Critical thinking, curiosity and parsimony in (emergency) medicine:‘Doing nothing’ as a quality measure?

Current medical decision-making is influenced by many factors, such as competing interests, distractions, as well as fear of missing an important diagnosis. This can result in ordering tests or providing treatments that can be harmful. Unnecessary tests are more likely to lead to false positive diagnosis or incidental findings that are of uncertain clinical relevance. Estimates indicate that almost one-third of all health spending is wasteful. The ‘Choosing Wisely’ campaign has identified many of these wasteful tests and treatments. This perspective proposes some suggestions to focus on our critical thinking, embrace shared decision-making and stay curious about the patient we are treating. Most importantly, ‘doing nothing’ could be a quality indicator for EDs, and ACEM supported audits and research to develop benchmarks for certain tests and procedures in the ED are important to achieve a cultural change.Griffith Health, School of MedicineNo Full Tex

New Zealand bicycle helmet law - do the costs outweigh the benefits?

Objectives: This paper examines the cost effectiveness of the compulsory bicycle helmet wearing low (HWL) introduced in New Zealand on 1 January 1994. The societal perspective of costs is used for the purchase of helmets and the value of injuries averted. This is augmented with healthcare costs averted from reduced head injuries. Methods: Three age groups were examined: cyclists aged 5-12 years, 13-18 years, and greater than or equal to19 years. The number of head and non-head injuries averted were obtained from epidemiological studies. Estimates of the numbers of cyclists and the costs of helmets are used to derive the total spending on new bicycle helmets. Healthcare costs were obtained from national hospitalisation database, and the value of injuries averted was obtained directly from a willingness-to-pay survey undertaken by the Land Transport Safety Authority. Cost effectiveness ratios, benefit:cost ratios, and the value of net benefits were estimated. Results: The net benefit (benefit:cost ratios) of the HWL for the 5-12, 13-18, and greater than or equal to19 year age groups was $0.3m (2.6), -$0.2m (0.8), and -$1.5m (0.7) (in NZ$, 2000 prices; NZ $1.00 = US$0.47 = UK pound0.31 approx). These results were most sensitive to the cost and life of helmets, helmet wearing rates before the HWL, and the effectiveness of helmets in preventing head injuries. Conclusions: The HWL was cost saving in the youngest age group but large costs from the law were imposed on adult (greater than or equal to19 years) cyclists

Incidence and costs of unintentional falls in older people in the United Kingdom

STUDY OBJECTIVE: To estimate the number of accident and emergency (A&E) attendances, admissions to hospital, and the associated costs as a result of unintentional falls in older people. DESIGN: Analysis of national databases for cost of illness. SETTING: United Kingdom, 1999, cost to the National Health Service (NHS) and Personal Social Services (PSS). PARTICIPANTS: Four age groups of people 60 years and over (60–64, 65–69, 70–74, and 75) attending an A&E department or admitted to hospital after an unintentional fall. Databases analysed were the Home Accident Surveillance System (HASS) and Leisure Accident Surveillance System (LASS), and Hospital Episode Statistics (HES). MAIN RESULTS: There were 647 721 A&E attendances and 204 424 admissions to hospital for fall related injuries in people aged 60 years and over. For the four age groups A&E attendance rates per 10 000 population were 273.5, 287.3, 367.9, and 945.3, and hospital admission rates per 10 000 population were 34.5, 52.0, 91.9, and 368.6. The cost per 10 000 population was £300 000 in the 60–64 age group, increasing to £1 500 000 in the 75 age group. These falls cost the UK government £981 million, of which the NHS incurred 59.2%. Most of the costs (66%) were attributable to falls in those aged 75 years. The major cost driver was inpatient admissions, accounting for 49.4% of total cost of falls. Long term care costs were the second highest, accounting for 41%, primarily in those aged 75 years. CONCLUSIONS: Unintentional falls impose a substantial burden on health and social services

Do consumer voices in health-care citizens’ juries matter?

Background There is widespread agreement that the public should be engaged in health-care decision making. One method of engagement that is gaining prominence is the citizens’ jury, which places citizens at the centre of the deliberative process. However, little is known about how the jury process works in a health-care context. There is even less clarity about how consumer perspectives are heard within citizens’ juries and with what consequences. Objectives This paper focuses on what is known about the role of consumer voices within health-care citizens’ juries, how these voices are heard by jurors and whether and in what ways the inclusion or exclusion of such voices may matter. Results Consumer voices are not always included in health-care citizens’ juries. There is a dearth of research on the conditions under which consumer voices emerge (or not), from which sources and why. As a result, little is known about what stories are voiced or silenced, and how such stories are heard by jurors, with what consequences for jurors, deliberation, decision-makers, policy and practice. Discussion and Conclusion The potential role of consumer voices in influencing deliberations and recommendations of citizens’ juries requires greater attention. Much needed knowledge about the nuances of deliberative processes will contribute to an assessment of the usefulness of citizens’ juries as a public engagement mechanism

