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PubMed2001

Audit in general practice: how much and how complete? Frequency of audit in general practice.

The aim of this study was to determine the frequency of audit and the proportion completed in a group of practices. Data obtained by interviewing a member of each practice and inspecting practice records were independently coded by researchers. Practices initiated an average of 3.5 (range 1-7) audits in 2 years, of which an average of 0.9 (range 0-3) were completed. Ten of 16 completed audits were externally funded or facilitated. Few audits are completed in general practice and practices require continuing support for audit.

Abstracting and Indexing↗
PubMed2005

The use of routinely collected computer data for research in primary care: opportunities and challenges.

INTRODUCTION: Routinely collected primary care data has underpinned research that has helped define primary care as a specialty. In the early years of the discipline, data were collected manually, but digital data collection now makes large volumes of data readily available. Primary care informatics is emerging as an academic discipline for the scientific study of how to harness these data. This paper reviews how data are stored in primary care computer systems; current use of large primary care research databases; and, the opportunities and challenges for using routinely collected primary care data in research. OPPORTUNITIES: (1) Growing volumes of routinely recorded data. (2) Improving data quality. (3) Technological progress enabling large datasets to be processed. (4) The potential to link clinical data in family practice with other data including genetic databases. (5) An established body of know-how within the international health informatics community. CHALLENGES: (1) Research methods for working with large primary care datasets are limited. (2) How to infer meaning from data. (3) Pace of change in medicine and technology. (4) Integrating systems where there is often no reliable unique identifier and between health (person-based records) and social care (care-based records-e.g. child protection). (5) Achieving appropriate levels of information security, confidentiality, and privacy. CONCLUSION: Routinely collected primary care computer data, aggregated into large databases, is used for audit, quality improvement, health service planning, epidemiological study and research. However, gaps exist in the literature about how to find relevant data, select appropriate research methods and ensure that the correct inferences are drawn.

Biomedical Research↗
PubMed1997

Computer-based surgical audit programs: a review of three current options.

BACKGROUND: In order to find the most useful computerized auditing system for the needs of the QE II Hospital surgical department three surgical auditing software programs were assessed. METHODS: The Otago University Surgical Auditing Program, the Australian Surgical Auditing Program, and RACS-Audit were trialled for a period of 1 month each. The software programs were evaluated to find the time requirements for data entry, the level of surgical knowledge needed for effective audit information entry, and the perceived usefulness of the generated reports. RESULTS: It was found that the Otago University program best suited the needs of the department. This system was designed for use in a hospital environment with multiple users. The method of data collection was simple and rapid. Entry of data into the program was logical, well structured and able to be performed by both junior medical staff and clerical staff. Reports generated by this system included information in an appropriate format for the departments' morbidity and mortality meetings. CONCLUSION: Personal computers are an ideal tool for the undertaking of surgical audit. Software programs are designed for different uses and should be critically assessed to ensure that the method of data entry, the time involved, and the reports generated enable an efficient and effective audit to be carried out.

General Surgery↗
PubMed1999

Approaches to the organization of multi-practice audits in primary health care in the UK.

OBJECTIVE: To investigate the approaches taken by audit groups in primary care in organizing multi-practice audits and to identify the strengths and weaknesses of the methods used. DESIGN: Postal questionnaire survey. SETTING: One hundred and six primary care audit groups in England and Wales. RESULTS: Ninety multi-practice audits had been conducted since 1993, 46 of which were audits of diabetes and 44 of asthma care. A total of 48 completed questionnaires (24 each for asthma and diabetes) were returned (response rate 53%). Audit groups reported inviting 3338 practices to take part, of which 1157 completed the audit. The commonest methods used to encourage practice participation were a personal letter (75%), audit group newsletter (63%) and sending an audit protocol to the practice (63%). Groups used various methods for selecting audit review criteria, however only three (6%) used a systematic review of available literature. Each audit group advocated a number of methods for identifying patients and for data extraction. Forty-one (85.6%) groups reported that practices received feedback of results in an individualized practice feedback report. In 19 (39.6%) audits, the audit group had not undertaken any follow-up. CONCLUSIONS: The findings indicate that multi-practice audit can encourage the participation of large numbers of practices. Audit groups are co-ordinating multi-practice audits and feeding back information to practices on a comparative basis. However, there are weaknesses in the design and conduct of some audits. Groups should pay more attention to the selection of audit criteria, methods of identifying and sampling patients, data collection procedures, and methods for implementing changes in performance. For other countries that are beginning quality improvement activities, the results of this study emphasize the need to give attention to basic methodological principles.

