"“We have lent a huge amount of money to the U.S. Of course we are concerned about the safety of our assets. To be honest, I am definitely a little worried.” "

Chinese premier Wen Jiabao 12th March 2009

""We have a financial system that is run by private shareholders, managed by private institutions, and we'd like to do our best to preserve that system."

Timothy Geithner US Secretary of the Treasury, previously President of the Federal Reserve Bank of New York.1/3/2009

Thursday, February 22, 2007

Lies, Damned Lies and Medical Statistics

In 1995, the Department of Health issued guidance that gave NHS Trust chief executives overall responsibility for ensuring the provision of effective infection control arrangements.

The Hospital Infection Working Group believed in 1995 that it might have been possible to achieve a 30 per cent reduction in hospital acquired infection.

Nothing very much happened until the National Audt Office reported in February 2000 , (when they were searching to control costs and not disease) - The Management and Control of Hospital Acquired Infection in NHS Acute Trusts in England (HC 230 Session 1999-00). Under the eagle eye and discerning analysis of Sir John Bourn it was noted that at any one time, 9 per cent of patients had an infection that had been acquired during their hospital stay. (Note these were called Hospital Acquired Infections HAI's)

The effects varied from extended length of stay and discomfort to prolonged or permanent disability and death. Based on American experience they calculated that in the England at least 5,000 patients a year, death. These infections were costing the NHS as much as £1 billion a year and around 15 per cent could be prevented by better application of good practice, releasing resources of £150 million for alternative NHS use.

In a a comprehensive study commissioned by the Department of Health and undertaken by the London School of Hygiene and Tropical Medicine and the Central Public Health Laboratory January 2000 and referred to by the NAO it was concluded (see Page 24 of the report) ;
Over the course of a 13 month period, 7.8% of patients acquired an infection during their stay in the study hospital which presented during the in-patient period.
 A further 19.1% of patients who did not present with an infection during the in-patient phase, reported symptoms of, and in some cases received treatment for, an infection manifesting post discharge which may be associated with their hospital admission.

 Patients with one or more infections incurred costs that were on average 2.8 times greater than uninfected patients, an average additional cost of £2,917 per case (ranging from £1,122 for urinary tract infections to £6,209 for bloodstream infections).

 Patients who acquired an infection remained in hospital on average 2.5 times longer than uninfected patients, an average equivalent to 11 extra days.

 Patients with a hospital acquired infection were 7.1 times more likely to die in the hospital than uninfected patients (after controlling for patient characteristics such as age, sex, diagnosis, admission speciality and type and pre-exiting illness). The death rate also varied with patient characteristics (for example 38% of elderly care patients who acquired a hospital infection died compared with 8% of elderly patients without a hospital acquired infection who died).

 Extrapolating the results of this study to NHS Trusts throughout England, the overall cost to the NHS of hospital acquired infection was £986.36 million comprising £930.62 million hospital costs plus a further £55.74 million costs due to infections which occurred post discharge.

It is therefore both insteresting and instructive that The Health Protection Agency FAQ's on MRSA has this helpful advice ..

Where does the figure of 5000 deaths due to MRSA each year come from?

This figure is incorrect. It comes from a very rough estimate of the number of deaths which may be attributed to all hospital acquired infections (HAI), not just MRSA. The estimate was made in 1995 by a working group of the Public Health Laboratory Health Service. It used an estimate of the percentage of deaths associated with all HAIs made in the USA in the 1980s (1% of all deaths in the USA). This percentage was applied to the total number of deaths occurring in the UK, yielding a crude estimate of 5,000 deaths from HAI.

Fast Forward to today

The National Statistical Office has today published figures for England and Wales for mention of MRSA and Clostridium difficile on death certificates. (See graph at top of post from ONS website)

The 3rd report into the number of death certificates in England and Wales that mentioned
Staphylococcus aureus infection increased each year from 2001 to 2005, from 1,211 to 2,083. The percentage of these deaths where Staphylococcus aureus was specified as meticillin resistant (MRSA) rose from 61 % in 2001 to 78 % in 2005.

The age standardised rates for deaths involving MRSA doubled for both males and females between 2001 and 2005. For men the rate increased from 12.5 to 25.0 per million population, while for women it rose from 6.7 to 14.5 per million population.

The 2nd annual report into the number of death certificates in England and Wales that mentioned Clostridium difficile increased from 1,214 in 2001 to 3,807 in 2005. Between 2004 and 2005 the number of deaths involving C. difficile increased by 69 %.

Age-standardised rates for deaths involving C. difficile among males in England and Wales almost tripled between 2001 and 2005, from 13.1 to 37.6 per million population. Among females, rates more than tripled, from 12.8 per million to 38.9 per million.

The complete statistics can be found in in Health Statistics Quarterly 33 (Spring
2007), published today.

They also point out that "Most of the deaths involving S. aureus or MRSA were in the older age groups. Mortality rates in 2005 for deaths involving MRSA in the 85 and over age group were 702 and 387 deaths per million population for males and females respectively. In the under 45 age group there were 1.1 and 0.8 deaths per million population for males and females respectively."

However the Health Protection Agency's MRSA surveillance units figures for England (Note NOT the UK) , up to November 27th 2006 show

1. There were 51,690 reports of Clostridium difficile disease in people aged 65 years and over in 2005, a 17.2% increase on 2004.

2. A total of 3,517 MRSA bacteraemia episodes was reported during the period October 2005 to March 2006. This marks a small decrease in the number of reports compared to the
beginning of the mandatory surveillance scheme and a 1.5% decrease on the previous six
Pert, pretty , glamorous and gorgeous Dr Georgia Duckworth, of the Health Protection Agency, says "We're on a plateau (?)but there is some evidence that individual hospitals and departments – principally those with the worst rates – are getting better." One might reasonably ask Dr Georgina quite what a plateu is and how it applies to the graph at the head of this article. Perhaps she could be familiarised with the expression "Straws, grasping at?"

So since 1995, when the Department of Health issued guidance that gave NHS Trust chief executives overall responsibility for ensuring the provision of effective infection control arrangements.

Hospital Acquired Infections have increased

Deaths from Hospital Acquired Infections MRSA / CD have increased over all hospital admissions and especially in the elderly - plus 65 age group. (Note no-one has mentioned Multiple Drug Resitant TB (MDRTB) .... Yet)

Commenting on the figures Health Minister Lord Hunt said "... we are now starting to see significant reductions in rates of MRSA infections." ! and ..."We have also provided £50 million funding which will give a cash injection to trusts to boost infection control measures."

One might reasonably ask My Lord Hunt what he means by "significant reductions in rates of MRSA infections" Perhaps he could be familiarised with the expression "Straws, grasping at?" It should be pointed out that My Lord Hunt's NHS career began in 1972 when he joined Oxford Regional Hospital Board as a works study officer. See pic below.

A Useful history of MRSA / HAI and the threat of Multiple Drug resistant TB can be found here

Also a Daily Torygraph article 21st Jan 2007 How have we fallen so far behind in battle to beat MRSA? makes comparisons with other European countries experience and the failure to use a 2 phase policy of testing people admitted to hospital (preventing so called Community Acquired Infections) and isolation until cured used in successfully for many years in Holland.

Perhaps these two routes mught produce faster solution at lower costs than an obession with hand wringing washing and blaming the cleaners .. Lord Patel has for long and often said that of there was a Royal College of Hospital Cleaners you would never have heard of HAI's, MRSA, Clostridium.

Nose swabs and rapid MRSA testing - see New Scientist 6th February 2007 won't solve the problem but they (with 100% isolation facilities) will help.

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