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PubMed1995

Prospective audit of abdominal aortic aneurysm surgery in the northern region from 1988 to 1992. Northern Vascular Surgeons Group.

Over a 5-year period a prospective audit was carried out on 1131 patients undergoing surgery for abdominal aortic aneurysm (AAA) in the northern region. A total of 470 operations was performed in teaching hospitals and 661 in district hospitals; emergency operations accounted for 41.5 per cent. The overall mortality rate was 25.8 per cent; for emergency cases this value was 50.0 per cent. Mortality rates for elective surgery were 3.9 per cent in teaching and 12.0 per cent in district hospitals. Patients with ruptured AAA admitted via the accident and emergency department had a higher mortality rate (64.3 per cent) than those admitted by their general practitioner (49.5 per cent) or those referred from the urology department (18.8 per cent). In all, 73 (6.5 per cent) patients were admitted with an alternative diagnosis, ranging from collapse of unknown cause (25) to torsion of the testes (one) and colonic obstruction (one). Age had a profound effect on mortality rates. For emergency cases the mortality rate varied from 47.0 per cent (in teaching plus district hospitals) in those aged less than 80 years to 70.1 per cent in those 80 years or over (chi 2 = 7.22; P = 0.007). For elective surgery the mortality rate varied from 7.6 per cent (in teaching plus district hospitals) in those under 80 years to 23.8 per cent in those 80 years or over (P = 0.0006). The overall mortality rate of 25.8 per cent is significantly less than that quoted in the Confidential Enquiry into Perioperative Deaths report of 1987. Furthermore, elective patients over 80 years of age may expect a survival rate of 76 per cent and, in the absence of major medical contraindications, should not automatically be denied surgery. Importantly, it is of note that this prospective audit identified 31 per cent more cases than recognized by regional audit data.

Aged↗

PubMed2003

Postoperative pain management on surgical wards-impact of database documentation of anesthesia organized services.

Postoperative pain management (POPM) should be based on an organization exploiting existing expertise and documenting the outcome of the POPM in each individual patient. The aims of the present study were to evaluate the adequacy of database documentation of POPM of an anesthesia organized, nurse-based, anesthesiologist-supervised acute pain service (APS) on surgical wards and to assess to what extent the information obtained was continuously used to improve practice. From 2890 registered cases in the database (patient controlled analgesia, n = 1975; epidural analgesia [EDA], n = 915), a homogeneous two-year sample of documentation charts from use of EDA for POPM in connection with major, open, abdominal surgical procedures (n = 381) was chosen for detailed analysis. The data charts contained information on patient data, drug dosage, total amount of infused drug, duration of EDA treatment, occurrence of side effects, and patient's level of satisfaction. The database information was easily accessible making assessment of relevant aspects of the routines, including associations between analgesic technique, patient related factors, and satisfaction with the services, immediately available. Only 58% of the data charts were properly completed and fed into the database but the clinical safety of the missing nondatabase documented sample was not found jeopardized. Although the database documentation routines were considered to fulfill basic requirements of data collection and monitoring of the appropriateness of POPM, they were not found to function optimally. The reason seemed to be inadequate feedback of information between the parties involved in the POPM services. The present study stresses the importance of establishing routines for adequate, continuous feedback of recorded audit data from the APS team to the surgical wards for the maintenance of a high level of compliance with accepted guidelines.

Adolescent↗

PubMed2004

Which cephalosporin for gonorrhoea?

The recommended treatment for gonorrhoea in the United Kingdom has, until recently, included the fluoroquinolone, ciprofloxacin, which consequently was used by most genitourinary medicine clinics. In 2002 national surveillance data showed that resistance to ciprofloxacin had risen to a prevalence of 9.8% (9% in 2003), indicating that the target of >95% efficacy in first line therapy was no longer achievable. The third generation cephalosporins, ceftriaxone (intramuscular) or cefixime (oral), are the recommended alternatives, but recent audit data reveal other cephalosporins are currently being used to treat gonorrhoea, notably including cefuroxime (intramuscular or, often, oral). A pharmacodynamic analysis was undertaken to determine whether all these regimens were equally potent. Ceftriaxone, 250 (or 500) mg intramuscularly, or cefixime, 400 mg orally, were calculated to give free drug concentrations above the MIC90 for 22-50 hours post dose whereas the cefuroxime regimens being used were pharmacodynamically borderline, achieving this target for only 6.8-11.2 hours and raising the spectre that continued use may select for stepwise increases in resistance, as occurred with penicillin. We therefore underscore that ceftriaxone or cefixime should be the agents of choice to replace ciprofloxacin, as recommended in the new treatment guidelines, and that cefuroxime is a poor substitute.