Asthma↗
PubMed2003

Management of colorectal cancer: variations in practice in one hospital.

AIMS: The Royal College of Surgeons of England and the Association of Coloproctology of Great Britain and Ireland guidelines for the management of colorectal cancer were published in 1996. We audited our practice against these guidelines. METHODS: Data from 211 consecutive patients undergoing colorectal cancer surgery, between September 1999 and September 2000, have been prospectively collected. Preoperative large bowel and liver imaging, assessment by colorectal specialist nurses and median number of lymph nodes resected have been compared between specialist colorectal and non-colorectal surgeons for rectal and colonic cancers. The adequacy of resection and rates of abdomino-perineal resection have been compared for rectal cancers. Following presentation of our findings, we re-audited practice between January and June 2002. RESULTS: There was marked variation in practice within our hospital. Colorectal specialists were more likely to conform to best practice guidelines, performed fewer abdomino-perineal resections and tended to perform more extensive lymphadenectomy. Following presentation of these data, compliance with guidelines was markedly improved and the number of rectal procedures performed by non-colorectal surgeons decreased. CONCLUSIONS: The ability of audit to change practice has been demonstrated. We feel that completion of this audit cycle has improved the quality of service we provide for colorectal cancer patients in our hospital.

Adult↗
PubMed2005

The utilisation of intraosseous infusion in the resuscitation of paediatric major trauma patients.

Intraosseous lines are a reliable and rapid tool for obtaining vascular access in emergency situations, particularly in children. Their use is recommended when intravenous access cannot be easily secured and there is a need for fluid or pharmacological resuscitation. Training in this technique is included in the Advanced Trauma Life Support (ATLS) and Advanced Paediatric Life Support course (APLS) provider courses. The objective of this study is to analyse the national use of intraosseous lines in paediatric trauma in England and Wales. Data has been collected from the Trauma Audit and Research Network (TARN) group longitudinally over 14 years from 1988 to 2002. From 23,489 paediatric trauma cases, intraosseous lines were used in only 129 patients. Compared with the remainder of the paediatric data, we found that these were the younger (1-6 years), more severely injured patients (higher ISS, lower GCS, higher head, thorax, and abdominal AIS). The mortality of these patients was high at 64% compared with 4% overall. IO line use was greater in general than in Paediatric hospitals, perhaps due to good intravenous access skills in paediatric centres. We recommend that intraosseous line use should be a skill available to everybody involved in paediatric trauma resuscitation, particularly those who may not have refined paediatric intravenous cannulation skills.

Age Distribution↗
PubMedDate not supplied

Home oxygen therapy after preterm birth in Western Australia.

