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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study Joshua D Stein, Rory M Marks, John Z Ayanian, Brahmajee K Nallamothu, et al. 357:doi 10.1136/bmj.j1415

In the abstract, authors write:

........Results Of 1 548 945 adults, 327 452 (21.1%) received at least one outpatient prescription for short term use of oral corticosteroids over the three year period...........Incidence rate ratios for adverse events within 30 day and 31-90 day risk periods after drug initiation........

What our query is, as follows:

At least one prescription means there could be more than one prescription in 3 years study period. But, if the other prescriptions are given within the follow up period of 90 days, to note the adverse events, then one can get intrigued that more than one prescription can have cumulative effect on the outcome (adverse event) compared to just one prescription.

Authors may clarify this issue.

Competing interests: No competing interests

23 May 2017
Neeru Gupta
Scientist F
Jugal Kishore, Akshun Jani (MBBS student), Neeta Kumar.
Indian Council of Medical Research
Ansari Nagar, New Delhi-110029.
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Re: UK poverty has “devastating” effect on children’s health, doctors warn Gareth Iacobucci. 357:doi 10.1136/bmj.j2285

Child poverty is finally getting some attention, thanks to a report (1) out this month from the Royal College of Paediatricians and Child Health and the Child Poverty Action Group. Politicians, however, haven’t seemed to notice; the 4 million children living in poverty in the UK still haven’t featured in any of the debates leading up to the general election. The Lancet made the assertion that “Policy is lacking to prevent adverse health in poor UK children” (2). But let’s be clear. It is not that policy is lacking - after all it was policy abrogation (3) that removed poverty reduction targets, with the Welfare Reform and Work Bill of 2015. Indeed, this bill has actively pushed more children into poverty, through introduction of the income cap and changes to tax credits. What’s lacking then is not policy, but political will. And it is important to make this distinction.

Poverty is a political problem. Poverty does not exist in a vacuum; it is neither natural nor inevitable. Poverty is created by political choices - and will only ever be dissipated by making different political choices.

It’s all a question of priorities.

The importance of socioeconomic status and the social gradient to health are well established. A series of major analyses commissioned by successive Labour governments, from Sir Douglas Black’s 1980 report on Inequalities in Health to Sir Michael Marmot’s 2008 review, Fair Society, Healthy Lives: a Strategic Review of Health Inequalities in England post-2010 all reiterate that progressive health outcomes can only be delivered through progressive economic and social policy. These reports point to the things that we as a society can do to improve public health. The fact that we live with problems like air pollution, food insecurity and a housing crisis is testament to the political choices that have been made about the economic organisation of our society. Despite the overwhelming evidence they provide, none of these reports has ever been seriously acted on, and since 2010 the policies of successive governments, particularly those linked to austerity and the withdrawal of social security, have aggravated the problems these reports aimed to alleviate. The latest research (4) shows that in 2015 infant mortality rose for the first time in a decade. Worse still, while mortality has been rising for the poorest children since 2010, it has continued to fall for more advantaged groups. In other words, inequalities are widening. This failure has left us with a higher proportion of children in poverty than any other western European nation (5) and persistent stark inequalities in health and well-being (6).

But just because the solutions might be political, it does not mean politicians are the only actors here. Civil society must also play their part - not least those of us who witness the effects of poverty on the bodies and minds of our patients everyday.

This presents doctors with an important challenge: What can we do as a profession and as professionals to act in our patients’ best interests here?

The British Association of Child and Adolescent Health (BACAPH) (7) are working with the RCPCH in beginning to grapple with this question for paediatricians. In our national campaign to End Child Poverty we are not only making policy demands of the government, we are also beginning to flesh out what ‘doctor-action’ at many different levels in response to big societal issues might look like. Spanning from how we do our work in the clinic right up to service organization and actively bringing issues such as child poverty to national attention, we contend that doctors can – and must – think more expansively about their roles in the quest to create a better world.

Mahatma Gandhi famously said, “Be the change that you wish to see in the world”. For those of us advocating against child poverty, change must start in ourselves. And it means getting political.