Anti-Bacterial Agents↗

PubMed1996

Using economics alongside medical audit. A case study of the management of endometriosis.

During 1993, the diagnosis and initial management of endometriosis in women was identified as an important topic to be addressed within the Gynaecology Audit Project in Scotland (GAPS). This paper documents the experience of using the medical audit data collected by this exercise to estimate the costs and outcomes associated with alternative treatments for endometriosis associated infertility. Its aim is not to draw firm policy conclusions but rather to demonstrate the economic methods and to highlight difficulties in the application of economics to audit. The average cost of medical management was found to be significantly higher than the average cost of expectant management because of the high costs of the drugs involved. There was little difference in clinical and health outcomes observed between those women managed expectantly and those women managed medically. The results of the economic assessment add cautious support to the growing volume of clinical evidence indicating expectant management as the first line treatment of choice although further research is required to substantiate these results in a larger sample of women presenting with this condition.

Endometriosis↗

PubMed1991

Issues for comparability of DRG statistics in Europe. Results from EURODRG.

DRG use has spread through most European countries thus offering an opportunity for improving hospital data bases at the European level. An EEC Concerted Action 'Use of DRGs to support Hospital Sector Management in the European Community' was approved by the Committee of Health Services Research of the EEC. A general overview of the project is presented as well as a detailed description of the results of the work on aspects related to DRG data production. These aspects (MBDS implementation and variables definition; coding systems and updating; mapping systems; data auditing; trimming methods; and DRG grouper versions) have been analyzed with the objective of increasing opportunities for valid international comparisons of DRG statistics between European countries.

Abstracting and Indexing↗

PubMed2001

National audit of the blood transfusion process in the UK.

The objectives of this initiative were to produce nationally tested audit tools, to influence the content of national guidelines, and to enable performance indicators to be set for the clinical transfusion process. Audit tools were developed for blood transfusion practice through a collaboration between Royal Colleges and specialist Societies with an interest in blood transfusion. National audits were carried out involving 50 hospitals in the first audit and 23 of the same hospitals in the second. Over 20% of participating hospitals did not have Hospital Transfusion Committees. Most hospitals had written policies for the taking of blood samples for grouping and compatibility testing. Formal training for the phlebotomists and nurses who took blood samples was almost universal, but only one-third gave training to doctors. The audits of transfusion practice demonstrated considerable variation in the performance of standard procedures in relation to the administration of blood, and little change in practice between the two audits. The first two objectives have been met in that audit tools were developed and published, and information from the first audits was used in the development of national guidelines for the administration of blood. A significant shortfall in the systems for monitoring and delivering transfusions is present in many hospitals. This justifies pursuing the third objective but this will require a new initiative. The type of analysis and the method used for the presentation of audit data developed in this study may be useful for setting performance indicators for the clinical transfusion process.

Blood Transfusion↗

PubMed2000

Pain at home: children's experience of tonsillectomy.

Earlier discharge following tonsillectomy increases the need for good pain management advice and effective analgesia. An audit determined the nature of children's pain experiences at home following tonsillectomy and identified pain management strategies used. Combined analgesia and formal pain assessment significantly reduced the number of children in moderate or severe pain on discharge. Pain could worsen following discharge, persist for three to ten days and be at times moderate to severe. 50% of parents contacted their GP and 75% of children required paracetamol and ibuprofen concurrently. Audit data was utilised to develop comprehensive written pain management advice and a discharge protocol for combined analgesia.

Adolescent↗

PubMed1995

A national breast cancer database.

The medical audit of technical and interpretive aspects of mammography has been recommended by a number of expert panels and as part of some regulations that govern the oversight of mammography. The value of the medical audit is to aid practitioners in the performance evaluation of mammography in their facilities. Collection and analysis of audit data at a regional or national level have the potential to allow for the comparison of practice-level performance with regional and national-level performance and to provide a public health tool for the evaluation and improvement of breast cancer detection. In addition, a regional and national-level breast cancer database has the potential for allowing monitoring and tracking of women participating in a screening program. Prior to establishing such a database, data must be protected from discovery and disclosure, and patient and physician confidentiality must be ensured.

Breast Neoplasms↗

PubMed2003

Exploring General Practitioners' attitudes to homeopathy in Dumfries and Galloway.