OBJECTIVES: To review our management of infants discharged home receiving supplemental oxygen. Stable preterm infants receive low flow O(2) by nasal cannulae aiming for SaO(2) of > or = 95%. Oxygen-dependent infants must pass an air test (ability to maintain SaO(2) > 80% during 4 h disconnection from oxygen) before discharge home with supplemental oxygen. A sleep study is performed before nocturnal O(2) is ceased. METHODS: Infants less than 33 weeks gestational age (GA) who were admitted January 1999-June 2001 and discharged home with supplemental oxygen were identified through the databases and medical records of the King Edward Memorial/Princess Margaret Hospitals. The data collected were compared with an audit performed a decade earlier. RESULTS: Ninety-three infants were discharged home with supplemental oxygen between 1999 and 2001 (10% neonatal intensive care unit admissions less than 33 weeks GA; median GA 26 weeks (interquartile range 25-28). All infants had an air test before discharge: 63% failed the first air test and 30% at least two air tests. The median delay between the first air test and discharge was 2 weeks. The median postmenstrual age at discharge was 40 weeks gestation (interquartile range 38-41). Ninety infants had a sleep study before nocturnal oxygen was ceased and nine failed the first sleep study. Hospital readmission rate was 60%. More preterm infants (less than 33 weeks) were discharged with supplemental oxygen in 1999-2001 (10%, n = 96 in 1999-2001) than in 1987-1992 (2.5%, n = 53) and this was associated with an earlier discharge (40 vs 44 weeks postmenstrual age), lower oxygen requirements at discharge (60 vs 125 mL/min), earlier discontinuation of daytime and nocturnal oxygen (1 vs 4 months postmenstrual age and 2.5 vs 6 months postmenstrual age) and no increase in readmission rate (64% vs 60%). The incidence of bronchopulmonary dysplasia for these infants has remained stable at 20%. CONCLUSION: Our home oxygen programme, based on an air test predischarge and a sleep study prediscontinuation of nocturnal oxygen, facilitates early discharge home. Our data suggest that over the last decade, bronchopulmonary dysplasia is associated with less impairment in lung function. Further evidence from randomized clinical trials is required to determine optimal target range for oxygen saturation in preterm infants.

Female↗
PubMed2004

Vagus nerve stimulation therapy after failed cranial surgery for intractable epilepsy: results from the vagus nerve stimulation therapy patient outcome registry.

OBJECTIVE: To determine the effectiveness of vagus nerve stimulation (VNS) therapy among patients with persistent or recurrent seizures after lobar resection, callosotomy, and other cranial operations for intractable epilepsy. METHODS: Data were obtained from the VNS therapy patient outcome registry, which was established after United States Food and Drug Administration approval of the VNS device in 1997 as a means of capturing open-label clinical data outside of protocol. The integrity of the systems for collecting and processing registry data was authenticated by an independent auditing agency. The effect of potential selection bias, however, remains uncertain. RESULTS: Two nonconsecutive cohorts were compared: patients tracked in the registry who had previously undergone cranial surgery for epilepsy (CS group, n = 921) and those who had not (non-CS group, n = 3822). For the CS group, the median reduction in seizure frequency was 42.5% after 3 months of VNS therapy, 42.9% at 6 months, 45.7% at 12 months, 52.0% at 18 months, and 50.5% at 24 months. For the non-CS group, analogous rates were 47.0%, 52.9%, 60.0%, 62.7%, and 66.7%, respectively. In the CS group, seizures were reduced by at least 50% in 55.1% of patients, at least 75% in 31.4% of patients, at least 90% in 17.3% of patients, and 100% in 5.1% of patients after 24 months of VNS therapy. Response rates were more pronounced in the non-CS group: at least 50% in 62.2% of patients, at least 75% in 43.7% of patients, at least 90% in 26.8% of patients, and 100% in 8.3% of patients. Patients in both groups experienced marked improvements in quality of life parameters. CONCLUSION: The effectiveness of VNS is maintained during prolonged stimulation, and overall seizure control continues to improve with time. Patients in whom prior cranial surgery had failed did not respond as favorably as all other patients receiving VNS therapy. Nonetheless, many of the former group improved substantially. Thus, on the basis of these open-label data, VNS therapy represents a potentially palliative treatment option for patients with refractory seizures after failed cranial surgery.

Adolescent↗
PubMed2002

Aortic aneurysm repair in a peripheral setting: audit 100 consecutive cases.