Links
1) http://www.rcpch.ac.uk/sites/default/files/user45042/Poverty%20and%20chi...
2) http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31350-8/fulltext?rss=yes
3) https://www.theguardian.com/society/2015/jul/01/government-scrap-legal-r...
4) http://www.bmj.com/content/357/bmj.j2258
5) https://www.unicef-irc.org/publications/733/
6) http://bit.ly/2q3qdU8
7) http://www.bacaph.org.uk/

Competing interests: No competing interests

22 May 2017
Guddi Singh
Paediatric Registrar
British Association of Child and Adolescent Public Health (BACAPH)
Whittington Hospital NHS Trust
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Re: Physician age and outcomes in elderly patients in hospital in the US: observational study Anupam B Jena, et al. 357:doi 10.1136/bmj.j1797

As a hospitalist, I was excited to read about the study performed by Tsugawa and co-workers to investigate factors associated with outcomes of care within a cohort comprising hospitalists, rather than comparing outcomes with non-hospitalists. [1] Although there seems to be a significant association between a physician’s age and 30-day mortality in the patient, it provides no robust evidence that older hospitalists' skills are outdated, as implied in the study hypothesis.

Hospital medicine is a new, 2-decade old discipline.[2] It can be said that a hospitalist at age 60 or more would have entered this new discipline after the age of 40, a stage where a physician would have already acquired mature skills and experiences in the course of his or her career. Older hospitalists usually lead hospitalist programmes, coordinate co-management projects, and are in charge of complex patients. These experienced hospitalists cannot be assessed and their competence and abilities cannot be evaluated based on mortality rates associated with their practice. It should be noted that hospitalists usually work as leaders of a multidisciplinary team including nurses, dieticians, physical therapists, and social workers who together contribute to the quality of care delivered to patients and subsequent outcomes. Although it is difficult to adjust practice-based factors such as teamwork using claims data, ignorance may alter results and it would be inappropriate to apportion blame on any one team member for the failure.

The Medicare sample in Tsugawa's study showed 30-day mortality rates over 10% for all categories of physician age. Mortality rates were higher than those noted in previous studies performed to evaluate hospitalists (range between 3.6% and 7.7%), in Medicare samples. [3 4] Increasing mortality rates among elderly Medicare patients treated by hospitalists suggest that hospitalists are increasingly involved with care of complicated cases, severely ill, and end-of-life patients. For example, a recent study showed that 30% of Medicare beneficiaries diagnosed with pneumonia needed intensive care unit (ICU) admission, with a 30-day mortality of 35.9%. Pneumonia is the commonest ailment treated by hospitalists [5]; therefore, adjustment of ICU admission for the mortality endpoint may control the severity of illness. Additionally, choice of palliative care may be common in the sample with old age and mortality rate over 10%. Although it is difficult to adjust for a Do-Not-Resuscitate status, it may be worth trying to adjust for palliative care claims or hospice consultation during the hospitalisation.

References:
1. Tsugawa Y, Newhouse JP, Zaslavsky AM, Blumenthal DM, Jena AB. Physician age and outcomes in elderly patients in hospital in the US: observational study. BMJ (Clinical research ed.) 2017;357:j1797
2. Wachter RM, Goldman L. Zero to 50,000 - The 20th Anniversary of the Hospitalist. The New England journal of medicine 2016;375(11):1009-11
3. Goodwin JS, Lin YL, Singh S, Kuo YF. Variation in length of stay and outcomes among hospitalized patients attributable to hospitals and hospitalists. Journal of general internal medicine 2013;28(3):370-6
4. Kuo YF, Goodwin JS. Effect of hospitalists on length of stay in the medicare population: variation according to hospital and patient characteristics. Journal of the American Geriatrics Society 2010;58(9):1649-57
5. Lindenauer PK, Rothberg MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD. Outcomes of care by hospitalists, general internists, and family physicians. The New England journal of medicine 2007;357(25):2589-600

Competing interests: No competing interests

22 May 2017
Nin-Chieh Hsu
Hospital medicine attending physician
Ming-Chin Yang, Chong-Jen Yu
National Taiwan University Hospital
No.7, Chung Shan S. Rd.(Zhongshan S. Rd.), Taipei, Taiwan
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Re: Patient access to health records: striving for the Swedish ideal Stephen Armstrong. 357:doi 10.1136/bmj.j2069

Reply to “100% access to records: if Sweden can do it for patients why can’t we” BMJ 2017;357:j2069
Dr Ralph Sullivan, MB ChB, FRCGP, DRCOG
RCGP Clinical Lead for Patient Online
RCGP Clinical Innovation and Research Centre
20 May 2017

General Practices in England have been providing online record access and transactional services including appointment booking and ordering repeat prescriptions for over ten years. It might be helpful to provide an up to date picture of what is available to patients in England and the uptake of online patient facing services.