This comparative quantitative study explored General Practitioners' (GPs) attitudes to homeopathy in Dumfries and Galloway, a predominantly rural area in South West Scotland where there is a local British Homeopathic Association Funded Homeopathic Clinic. It aimed to determine whether there was an association between expressed attitudes to homeopathy and a number of variables. Issues arising from the House of Lords Report on CAM were also explored. A self-administered questionnaire was addressed to all 135 GPs within Dumfries and Galloway. Descriptive statistics were used in the data analysis. The response rate was 75%. The NHS GP clinic accounted for 47% of total referrals for homeopathy. A total of 86.1% of GPs within Dumfries and Galloway were in favour of a local NHS Homeopathic Specialist Clinic. Forms of evidence most influential to GPs regarding homeopathy were: randomised controlled trials; audit data on patient outcomes; safety and patient satisfaction.

Attitude of Health Personnel↗

PubMed2000

The frequency of smoking and problem drinking among general hospital inpatients in Brazil - using the AUDIT and Fagerström questionnaires.

CONTEXT: Although the CAGE questionnaire is one of the most widely used alcohol screening instruments, it has been criticized for not identifying people who are drinking heavily or who have alcohol related problems but do not as yet show symptoms of alcohol dependence. The AUDIT (Alcohol Use Disorder Identification Test) questionnaire was developed by WHO as a screening instrument specifically designed to identify problem drinkers, as well as those who were already dependent on alcohol. OBJECTIVE: The aim of this study was to use the AUDIT and Fagerström questionnaires in a general hospital inpatient population to measure the frequency of problem drinking and nicotine dependence, and to see if levels varied between medical speciality. DESIGN: Retrospective cross-sectional study. SETTING: Federally funded public teaching hospital. SAMPLE: 275 inpatients from both genders. MAIN MEASUREMENTS: Socio-demographic data, AUDIT (Alcohol Use Disorders Identification Test) and Fagerström Test for Nicotine Dependence. RESULTS: We interviewed 275 inpatients, 49% of whom were men and 51% women. Thirty-four patients were identified as "cases" by the Audit questionnaire; 22% of the male patients and 3% of the females. Just over 21% of inpatients were current smokers. The gastroenterology (26%) and general medicine (16%) inpatient units had the largest number of individual cases. CONCLUSIONS: Only by knowing the prevalence of alcohol abuse/dependence and nicotine dependence in a general hospital can we evaluate the need for a specialized liaison service to identify and treat these patients.

Adolescent↗

PubMed2004

Assessing the impact of heart failure specialist services on patient populations.

BACKGROUND: The assessment of the impact of healthcare interventions may help commissioners of healthcare services to make optimal decisions. This can be particularly the case if the impact assessment relates to specific patient populations and uses timely local data. We examined the potential impact on readmissions and mortality of specialist heart failure services capable of delivering treatments such as b-blockers and Nurse-Led Educational Intervention (N-LEI). METHODS: Statistical modelling of prevented or postponed events among previously hospitalised patients, using estimates of: treatment uptake and contraindications (based on local audit data); treatment effectiveness and intolerance (based on literature); and annual number of hospitalization per patient and annual risk of death (based on routine data). RESULTS: Optimal treatment uptake among eligible but untreated patients would over one year prevent or postpone 11% of all expected readmissions and 18% of all expected deaths for spironolactone, 13% of all expected readmisisons and 22% of all expected deaths for b-blockers (carvedilol) and 20% of all expected readmissions and an uncertain number of deaths for N-LEI. Optimal combined treatment uptake for all three interventions during one year among all eligible but untreated patients would prevent or postpone 37% of all expected readmissions and a minimum of 36% of all expected deaths. CONCLUSION: In a population of previously hospitalised patients with low previous uptake of b-blockers and no uptake of N-LEI, optimal combined uptake of interventions through specialist heart failure services can potentially help prevent or postpone approximately four times as many readmissions and a minimum of twice as many deaths compared with simply optimising uptake of spironolactone (not necessarily requiring specialist services). Examination of the impact of different heart failure interventions can inform rational planning of relevant healthcare services.

Adrenergic beta-Antagonists↗

PubMed2000

Medicine information help lines: a survey of hospital pharmacy-based services in the UK and their conformity with guidelines.