BACKGROUND: Subspecialization of vascular surgery and the advent of endovascular techniques for aortic aneurysm repair have had a large impact on the approach to aortic surgery in main centres. Centralization of vascular surgery has been proposed to lower mortality and morbidity rates. More recently, clinical governance standards have been set by professional bodies for acceptable adverse outcome rates in aortic surgery. A peripheral general surgeon's experience with aortic surgery is reviewed in the present report in order to identify the local adverse outcome rates, and to relate them to case data and governance recommendations. METHODS: A retrospective audit of 100 cases of elective and emergency aortic aneurysm repair (performed by the senior author over a 10-year period) was undergone for the present review. Demographic and outcome data were recorded, and a data analysis was performed to identify factors related to mortality. Significance was tested using chi-squared analysis. RESULTS: Postoperative mortality rates were 1.7% for elective cases and 21% for acute cases. Mortality was related to rupture of the aneurysm, blood loss and American Society of Anesthetists score > 3. CONCLUSION: Morbidity and mortality rates from this audit compare favourably with those from larger vascular units. They are well within the accepted clinical governance rates, although the latter do not account for any case mix variation which may exist between peripheral and tertiary referral centres. These results support the continuation of aortic aneurysm surgery in peripheral centres.

Aged↗
PubMed2004

Retrospective cohort study of false alarm rates associated with a series of heart operations: the case for hospital mortality monitoring groups.

OBJECTIVE: To examine the efficacy of different methods of detecting a high death rate and determining whether an increase in deaths after heart transplantation could be explained by chance. DESIGN: Retrospective analysis of deaths after heart transplantation. Seven methods were used: mortality above national average, mortality excessively above national average, test of moving average mortality, test of number of consecutive deaths, sequential probability ratio test (SPRT), cusum graph with v-mask, and CRAM chart. The national average mortality was not available and a rate of 15% was used instead as the benchmark. SETTING: Regional cardiothoracic unit. PARTICIPANTS: All 371 patients who received a heart transplant in the programme, 1986-2000. MAIN OUTCOME MEASURES: 30 day survival after transplantation. RESULTS: All methods provided evidence that the 30 day mortality had been high at some stage. The probability that the finding was a false positive depended on which test was used. At the end of the series the average mortality, sequential probability ratio, and cusum tests indicated a level of deaths higher than the benchmark while the remaining four tests yielded negative results. CONCLUSIONS: If the decision to test for outlying mortality is made retrospectively, in the light of the data, it is not possible to determine the false positive rate. Prospective on-site mortality monitoring with the CRAM chart is recommended as this method can quantify the death rate and identify periods when an audit of cases is indicated, even when data from other institutions are not available. A hospital mortality monitoring group can routinely monitor all deaths in the hospital, by specialty, using hospital episode statistics (HES) data and appropriate statistical methods.

Cohort Studies↗
PubMed1995

A prospective audit of total parenteral nutrition at a major teaching hospital.

OBJECTIVE: To examine patterns of use and clinical outcomes of total parenteral nutrition (TPN). DESIGN: A prospective six-month audit (December 1992-June 1993). PATIENTS AND SETTING: All inpatients administered TPN at a metropolitan teaching hospital during the audit period. MAIN STUDY MEASURES: Process measures included data about TPN initiation (bodyweight, period not receiving oral/nasogastric feeding, serum albumin level, compliance with hospital guidelines), TPN delivery data (kilojoules, and nutrient and electrolyte content), and bases for cessation or changes of TPN (biochemistry data, gastric and intestinal function). Outcome measures included body mass change, infection rate, detection of biochemical abnormalities, and death. RESULTS: During the audit 168 consecutive patients received 175 TPN courses. These patients were followed until discharge or death; 49 patients (29%) died. Intensive care units accounted for 57.7% of TPN use. Deviations from approved hospital guidelines for initiation of TPN were common. Only a minority of patients were malnourished on objective audit criteria; 18% of men and 13% of women were underweight by body mass index criteria and 36% were malnourished when serum albumin level (< 30 g/L) was considered. Early initiation of TPN outside accepted guidelines was common. Complications included bacteraemia (9.1% of patients tested) and catheter-tip sepsis (55.2% of 87 catheters tested). Four patients died; line sepsis caused one death and probably a further two. The incidence of glucose intolerance was 36.5%, and 25% had markers of abnormal liver function. CONCLUSIONS: TPN use is associated with a high risk of morbidity, and a 1.7% mortality. We recommend better patient selection for TPN, more appropriate use of enteral feeding, better infection control procedures, avoidance of substrate overload (particularly glucose), and earlier change to enteral nutrition.

