PERSONAL VIEW Charges for scoring systems may change practice Much medical knowledge is copyrighted, but charges to reproduce clinical scoring criteria such as the Mini Mental State Examination may see them disappear from guidelines, writes Hugo Farne small but important change is number of titles—when previously the bulk quietly taking place in academic of article citations were accounted for by publishing, to the detriment of a few papers in the top journals10—and authors and readers alike. falling library budgets have been met with The National Institute rises in subscription charges in excess of Afor Health and Care Excellence (NICE) inflation (the “serials crisis”).11 Aggressively recommends using the Wells score to assess pursuing publishers who quote their content, patients with a suspected pulmonary particularly scoring systems that are often embolus, for example, and it recommends reproduced, can provide additional revenues the CHA2DS2-VASc score to identify which for journals. patients with atrial fibrillation are at high risk of stroke and should start prophylactic Intellectual property anticoagulation. However, if you wish It is only right that journals should seek to publish an article, book, smartphone to protect the intellectual property of their application, or website that reminds readers authors against plagiarism. However, scoring of these scoring systems, it will cost you systems were intended to be used as widely dearly—as much as $750 (£486; €690) goes as possible. By charging such high fees, these to the Annals of Internal Medicine for the Royalties for reproduction: room for improvement scoring systems will inevitably be less widely Wells score and $360 to the journal Chest read and used, much as articles incurring a for the CHA2DS2-VASc score (see table). Even For similar reasons, the Mini Mental State subscription charge are cited less often than publicly funded bodies are charging: NICE Examination (MMSE)8 has been replaced open access articles.12 told me that it would charge £75 a time for by less well known and less well validated The UK General Medical Council’s guide items reproduced from its guidelines. alternatives in core textbooks: the 2007 Good Medical Practice states that doctors edition of the best selling Oxford Handbook must provide treatments based on “the best Payment of royalties of Clinical Medicine removed the MMSE, available evidence.” We are, by extension, Scoring systems are increasingly used adding a note to say that it was “now subject compelled to ensure that the best evidence because of their incorporation in guidelines to copyright owned by PAR [Psychological is as “available” as possible. Readers and and their availability on smartphone Assessment Resources].”9 subscribers should demand that journals applications and websites. In theory at Anecdotally, this may also have affected make reproduction of scoring systems free (or least, reproduction of these scoring systems clinical practice. Colleagues in neurology at least cheap), and authors of new scoring demands payment of royalties. tell us that the MMSE is no longer used even systems should choose journals committed to As joint authors of an educational book in memory clinics at the National Hospital this. If publishing scoring systems continues for medical students, my coauthors and I for Neurology and Neurosurgery, a tertiary to come at such a high cost, it will be patients were keen to familiarise the next generation hospital in London. It seems likely that who ultimately pay the price. of doctors with the more commonly used guideline drafting bodies such as NICE will Hugo Farne is specialist registrar and academic clinical scoring systems. However, we had to remove ultimately follow suit. fellow in respiratory medicine, Imperial College London, some established ones, such as the Wells Journals have been under substantial St Mary’s Hospital Campus, London W2 1NY score, from the second edition because of the financial pressure for some time. Increasing [email protected] exorbitant cost involved. competition from an ever expanding Cite this as: BMJ 2015;351:h4325 Costs of reproducing scoring systems Scoring system Journal (publisher) Fee to reproduce one figure or table ($) Conference or Textbook* presentation** Website** TIMI score1 JAMA (American Medical Association) 1000 600 600 CAGE questionnaire2 JAMA (American Medical Association) 1000 600 600 Wells score for pulmonary embolism3 Annals of Internal Medicine (American College of Physicians) 750 375 125 Light’s criteria4 Annals of Internal Medicine (American College of Physicians) 750 375 125 Pneumonia Severity Index (PSI)5 New England Journal of Medicine (Massachusetts Medical Society) 616.88 Requires publisher review Requires publisher review 6 CHA2DS2-VASc Chest (American College of Chest Physicians) 360 90 270 (for 7-12 months only) HAS-BLED7 Chest (American College of Chest Physicians) 360 90 270 (for 7-12 months only) * Published in English; worldwide circulation of 5000. ** For a physician or academic to use untranslated