Yes, The Government Should Tax Soft Drinks: Findings from a Citizens’ Jury in Australia

Taxation has been suggested as a possible preventive strategy to address the serious public health concern of childhood obesity. Understanding the public’s viewpoint on the potential role of taxation is vital to inform policy decisions if they are to be acceptable to the wider community. A Citizens’ Jury is a deliberative method for engaging the public in decision making and can assist in setting policy agendas. A Citizens’ Jury was conducted in Brisbane, Australia in May 2013 to answer the question: Is taxation on food and drinks an acceptable strategy to the public in order to reduce rates of childhood obesity? Citizens were randomly selected from the electoral roll and invited to participate. Thirteen members were purposively sampled from those expressing interest to broadly reflect the diversity of the Australian public. Over two days, participants were presented with evidence on the topic by experts, were able to question witnesses and deliberate on the evidence. The jurors unanimously supported taxation on sugar-sweetened drinks but generally did not support taxation on processed meats, snack foods and foods eaten/ purchased outside the home. They also supported taxation on snack foods on the condition that traffic light labelling was also introduced. Though they were not specifically asked to deliberate strategies outside of taxation, the jurors strongly recommended more nutritional information on all food packaging using the traffic light and teaspoon labelling systems for sugar, salt and fat content. The Citizens’ Jury suggests that the general public may support taxation on sugar-sweetened drinks to reduce rates of obesity in children. Regulatory reforms of taxation on sugar-sweetened drinks and improved labelling of nutritional information on product packaging were strongly supported by all members of the jury. These reforms should be considered by governments to prevent childhood obesity and the future burden on society from the consequences of obesity

Economic evaluation of a community based exercise programme to prevent falls

OBJECTIVE: To assess the incremental costs and cost effectiveness of implementing a home based muscle strengthening and balance retraining programme that reduced falls and injuries in older women. DESIGN: An economic evaluation carried out within a randomised controlled trial with two years of follow up. Participants were individually prescribed an exercise programme (exercise group, n=116) or received usual care and social visits (control group, n=117). SETTING: 17 general practices in Dunedin, New Zealand. PARTICIPANTS: Women aged 80 years and older living in the community and invited by their general practitioner to take part. MAIN OUTCOME MEASURES: Number of falls and injuries related to falls, costs of implementing the intervention, healthcare service costs resulting from falls and total healthcare service costs during the trial. Cost effectiveness was measured as the incremental cost of implementing the exercise programme per fall event prevented. MAIN RESULTS: 27% of total hospital costs during the trial were related to falls. However, there were no significant differences in health service costs between the two groups. Implementing the exercise programme for one and two years respectively cost $314 and$265 (1995 New Zealand dollars) per fall prevented, and $457 and$426 per fall resulting in a moderate or serious injury prevented. CONCLUSIONS: The costs resulting from falls make up a substantial proportion of the hospital costs for older people. Despite a reduction in falls as a result of this home exercise programme there was no significant reduction in healthcare costs. However, the results reported will provide information on the cost effectiveness of the programme for those making decisions on falls prevention strategies

Would those who need ISA, use it? Investigating the relationship between drivers' speed choice and their use of a voluntary ISA system

Intelligent Speed Adaptation (ISA) is one of the most promising new technologies for reducing the prevalence and severity of speed-related accidents. Such a system could be implemented in a number of ways, representing various "levels of control" over the driver. An ISA system could be purely advisory or could actually control the maximum speed of a vehicle. A compromise would be to introduce a system that allows a driver to choose when to engage ISA, thus creating a “voluntary” system. Whilst these voluntary systems are considered more acceptable by drivers, they will not offer safety benefits if they are not used by the driver. Two studies were carried out that examined the relationship between drivers’ reported and actual speeding behaviour, their propensity to engage a voluntary ISA system and their attitudes towards such a system. These studies were carried out in a driving simulator and in an instrumented vehicle. In both the studies, drivers’ propensity to exceed the speed limit was lowered when ISA was available but this effect was confined to the lower speed limits. In general, drivers engaged ISA for approximately half of their driving time, depending on the speed limit of the road and indeed, on the nature of the road and the surrounding traffic. This was particularly true in the field study where drivers were more inclined to “keep up with” the surrounding traffic. The results from the on-road study indicated that those drivers who considered ISA to be both a useful and pleasant system, were overall more likely to engage it. However, those drivers who confessed to enjoying exceeding the speed limit were less likely to use ISA. This is an important finding when considering the mechanisms for implementing ISA: those drivers who would benefit most would be less likely to use a voluntary system