibrillation patients, half of whom were not on anticoagulants – 11,500 litigation opportunities. A case would be hard to defend without a documented rationale for withholding treatment.
From the ambulance-chasing perspective this means one in every nine stroke patients represents a business opportunity: certainly worth a letter requesting the records if only the patient will accede. The archive of patient data is easy to search. It is a treasure trove for medical negligence lawyers. It is just surprising it has not already happened.
-- Tom Marshall, Deputy Director CLAHRC WM, Prevention and Detection of Diseases
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International differences in trial results
Many researchers accept that the efficacy of treatments may differ between countries, and that differences need to be considered when assessing the potential benefits of treatments whose trials were conducted in a different country. The CLAHRC WM Director has recently had a paper published on international differences in the results of cardiovascular trials, looking at 59 meta-analyses of RCTs.[1] In most meta-analyses, relative to the control, the intervention was more favoured in trials conducted in Europe than those in North America for non-fatal endpoints (70% of meta-analyses, P=0.017), while there were non-statistically significant differences for fatal endpoints (65% of meta-analyses, P=0.066). It was not possible to determine which types of interventions were more likely to show international differences. The size of the effect, though significant for non-fatal outcomes, was small and the results of trials travel reasonably well across the North Atlantic.
-- Richard Lilford, Director CLAHRC WM
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References
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Director's Choice - From the Journals
Preventable hospital deaths and other measures of safety
Readers of this blog may well know the views of the CLAHRC WM Director on using hospital mortality to compare hospital safety.[1] [2] Following the recommendations in the Keogh review, published in 2013, there was greater interest in looking at preventable hospital deaths in order to improve the NHS.
Helen Hogan and colleagues have recently published findings of a retrospective case record review that looked for relationships between preventable hospital deaths and eight other measures of safety in ten English acute hospital trusts.[3] Of the eight measures of safety they looked at, only MRSA bacteraemia rate had a significant association with proportion of preventable deaths (P<0.02). Hospital Standardised Mortality Ratios (HSMRs), widely used in the UK to measure safety, was not significantly associated (P=0.97). Additionally, the difference in the proportion of preventable deaths between hospitals was not statistically significant (P=0.94), varying from 3–8%. The authors are planning a larger study in order to establish these findings, with 24 additional UK hospitals.
-- Richard Lilford, Director CLAHRC WM
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Congratulations
Congratulations to Prof Christian Mallen (last issue's CLAHRC Personality) who has been awarded a NIHR Research Professorship in recognition of his contributions to primary care research. Prof Mallen plans to use the Professorship to address missed opportunities to improve the diagnosis and management of musculoskeletal disorders in a primary care setting, and support research with the potential for rapid translation into clinical practice, with the aim to help improve care for patients.
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16 Jul 2014, 10:00-15:30
Miscommunicating Public Health:
Critical Perspectives from History, Policy and Practice
Institute for Advanced Study, Milburn House, University of Warwick.
An inter-disciplinary symposium concerned with communication in public health, and in particular the interplay between research and practice, and miscommunication and its effects. It will provide opportunities to discuss the impact of miscommunication, and aspects and purpose of knowledge translation.
Speakers confirmed include Dr Kathryn Oliver (Messages and messengers in public health: how evidence and stories are used in policy making); Dr Rebecca Johnson (Lessons from the field - examples of miscommunication); and Dr Rebecca Williams (Policy making in health, focussing on history of population control in India).
Lunch and refreshments will be provided.
If you would like to attend, then please register your attendance with rebecca.johnson@warwick.ac.uk
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15 Oct 2014, 11:00-15:00
National CLAHRC Workshop: Chronic Diseases and Integrated Care
The Studio, Cannon Street, Birmingham
A workshop for CLAHRC Theme leads and researchers who are working in the area of chronic diseases and integrated care to develop synergies, look for opportunities for collaboration, and share current work, challenges and methodological issues. Delegates should arrive ready to talk for 10 minutes on their programme of work. NB three delegates per CLAHRC.
You can register for this workshop, and view further details, here.
Upcoming Events - further details to follow
For more information, please contact Jo Sartori.
3 Nov 2014
Different Methods for Service Delivery Workshop
5 Dec 2014
Psychology of Change Workshop: Applying Psychological Theory to Designing and Evaluating Interventions to Change Behaviour
This workshop will look at how we apply psychological theory to designing and evaluating interventions to change behaviour. The workshop will feature Dr Lou Atkins, from Prof Susan Michie's group at University College London, and also input from behavioural scientists from the Warwick Global Research Program which links psychology, economics, organisational studies and medicine. The idea behind the workshop is to identify opportunities for ground breaking research.
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Kandala NB, Mandungu TP, Mbela K, Nzita KPD, Kalambayi BB, Kayembe KP, Emina JBO. Child mortality in the Democratic Republic of Congo: cross-sectional evidence of the effect of geographic location and prolonged conflict from a national household survey. BMC Public Health. 2014; 14: 266.
Kandala NB, Stranges S. Geographic variation of overweight and obesity among women in Nigeria: a case for nutritional transition in Sub-Saharan Africa. PLoS One. 2014; 9(6): e101103.
Foster N, Mallen C, Dunn KM, van der Windt D, Hill J, Protheroe J, Jowett S, Hay E. Stratified primary care for musculoskeltal pain, funded by NIHR Programme Grant. £1,930,360. 2014-2019.
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CLAHRC Personality of the Issue
Dr Ngianga-Bakwin Kandala
Ngianga-Bakwin Kandala is currently a Principal Research Fellow in Health Technology Assessment and has a joint appointment with the University of Oxford (KEMRI-Oxford Collaborative Programme) and the University of Warwick, Warwick Medical School, Division of Health Sciences, Population and Evidence Group. In addition, he is visiting Professor at the University of Witwatersrand, South Africa.
He previously worked as a Medical Statistician at the University of Southampton and King’s College London; was a Mellon foundation fellow at the University of Montreal, Canada; an Associate Lecturer at the University of Lagos, Nigeria; and an Associate Professor at the University of Botswana. He obtained a PhD in Economics/Statistics from the University of Munich (LMU) in Germany in February 2002.
For the past 16 years, his main research interests have been in Bayesian statistical methods and their application to epidemiology and health. In particular, addressing maternal and child health and a variety of health-related health inequalities (including chronic conditions) both in the developing countries and command economies, using large scale household data. He has been Principal Investigator on grants from Economic and Social Research Council (ESRC), the British Council and the National Institute for Health Research (NIHR).
Kandala has published widely in high-impact, peer reviewed journals in both the field of Statistics and Health in diverse populations. Further, he has recently published a book with Springer Science on ‘Advance Techniques in modelling Maternal and child health in Africa’ (2014).
His current research interests include, statistical methods applied to epidemiology, survival analysis, meta-analysis, Bayesian Analysis, Health Economics and Health Technology Assessment.
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