Unwarranted variation in health care

We are all very aware that there is variation in health care across populations based on many factors including level of education, access, wealth and geographical location. The reasons for this variation are complex to analyse and some variation may be justifiable and necessary. Cheung et al discuss this important and topical issue in a narrative review. The authors look at variation in effective (or high value) care, for example uptake of immunisation, preference centred care where the optimal course of action is not always clear and supply sensitive care where health care utilisation is influenced by the availability of local resources. The authors highlight many examples using data from the recently published NHS Atlas of Variation (http://www.rightcare.nhs.uk/index.php/atlas/children-and-young-adults) which documents the rates of specific interventions by geographical location across England including, for example, a seven fold variation in admission rates for diabetic ketoacidosis and fivefold variation in rates of diagnostic endoscopy. This area of health care is ready for discussion and debate and information of this type is one of the many factors that should be taken into account when decisions about how health care is delivered across a population. See page 57

Investigation following resuscitated cardiac arrest

Up to two thirds of resuscitated cardiac arrests in children and young people are due to inherited heart disease with important implications for the child and their families even if the child doesn't survive. Skinner approaches this important issue with a question based approach to management including a detailed summary of investigations and helpful flow algorithm. The author highlights the importance, even in the context of non-survivable brain damage, of not missing this opportunity to identify, or exclude, a lethal familial condition. See page 66

Postnatal depression in mothers bringing infants to the emergency department

Postnatal depression is common and is well known to have significant short and long term implications for the sufferer and their family, and relevant in the assessment and management of infants who present unwell. There are various screening tools that can be employed including the Edinburgh postnatal depression scale which scores responses to questions based on how the mother has been feeling over the previous 7 days. There is ongoing debate about whether screening should be universal or targeted. Stock et al report on their experience of screening mothers who bring infants to the emergency room. 16% of the mothers screened positive for post natal depression (twice the prevalence in previous population studies). Infants whose mothers screened positive presented with a wide range of symptoms. Risk factors included a past history of depression (RR4.8), single parents, low socioeconomic status, stressful life events and ‘crying baby’ as the presenting problem. Mothers found completing the screening proforma and social work assessment (where appropriate) acceptable. The authors highlight the importance of postnatal depression in all healthcare settings and the importance of questioning about mood and coping as part of the overall assessment of infants who present to health with acute or chronic illness. See page 36

Adolescents’ health care needs: the same the world over

Tsai et al explore adolescent perspectives on health needs and preferred sources of information in Taiwan by school based questionnaire of more than 5000 adolescents aged 12–18 years. The findings are of interest. Participants wanted information on weight, height and dietary health. Academic stress, sleep problems and emotional issues were highlighted as key areas of concern. Only a small proportion used health care services for mental and emotional issues. Chronic ill health and suburban location were associated with increased needs. Parents were the primary source of health information, although students turned to teachers for particularly sensitive issues. The internet and social media were popular sources of information.

The accompanying editorial discusses adolescent health care needs, the same the world over and emphasises the fact that access to this potentially vulnerable group requires a multipronged approach taking into account local needs and local resources and the impact on adolescent health longer term. See pages 9 and 2

Risk of testicular cancer in isolated cryptorchidism

Testicular cancer is the commonest malignancy seen in young adult males with cryptorchidism (failure of the testes to descend into the scrotum before birth) a known risk factor. Lip et al explore the increased risk in boys with isolated cryptorchidism by meta-analysis and conclude that based on available data (nine case control studies, three cohort studies) the relative risk compared with the general population is 2.9, perhaps somewhat lower than previously thought. The authors do however emphasise the lack of high quality evidence available and that the impact of factors such as laterality, degree of descent and early orchidopexy require clarification to further stratify patient risk. Early orchidopexy is of course still essential to maximise fertility, reduce the risk of torsion and place the testis in the scrotum for cosmetic reasons and to facilitate self examination in view of the increased cancer risk. See page 20

In F&N this month

Seaton et al report on babies born at the threshold of viability looking at changes in survival and workload over 20 years in their region. Resources allocated to these babies have increased significantly over time. No babies born at 22 weeks gestation survived. Survival for infants born at 24 and 25 weeks has increased with little change in the outcome of infants born at 23 weeks gestation many of whom ultimately die. Current recommendations suggest babies born at 24 weeks of gestation should normally receive active intervention whereas babies born at 23 weeks should be discussed and a decision made whether intervention is appropriate. These important data support that recommendation and will be used to further inform the continuing discussions and debate around this issue.