Online access to electronic health records can play an important part in engaging patients in taking a more active role in their healthcare1. Online access to coded information about diagnoses, laboratory test results, allergies, adverse drug reactions, immunisation records and medication2 is currently available at 94% of GP practices in England. Some practices also offer access to free text consultation records and clinical correspondence such as hospital reports. Only 541,148 patients (0.9%) had registered for access to their records by February 20173. Some hospital departments, including nearly all renal departments, offer online access to key information through systems such as PatientView4.

9,578,944 patients in England (16.4%) were registered to be able to order repeat prescriptions online and 1,722, 391 prescriptions were ordered online in February 20173.
Patients use record access to improve and monitor their health and their care:

• To check coded laboratory results to self-monitor long term conditions
• To look for specific codes to check the data recorded by the practice about key medical information, including preferences about health care such as those relevant to palliative care
• To read clinical correspondence to follow hospital and prepare for hospital visits, especially for patients with complex health problems who attend more than one trust
• To read free text access and attached standard word processed documents created by the practice can provide online access to shared care plans
• To use portable access to the record on tablet computers or smartphones to share data with other health professionals in all health settings
• To provide record access to family members and carers who are supporting the patient

The uptake of online record access is hampered by a number of factors. They can be roughly divided into patient, technological and health professional. There are also reservations among General Practice teams about providing record access in GP practices. The Royal College of General Practitioners explored the concerns of GP practice team members about record access in 2016. The results are summarised in the figure below. Access to medical records and clinical data, is more likely to be used by those (or carers of those) in regular contact with their healthcare team5. The technology is not straightforward and can exclude the patients who could benefit most (see above).

Patients may need help to understand the data in their record. A report on health literacy from the Royal College of General Practitioners published in 2014 emphasised that it is essential for doctors to make careful use of effective communication skills when they convey information to their patients, and backup verbal messages with information leaflets or documents provided in a format, on paper or electronically that the patient finds accessible6. There are reliable sources health information online such as the very flexible Information Prescription Service on the NHS Choices website7 or Lab Tests Online, which is available online in a number of languages8 or via a mobile app.

The RCGP and NHS England have produces educational materials and practice support for GPs to help them offer online record access effectively and safely2,9.

Figure. GP Practice Team Members' Perception of Risk from Patient Online Record Access. Percentage of 168 respondents reporting concerns (RCGP Survey August 2016, unpublished)

References

1. Video of Graeme’s story, GP Online Services, NHS England. Accessed on 18 May 2017 at http://www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/gp-online-se...
2. Patient Online, NHS England. Accessed 18 May 2017 at https://www.england.nhs.uk/ourwork/pe/patient-online/
3. Patient Online, NHS England. Accessed 18 May 2017 at https://www.england.nhs.uk/ourwork/pe/patient-online/
4. PatientView, Renal Information Exchange Group, Accessed on 18 May 2017 at http://rixg.org/patientview2/
5. Wyatt, J., Sathanandam, S., Rastall, P., Hoogewerf, J. and Wooldridge, D, Personal Health Record Landscape Review: Final report. Royal College of Physicians (2015). Accessed on 6 December 2016 at https://www.rcplondon.ac.uk/projects/outputs/personal-health-record-phr-...
6. Health Literacy, Royal College of General Practitioners (2014). Accessed on 18 May 2017 at http://www.rcgp.org.uk/clinical-and-research/clinical-resources/health-l...
7. Health A-Z, Conditions and treatments, NHS Choices. Accessed on 18 May 2017 at http://www.nhs.uk/Conditions/Pages/hub.aspx
8. Lab Tests Online, global sites and mobile apps (2017). Accessed on 18 May 2017 at http://labtestsonline.org.uk
9. RCGP Learning Patient Online Toolkit. Accessed on 11 May 2017 at http://elearning.rcgp.org.uk/course/view.php?id=180

Competing interests: No competing interests

22 May 2017
Ralph Sullivan
GP
RCGP
Carnforth
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Re: Physician age and outcomes in elderly patients in hospital in the US: observational study Anupam B Jena, et al. 357:doi 10.1136/bmj.j1797

Dr Sharma's response introduces even more questions

Apart from the point I made in my earlier response that 200+ care episodes a year would seem ridiculously low volume not "high volume" in a UK setting for an acute geriatrician or general or acute physician managing the whole care episode often with very little recourse to speciality referral...