Female↗
PubMedDate not supplied

A database coding system for vascular procedures.

A coding system was developed to overcome the difficulties encountered in data registry and retrieval from a national audit. In vascular surgery operations are frequently combined, and neither the OHIP fee schedule of codes (Ontario, Canada) nor the ICD-9 system provides sufficient detail for most vascular surgeons to retrieve information for long-term follow-up. However, some wish to record minimal data on their operative procedures. A numeric classification system was developed. A five-digit number is used, the first two digits classifying the operative procedure and anatomic details. Two decimal digits code the classification of operation (e.g., aortic aneurysm, tube graft, aortoiliac, or aortobifemoral) and the final digit may be used as a modifier. "Holes" in the numeric system allow for new operations to be added as they develop. Codes are stored in a database with the following fields: 1) codes; 2) description of operation; 3) translation. The translation field may be modified to permit translation of any existing databases into the system. This database has been distributed with a data registry program free of charge to vascular surgeons in Canada to allow nationwide registry of vascular surgery patients. A numeric code eliminates spelling and abbreviation errors, and can be sufficiently broad-based to allow all surgeons to participate in a nationwide audit.

Abstracting and Indexing↗
PubMed2005

An audit of patients investigated by Hysterosalpingo-Contrast-Sonography (HyCoSy) for infertility.

We reviewed 171 case notes of patients investigated by HyCoSy for sub-fertility in South Manchester University Hospital to assess HyCoSy as a screening test for tubal occlusion, in low risk infertile women and to evaluate the performance of HyCoSy in our unit by confirming its results with the results of laparoscopy & dye test in those patients who had both procedures. We also assessed the prognostic significance of HyCoSy, for fertility outcome over a follow-up period ranging from 12 to 63 months. An audit proforma was designed to collect data on maternal age, type of infertility (primary or secondary), duration of infertility and parity. History suggestive of ovulatory factors (PCO), pelvic inflammatory disease and endometriosis was noted. Findings of standard trans-vaginal scan, hysterosalpingography and HyCoSy were recorded. In total 333 tubes were examined in 171 patients. There were 121/171 diagnoses of bilateral patent tubes, 24/171 bilateral blocked tubes and 26/171 findings of one patent tube. In 15 (8.8%) women, laparoscopy and dye test was performed after HyCoSy and 19 patients had laparoscopy and dye test before HyCoSy. The findings in both investigations were similar. 70 additional uterine and adnexal pathologies were detected. Out of 171 40.9% (n=70) women conceived, 62 of these women had both tubes patent and 8 had one patent tube. In conclusion we have found that HyCoSy is a valuable cost effective screening test for low risk couples. Its results in our hands are as good as demonstrated by other studies. HyCoSy can be offered as a screening test for low risk infertile women as it is an effective alternative for laparoscopy and dye test.

Adolescent↗
PubMed2003

The best of both worlds? Potential of hybrid prospective/concurrent risk adjustment.

BACKGROUND: There remains considerable uncertainty about whether prospective or concurrent risk adjustment (RA) is preferable. Although concurrent models have better predictive power than prospective models, the large payments associated with concurrent RA create incentives for fraudulent coding. A hybrid strategy--in which prospective payments were used for patients with low expected costs and concurrent payments were available upon the diagnosis of a small number of common, expensive conditions--might improve predictive performance while requiring less auditing than fully concurrent RA. In addition, within-condition RA (using clinical data) for the selected conditions could further improve predictive power. OBJECTIVES: To assess how such a hybrid strategy might perform, focusing on a small number of chronic, expensive conditions that are verifiable (hence auditable). SUBJECTS AND MEASURES: All patients from seven health plans who had two complete years of utilization data were considered. RA models were estimated among patients younger than 65 (n = 319,209) using the Hierarchical Coexisting Conditions (HCC) model with and without stratification of the sample based on the presence of one or more of 100 verifiable, expensive, predictive conditions (VEP100). R2 and predictive ratios were calculated for each model studied. RESULTS: Patients with a VEP100 condition (9.3% of the population) accounted for 84.3% of the variation in cost. R2 was 0.08 using a prospective HCC model on the entire population, but increased to 0.26 for a hybrid using prospective HCCs on the 90.7% of the sample without a VEP100 condition and a simple concurrent model consisting of dummy variables for each of the VEP100 conditions. CONCLUSION: Combined with targeted auditing, a hybrid approach to RA could improve our ability to match payments to costs. However, because this would require additional, costly data collection, more research is needed to determine whether this benefit justifies the data collection and auditing burden.