OBJECTIVE: To describe the prevalence and nature of hospital pharmacy-based medicine help lines for consumers in the UK and to compare service provision with published guidelines. BACKGROUND: Since 1992, telephone help lines for patients have proliferated in hospital pharmacies in the UK. There is no common template for such services with variations in target group, number and type of calls, and arrangements for training and audit. Data on these factors will help guide further development of such services. METHODS: All medicine help lines operating from hospital pharmacies in the UK were identified through the national Drug Information Pharmacists network. They were sent a piloted questionnaire covering many aspects of help line operation, including funding, method of advertisement, procedures, target group, number and nature of calls, and audit procedures. RESULTS: Eighty-two help lines were identified in England, Scotland, Wales, and Northern Ireland. Completed responses were received from 69 help lines (84% response rate). The pharmacy drug information center was the help line site in 57% of hospitals; all other help lines were located in the dispensary. In 55% of cases, help lines were open only to patients of the hospital. In the remainder of help lines, calls from the public were answered (although the majority of help lines only advertised to hospital patients). Calls were answered by pharmacists only in 45% of services, and additional staff training had been provided in 43%. Only 48% of services had written procedures or guidelines for operation of the help line. Forty-six percent of the services received fewer than five calls per week, 31% received between five and 10 calls per week, and 22% received 11 or more calls per week. In 59% of the sites, calls took an average of 10 minutes or less to answer; it took 11-15 minutes in 32% of the sites and >15 minutes in 9% of the sites. The most common queries related to adverse effects, dosage and administration, and interactions (including alcohol). Only 33% of help lines had any auditing or monitoring of the service in place. CONCLUSIONS: The increasing use of the telephone to provide services directly to consumers is reflected in the growth of hospital-based medicine help lines in the UK. The telephone route is likely to become more important as patients' needs for information about their medicines increase. However, the rate of calls is low when compared with the number of patients issued prescriptions; further research is needed to investigate the reasons for this low response. There is currently reason for concern because most help lines lack not only professional training in telephone counseling, but also proper documentation, monitoring, and audit procedures.

Drug Information Services↗

PubMed2001

Why do GPs not implement evidence-based guidelines? A descriptive study.

BACKGROUND: There is an acknowledged gap between research findings and their implementation in clinical practice despite the existence of effective educational interventions. OBJECTIVES: Our aim was to identify what is impeding GPs from pursuing currently recognized good practice and implementing evidence-based guidelines in their management of hypertension in the elderly. METHOD: We carried out a qualitative study using semi-structured interviews conducted during focus group outreach visits to 34 GPs from nine practices in Merseyside involved in an educational programme designed to improve the management of hypertension in the elderly. RESULTS: Several barriers to the implementation of evidence-based guidelines in the management of hypertension in the elderly were identified. These included: doubts about the applicability of trial data to particular patients; the poor adherence of GPs to practice protocols; ageist attitudes of some GPs; the effect of time pressure and financial considerations making the subject a low priority; the absence of an effective computer system; and the absence of an educational mentor. All participants demonstrated a very positive attitude to practice-based education. They also welcomed external audit data, which compared their performance with that of other practices. Single-handed GPs were particularly enthusiastic about this approach as it provided them with the peer pressure they lacked. CONCLUSIONS: In order to bridge the gap between research and practice, educators need to address the various 'barriers to change' amongst practitioners.

Evidence-Based Medicine↗

PubMed2004

Red cell requirements for intensive care units adhering to evidence-based transfusion guidelines.

BACKGROUND: Anemia commonly complicates critical illness. Restrictive transfusion triggers are appropriate in this setting, but no large studies have measured red cell (RBC) requirements for intensive care patients when evidence-based transfusion guidelines are followed consistently. STUDY DESIGN AND METHODS: Data were recorded daily for 1023 of 1042 sequential admissions to 10 intensive care units (ICUs) over 100 days. The sample comprised 44 percent of all ICU admissions in Scotland during this period. RBC transfusions and the occurrence of clinically significant hemorrhage were recorded for every ICU day. Transfusion episodes were classified as either associated with or not associated with hemorrhage. Measures of RBC use were derived for the cohort and for Scotland with national audit data. RESULTS: A total of 39.5 percent (95% confidence interval [CI], 36.5%-42.5%) of admissions received transfusions. Eighteen percent of admissions received at least one transfusion associated with hemorrhage and 26 percent received at least one transfusion not associated with hemorrhage. The median (interquartile range) transfusion trigger in the absence of hemorrhage was 78 (73-78) g/L. The overall mean RBC use was 1.87 (95% CI, 1.79-1.96) units per admission or 0.34 (95% CI, 0.33-0.36) units per ICU-day. Forty-seven percent of RBCs administered were not associated with clinically significant hemorrhage. Mean RBC requirements for intensive care in Scotland were estimated to be 3950 (95% CI, 3780-4140) per million-adult-population per year. This represented 7 to 8 percent of the Scottish blood supply. CONCLUSIONS: Despite evidence-based transfusion practice, 40 percent of ICU patients receive transfusions, which account for 7 to 8 percent of the national blood supply.

