Friday, July 25, 2014

Prevention is not a medical paradigm

Pharmaceutical Pinball
Pharmaceutical Pinball (Photo credit: DES Daughter)
Healthcare will not ever be about prevention. It is cogent to say that the economics of cure are unsustainable, but healthcare is not about helmets and seatbelts, or electric lighting or piped water or soap or ....

No-one gets paid to prevent anything. Insurers get paid to mitigate risk not eliminate it. So, too, do pharmaceutical companies. And sin taxes are essentially  risk premiums - that is insurance products and bad ones at that, priced by political calculus rather than actuarial coefficients.

Modern Healthcare

Healthcare used to be about local experience and anecdote, then about science, then economics. Now it is about politics.

As the science has gotten better it has also become unmanageably complex.

Wednesday, July 02, 2014

Cognitive Bias

"When we attempt to understand past events, we implicitly test the hypotheses or rules we use both to interpret and to anticipate the world around us. If, in hindsight, we systematically underestimate the surprises that the past held and holds for us, we are subjecting those hypotheses to inordinately weak tests and, presumably, finding little reason to change them."


Tuesday, July 01, 2014

ED Attendances by Age

E. Hassen, R. Bhalla 
Accident and Emergency Department 
Correspondence to E. Hassen; email doctor@drhassencom. 

There is a dearth of epidemiological research into paediatric attendances at Emergency Departments in the UK. This study looks at all types of ED attendances by children at a single site through one year. 

Data and methods: 
Routine data on all attendances by children aged 1-15 years were available (period: 1 January 2005 to 31 December 2005). The data were analysed by time of year (weekly) for each age cohort. 

Attendances peaked at age 2 and decreased for each cohort to a minimum at age 8 before rising again to age 15. For all ages attendances were higher for males compared to females. For the year, paediatric attendances peaked in week 28 as did total ED attendances. However, as a proportion of the total, paediatric attendances peaked in week 27. 

This study has shown that paediatric attendances at our ED are activity dependant, age sex and population dependant. There is considerable variation in ED attendance rates across the country with many factors responsible and few published comprehensive audits to guide planning. It is to be hoped that others will answer the same questions as a basis for further much needed research in Emergency Medicine. 

Abbreviations: ED, emergency department 
Keywords: children; emergency department; epidemiology; paediatric 

There is a dearth of epidemiological research into paediatric attendances at Emergency 
Departments in the UK. Most Emergency Medicine research in the UK has looked at types of injuries although several have looked at all types of ED attendance. Only one 
study has looked at the epidemiology of ED attendances specifically. This latter study found that most attendances were due to injuries and that these varied by age and location and that the variations were not stable across sites. More information is needed from more sites for longer periods through the country in addition to the sentinel sites 
monitored by the DTI given the contingent and complex causes of ED attendances. 

The lack of research in Emergency Medicine is due to the fact that this is a new 
speciality, that Emergency Medicine lacks political capital, that no dedicated funding 
exists for Emergency Medicine research, that no dedicated organisation is responsible for 
Emergency Medicine research, that Emergency Medicine practitioners have an action 
focus rather than a research focus and that Emergency Departments are under-resourced 
for service provision without the ability to do research. The Joint Statement on Children’s 
Attendances at Accident & Emergency Departments was published in 1999 with its most important references from 1985. The Care Group Workforce Team Recommendations 2003 Report did not deal with Emergency Medicine. The most recent numbers published for NHS Direct referrals to Emergency Departments were for 1999-2000, the first year that NHS Direct was operating. 

Emergency Medicine is still an orphan speciality and needs research that proves the 
growing workload and the effectiveness (clinical, social and financial) of Emergency 
Departments. Towards that end we contribute this study. 
This study looks at all types of ED attendance at one hospital to report on the use of the 
Emergency Department by children to see how these vary by age, sex and season. 


The Study Hospital is a district general hospital in North East Wales serving a 
population of 250,000. It is situated on the outskirts of the town (pop 70,000), 
which is near the Welsh/English border in North Wales. The catchment area extends 
beyond the county to include patients from Flintshire, Powys, south 
Gwynedd, as well as some from Cheshire, the Wirral and Shropshire. 

The Emergency Department is fully computerised and records information on every 
attendance made. Data on all new ED attendances by children aged under 16 years of age 
were available for the period 1 January 2005 to 31 December 2005 (12,443 records). 


In 2005 ED attendances peaked at age 2 and then decreased to a minimum at age 8 before rising again. For all attendances the peak was reached in week 28, which was also the week in which paediatric attendances peaked; however, as a proportion paediatric 
attendances peaked in week 27. For all ages males presented more frequently than 
females with the smallest difference at age 2 and the largest difference at age 12. 

We have an advantage compared to the fragmented health services sector in America: 
most accidents and emergencies in the UK are dealt with by the NHS in the Accident & Emergency Department. Centralised data collection, analysis and dissemination are 
possible. We hope it happens; soon. 

We would like to thank the ED staff at the Study Hospital 


Funding: None. 
 Competing interests: none declared 


1. Downing, A, Rudge, G. A study of childhood attendance at emergency 
departments in the West Midlands region. Emerg Med J 2006 23: 391-393. 

2. Scuffham, P, Chaplin, S, Legood, R. Incidence and costs of unintentional falls in 
older people in the United Kingdom. J Epidemiol Community Health 2003 57: 

3. Accident & Emergency Services for Children: Report of A Multidisciplinary 
Working Party. RCPCH. June 1999. 

4. Long Term Conditions Care Group Workforce Teams Recommendations - 2003 
Report to the Workforce Numbers Advisory Board. DHHRD Care Group 
Workforce Teams. Nov 2003. 

5. Outcomes of calls to NHS Direct, 1999-00: Social Trends 31. DoH 2002. (Last accessed 20 June 2006). 

6. Helen Cooper, Chris Smaje, Sara Arber. Use of health services by children and 
young people according to ethnicity and social class: secondary analysis of a 
national survey. BMJ 1998; 317:1047-1051. 

7. MacFaul R and Werneke U. Recent Trends in hospital use by children in England. 
Arch Dis Child 2001; 85:203207. 

8. Emergency Care for Children: Growing Pains (2006). Board on Health Care 
Services. 2006.