1. It may be that more senior, experienced physicians are more likely to recognise and accept that a patient is dying and to move towards a palliative or minimally interventionist approach. They may also be more likely to accept that discharge from hospital is not free of risk and that a higher readmission rate is perfectly acceptable in the context of trying to get people back home. A far more balanced range of outcomes is required than crude mortality or readmission rates - outcomes based on the person's own goals for their care or for a good death.

2. The USA has a far higher proportion of intensive care beds than systems such as the NHS. Although UK hospitals have excellent 24/7 access to critical care outreach teams, most patients dying in british hospitals do not die in ICU or HMU but in general ward settings and many won't receive input from ICU outreach teams or cardiac arrest teams because there has already been a decision not to escalate treatment further or to initiate supportive or palliative care

Not only is the study subject to multiple confounders but its external validity in other very different health systems is doubtful.

David Oliver

Competing interests: No competing interests

22 May 2017
David Oliver
Consultant Physician
NHS
Berkshire
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Re: Disturbed grief: prolonged grief disorder and persistent complex bereavement disorder Paul A Boelen, Geert E Smid. 357:doi 10.1136/bmj.j2016

The helpful review by Boelen and Smid [1] is welcome. When elderly women titled ‘Mrs’ presented to the back pain clinic alone – the following discussion often took place as part of the personal history prior to questions relating to their presenting symptom in my back pain clinic:-
Q. I notice you are alone today – can’t your husband come with you?
Often the answer was: I’m afraid I lost my husband.
Q. Oh dear – when was that?
Often the answer was: over two years ago now!
Q. I’m sorry to hear that – are you beginning to put the bits and pieces of life together again?
There were two answers usually given:
Answer 1. Of course – there are the grandchildren to think about – life has to go on! [firm voice]
Answer 2. Of course not – we shared the same bed together for xx years... [weepy voice and tears].
This group would often admit to daily tearfulness suggesting that counselling and anti depressive therapy might be helpful.
Occasionally one received a surprising answer – I’m glad he’s dead – he was a b.....!
All that information was elicited prior to investigating the back pain – reinforcing the importance of the personal history at the beginning of the consultation. This anecdote supports Boelen and Smid’s view that prolonged grief disorder may present to any clinician [1].

(1) Boelen PA, Smid GE. Disturbed grief: prolonged grief disorder and persistent complex bereavement disorder. BMJ 2017; 357(20 May):320-323.

Competing interests: No competing interests

22 May 2017
Andrew O. Frank
Retired consultant physician in rehabilitationn medicine and rheumatoloogy
Northwick Park Hospital
Harrow, HA1 3UJ
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Re: Physician age and outcomes in elderly patients in hospital in the US: observational study Anupam B Jena, et al. 357:doi 10.1136/bmj.j1797

Dear editor:

We read with great interest the recent article by Yusuke Tsugawa et al. concerning “Physician age and outcomes in elderly patients in hospital in the US: observational study”. Their admirable study on this meaningful topic is worthy of applause. However, we have some concerns about the strength of the conclusion that within the same hospital, patients treated by older physicians had higher mortality than patients cared for by younger physicians, except those physicians treating high volumes of patients. However, some potential factors may bias the conclusion, and should be adjusted.

1. Incidence rate of cardiovascular disease (CVD) has significant seasonal trend, being highest in winter. If not adjusted, it may cause bias (1).

2. In acute HF, right ventricular failure and renal dysfunction predict longer-than-average LOS, which is a proxy for more severe HF and is associated with worse post discharge outcomes (2).

3. Factors like the habit of smoking and BMI could increase the mortality rate in some case(3); we believe that this should be adjusted.

The findings should be cautiously accepted, further investigation and statistical analysis are needed.

Reference:
1. Yang J, Zhou M, Ou CQ, Yin P, Li M, Tong S, et al. Seasonal variations of temperature-related mortality burden from cardiovascular disease and myocardial infarction in China. Environ Pollut 2017;224:400-406.
2. Omar HR, Guglin M. Longer-than-average length of stay in acute heart failure : Determinants and outcomes. Herz 2017.
3. Vosoughi AR, Emami MJ, Pourabbas B, Mahdaviazad H. Factors increasing mortality of the elderly following hip fracture surgery: role of body mass index, age, and smoking. Musculoskelet Surg 2017;101(1):25-29.

