We select the letters for these pages from the rapid responses posted on bmj.com favouring those received within five days of publication of the article to which they refer. Letters are thus an early selection of rapid responses on a particular topic. Readers should consult the website for the full list of responses and any authors' replies, which usually arrive after our selection.
Clostridium diffiCileImprovement targets for C difficile must be validWe have identified a potentially distorting factor in the delivery of reductions in Clostridium difficile rates.1 A letter sent to chief executives of trusts, primary care trusts, and strategic health authorities in England in December 2006 stated that the forthcoming NHS operating framework for 2007-8 and the NHS contract require primary care trusts to agree a local target with their acute hospital providers for a significant reduction in C difficile infections. 2 The target is expected to be "locally appropriate" and based on "current performance." A reduction of at least 25% was suggested for trusts with a rate greater than four cases per 1000 bed days (in people over 65), while maintenance of the current rate would be an appropriate target for trusts with a rate of one per 1000 bed days or lower. with this figure. Therefore the reductions imposed are in many cases far in excess of the targets suggested in the letter from the Department of Health, or as stated by the strategic health authority (table). Since it was explained to the authority that these targets are inappropriate, it has agreed to recalculate them. When targets for methicillin resistant Staphylococcus aureus (MRSA) bacteraemia were set, they were imposed centrally and have been non-negotiable, despite statistical evidence showing that the methods used were invalid. 3 The MRSA targets will not be met; if C difficile rates are to be reduced targets must be potentially attainable. Although we are in favour of targets that increase the focus on reducing hospital acquired infections, we draw attention to the importance of using contemporaneous baseline data when trying to control a rapidly expanding problem. Infection control teams in trusts should ensure they are aiming at the right target, which should be scientifically valid.
trAnsPArenCy in niCelet's open whole process of cost effective modellingThe National Institute for Health and Clinical Excellence (NICE) needs to go much further than allowing access to its modelling data. 1 The whole cost effectiveness modelling process needs to be opened up to involvement by all stakeholders, and inspection by the public, as it happens. The independent group should be contracted to develop the one and only model that NICE will consider in its appraisal, and it should do so in full and continuous collaboration with all registered stakeholders and interested parties who sign up to the NICE guidelines. The model will be run with any alternative parameters suggested by various parties and the alternative results (along with their evidential basis) submitted t...