Adult↗

PubMed1995

Videokeratography: a comparison between 6 mm sutured and unsutured incisions for phacoemulsification.

One of the main aims of small incisions in cataract surgery is to reduce surgically induced astigmatism to a minimum. A prospective study was set up to compare sutured with unsutured 6 mm scleral pocket frown incision wounds for phacoemulsification. Videokeratography was used to study the topographical changes induced by surgery. Two groups of 15 patients were allocated to have either sutured or unsutured 6 mm frown incisions for their phacoemulsification. Videokeratography was performed 1 day pre-operatively, and repeated 6 weeks post-operatively. Statistical analysis of the resultant data is discussed. The results show a modest flattening in the vertical meridian in both groups of patients which was slightly larger in the unsutured group. The astigmatic change did not differ significantly between the two groups. The 6 mm scleral pocket incisions induce a small amount of astigmatism whether sutured or unsutured. However, we felt it was perhaps safer to suture an incision of that size. Videokeratography is an invaluable tool for collection of outcome audit data, and allows for accurate graphical assessment of the effect of differing surgical approaches.

Aged↗

PubMed1995

Inpatient and post-discharge wound infections in general surgery.

The wound infection incidence during inpatient stay was compared with the post-discharge infection incidence for 1 month using audit data and a patient questionnaire. The true infection rate was found to be 20% compared with an apparent rate of 2.4% (P < 0.001). The study highlights the problems of postoperative monitoring in the context of shorter inpatient stays and fewer routine outpatient appointments.

Cross Infection↗

PubMed2000

A comprehensive package of support to facilitate the treatment of problem drug users in primary care: an evaluation of the training component.

Since the early 1980s, government policy documents and specialist reports have encouraged the involvement of general practitioners (GPs) in the treatment of problem drug users. In spite of such policy initiatives, their involvement has been patchy and slow. In response to this apparent reluctance, the London Boroughs of Brent and Harrow established the substance misuse management project (SMP) to support and train GPs in the management of substance misuse. The SMP is a GP-led project that provides ongoing support, shared-care protocol, primary care team training, treatment audits and financial reimbursements. In 1996, the SMP worked with GPs who were not currently involved in treating problem drug users, and those who were providing only minimal interventions. This paper evaluates the training and support given to these GPs and examines changes in their practice. A pre- and post-test survey was undertaken of GP knowledge, attitudes and levels of activity. A structured questionnaire was administered to all GPs before training (n=40) and re-administered between 6 and 9 months following training. SMP audit data were also reviewed to validate any reported changes in practice. All GPs initially reported insufficient knowledge to manage problem drug users. One-fifth were unaware they could prescribe methadone, and nearly half believed drug problems should be treated by specialist services. Post-training, the GPs had increased their levels of treatment activity and reported greater confidence and willingness to treat. This study demonstrates the potential to involve GPs in the treatment of problem drug users. The training was part of a package that included ongoing support sessions, team training, audits of treatment and financial reimbursements. It is proposed that, whilst training is a necessary condition, a more comprehensive package of support is needed to facilitate the treatment of problem drug users in primary care.

Journal Article↗

PubMed2002

Prevalence of primary open angle glaucoma in general ophthalmic practice in the United Kingdom.

AIM: To estimate the predicted prevalence of primary open angle glaucoma (POAG) from the activity of a local ophthalmology department. METHOD: Using clinic audit data, the local incidence and prevalence of POAG in the registered population of two primary care trusts were calculated. RESULTS: The local derived prevalence estimate for POAG was 978 per 100 000 people aged 40-89 years (95% CI 753 to 1272) compared with the expected prevalence from a published model of 1230 people per 100 000 people aged 40-89 years. CONCLUSION: The derived prevalence was not statistically significantly different from that predicted. Based on the published evidence that about half of the POAG cases are undetected, it would have been expected that local audit figures would have yielded figures about 50% lower than the epidemiological model. The main reason for this higher prevalence is thought to be differences in the diagnostic criteria used. This lack of consensus on the case definition for POAG is a deficit, which will hamper future needs assessment.

Adult↗