Competing interests: No competing interests

22 May 2017
Wen Li
Phisician
Yunzhi Chen
Guiyang University of Chinese Medicine
Daxuecheng Guianxinqu Guiyang Guizhou China
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Re: Physician age and outcomes in elderly patients in hospital in the US: observational study Anupam B Jena, et al. 357:doi 10.1136/bmj.j1797

My conclusions about this research paper: Dr Yusuke Tsugawa is a clever scientist in publishing papers in high impact journals. In two other (different?) studies he and his colleagues showed that US patients treated by international graduates had lower mortality than patients cared for by US graduates [1] and that hospitalized patients treated by female internists have lower mortality compared with those cared for by male internists [2]. Well, the author is smart; he and his coworkers are members of Institutions of Harvard, Boston. The conclusions of this article are: patients treated by older physicians had higher mortality than patients cared for by younger physicians except those physicians treating high volumes of patients.

But what are the consequences for patients, policymakers and the public?

These points are perfect headlines for newspapers: The best internists are young, female, and international graduated?. I´m 62 years old, but only a psychiatrist. Otherwise I would stop my job now and go home. The problems of this research paper are known: confusion and a mix-up of correlation and causality and using the US terminology (“hospitalists”) and health system (differences in the type of patients) and generalizing it. What does the term “high volume of activity” mean? To be a better physician, should I treat 10 patients per day or one patient per year? But is it a problem, to see 100 patients per day, as many GPs in Germany do? Do the authors know limitations in clinical practice concerning fatigue, burnout or resilience? Oher critical points are demonstrated in a rapid response of D. Oliver [3].Outcomes in adult acute medical specialities are determined by availability of a multi professional staff, technical skills and community services outside hospitals and NOT by an individual senior medical practitioner. What are the complex answers of the authors to the question “experience” versus risk of being further away from having been a medical registrar? The article has ignored many potential confounding factors. The conclusions are unproven and dangerous.

1) Tsugawa Y et al. Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study BMJ 2017;356:j273
2) Tsugawa Y et al. Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA Intern Med. 2017 Feb 1;177(2):206-213. doi: 10.1001/jamainternmed.2016.7875
3) Oliver D, Rapid response: Re Physician age and outcomes in elderly patients in hospital inthe US: observational study. BMJ 2017;357:j1797

Competing interests: No competing interests

22 May 2017
Detlef Degner
Psychiatrist, senior consultant
Department of Psychiatry, Medical School, Georg- August- University Göttingen, Germany
Von Siebold -Str 5, D- 37075 Göttingen, Germany
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Re: Governments must be open about prices they pay for drugs, says WHO Anne Gulland. 357:doi 10.1136/bmj.j2341

Despite ongoing recession and implementation of strict austerity measures, prices of generics in Greece are still high, sometimes up to 880% higher than the same generics in Sweden! [1]
Even so, generics in Greece are prescribed only in 20% of patients. [2][3]
References
[1] http://neoskosmos.com/news/en/generic-drug-prices-sky-high
[2] http://gabi-journal.net/news/measures-to-increase-generics-use-in-greece
[3] https://www.ihs.com/country-industry-forecasting.html?ID=10659107152

Competing interests: No competing interests

22 May 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Kalamaria, Thessaloniki, Greece
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Re: Assisted dying for healthy older people: a step too far? Els van Wijngaarden, Ab Klink, Carlo Leget, Anne-Mei The. 357:doi 10.1136/bmj.j2298

Having only been able to read the 'open access' introduction, and without any familiarity with the Dutch law, my initial thought is that there is still the use of the word 'euthanasia' as well as the term assisted-suicide: it is assisted-suicide that I support, because 'euthanasia' covers rather wider concepts. The Nazis 'euthanised' many people - murdered is a better word there.

I think that extending assisted-suicide to 'healthy people' is something which can be argued over in the future: the first step, to my mind, is to settle the issue of whether assisted-suicide, if it is to be available, should be available to people whose lives are intolerable because of pain or some other factor(s), but who are not actually 'dying'. In other words, to question why this '... and the patient is expected to die within 6 months' [or a year, or whatever] intrudes on the assisted-suicide debate: if my life is intolerable because of unbearable pain which could not be relieved, and my life seemingly stretches ahead for decades, then doesn't that look like a stronger reason for suicide than if I'm dying as well as being in agony?

Competing interests: No competing interests

22 May 2017
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN
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