materials in electronic format only with a worldwide audience. the bmj | 12 September 2015 21 OBSERVATIONS CONSULTANT COVER Martin McKee Would seven day working save 6000 lives a year? The UK government’s claim turned out to come from a single study that shows nothing so simple On 16 July 2015, Health Secretary deaths because the 30 day mortality outcomes in units with consultant Jeremy Hunt used BBC Radio 4’s rate is 11% higher among those rounds seven days a week than in Today programme to warn the admitted on Saturdays and 16% those with fewer. It did find a dose- British public that “we have about higher on Sundays. response relation with registered 6000 avoidable deaths every year But what about people who are nurse staffing levels at weekends, in the NHS” and that “lack of senior already in hospital at a weekend? suggesting that the answer may lie consultant cover at weekends is one They had a significantly reduced risk other than with consultants.13 of the critical points.”1 of dying on a Saturday (5% less) and But it subsequently emerged Sunday (8% less). This is presumably What would it cost? that only one of more than 4000 because fewer major procedures Many parts of hospitals, such consultants has opted out of are taking place, consistent with as emergency departments and weekend working.2 And we do not the observation that mortality often intensive care units, already work know whether excess mortality is falls when doctors go on strike.8 The 24 hours a day, seven days a week. a consequence of lower quality simplistic solution to stop major The health There may be other parts that of care or of some difference in surgery on a few more days each secretary should, but which ones and with case mix comparing weekend with week has obvious flaws. describes the what consequences for the rest weekday admissions. The evidence The situation is further excess deaths as of the hospital or, more likely, the underpinning Hunt’s claim has complicated by the observation configuration of hospital networks? received too little attention. that patients admitted on a Sunday “avoidable” and Given the challenges of rapidly One reason for the lack of scrutiny who are not emergencies have a links them to his expanding the consultant workforce, was that the Department of Health 62% greater risk of dying in the perception of a as well as the specialised support that did not disclose the evidence. The next 30 days than those admitted lack of consultant consultants require, staffing levels will BBC reported, “The 6000 figure . on a Wednesday (95% confidence cover at weekends. inevitably be reduced at other times that was used by the government interval 50% to 75%). This may be This may well be in the week. And at a time when the was from research that has yet to be an example of “confounding by the case for some NHS faces unprecedented financial 3 9 published.” indication,” with patients who are deaths, but there pressure, what would seven day Hunt did refer to a paper published at greatest risk admitted early to are many other working cost? One study suggested in 2012,4 but only as background. prepare them for elective surgery. that it would exceed the guidelines Consequently, it was a surprise Then there is the matter of possibilities on cost per quality adjusted life when, on 13 August 2015, in attribution. The health secretary year (QALY) applied by the National response to freedom of information describes the excess deaths as Institute for Health and Care requests I made, the department “avoidable” and links them to his Excellence by a factor of between 1.5 said that Hunt’s comments had perception of a lack of consultant and 2.4, or between £339m (€416m; indeed been based on the 2012 cover at weekends. This may be the $520m) and £831m a year.14 paper; the “yet to be published” case for some deaths, but there are The updated analysis in the research received no mention.5 We many other possibilities. The most accompanying paper suggests that now know that the new study that the obvious is that patients admitted as the increase is real but, crucially, the Department of Health was referring emergencies at weekends have been authors note “to assume that they to is an updated analysis by the clinging on for several days in their are avoidable would be rash and same authors that is published in own homes or in residential care.10 misleading” and suggest a range this issue of The BMJ,6 but this was It is also possible that the onset of possible explanations.6 Given not available to anyone seeking the of the weekend, when community the changing nature of medicine evidence base at the time the policy support services may be difficult to some changes to working patterns was announced, contrary to the code access, may influence the decision are probably necessary, but it of practice for official statistics.7 by general practitioners to refer for would be useful to have a better admission or by families to take the understanding of the reasons for What did it show? patient to an emergency department.