Adolescent↗
PubMed1994

Patterns of paging medical interns during night calls at two teaching hospitals.

OBJECTIVE: To assess the patterns of paging medical interns during night calls. DESIGN: Descriptive study; diaries were used to log calls between 7 pm and 7 am for 1 week in February 1991. SETTING: Two teaching hospitals in Halifax. PARTICIPANTS: All 10 interns assigned to the 15 medical units and nurses from 3 representative medical units. MAIN OUTCOME MEASURES: Number and nature of calls. RESULTS: The overall response rate was 90%. A total of 309 calls were logged by the interns and 107 by the nurses. Each intern had 17 calls on average (range 6 to 33) per 12-hour period. Of the calls 27% occurred after midnight, 25% disrupted sleeping, and 19% interrupted direct patient contact. Overall, the most common reasons for paging interns were related to prescribing of medications (42% of the calls), direct patient assessment (25%) and reporting of laboratory results (18%). According to the nurses, there were no delays in the interns' responding to the pages, and 61% of the calls led to a new physician order. CONCLUSIONS: Paging frequently interrupts interns during work and rest on night calls. Assessment of paging patterns may be useful in identifying specific interventions to reduce the number of calls so that interns will have fewer interruptions during patient encounters and more rest. The collection of data from nurses in a routine nursing audit may be useful for evaluating the communication between interns and nurses and, indirectly, for assessing interns' workload.

Data Collection↗
PubMed1996

A clinician friendly computerised head and neck oncology audit: the first year results.

Surgical audit is only as good as the information recorded and data entry is often onerous and the domain of the enthusiastic clinician or research follow. A head and neck oncology audit which incorporates a specific software program has been established in our department. The software interface increases the user friendliness of two conventional database systems, ACCESS and SUPERBASE and structures data input for the clinical situation. The program has been designed for ease of use by every clinician irrespective of their computer competence. The departmental prospective audit has been active since January 1993 and the essential details on new patient presentation, assessment, surgery and outcome for the first year are included in this article.

Aged↗
PubMed2002

Can cancer centres in New Zealand help the cancer registry generate survival data? A pilot study in prostate cancer.

AIMS: One of the current limitations of reports issued by the New Zealand Cancer Registry (NZCR) is that the only measure of the success of treatment is provided by the mortality ratio. A pilot study was therefore carried out to see if collaboration between cancer centres and the NZCR might allow the generation of more meaningful survival data that could be used for the audit of treatment outcome. METHODS: Clinical details of patients seen at the Wellington Cancer Centre (WCC), in whom a diagnosis of prostate cancer was made in 1997, were provided to the NZCR. These details were matched with registration and mortality data held by the NZCR. RESULTS: WCC records identified 82 patients who were diagnosed with prostate cancer in 1997. Of these, the NZCR registered 60 (73%) in 1997, 3 (4%) prior to 1997, and 14 (17%) after 1997. Five patients (6%) were not registered at all. In the cohort of 82 patients, 17 (21%) had subsequently died. Of these, 11 (65%) had been treated with palliative intent, and six (35%) with radical intent. Of those patients treated radically, three had died of prostate cancer and three of other causes. CONCLUSIONS: Cooperation between Cancer Centres and the NZCR would allow the NZCR to generate useful survival data. This could help evaluate the impact on survival of specific treatments and interventions, such as screening programs. Regional variations in outcome could be detected. The exercise is feasible, without compromising patient confidentiality.

Cancer Care Facilities↗