Measuring serum total cholesterol: do vascular surgeons know what they are doing?
(17/5672)
Raised serum total cholesterol (TC) is an accepted risk factor for both coronary and peripheral vascular disease and three landmark trials have shown the benefit of lowering TC using statins. Vascular surgeons tend to measure TC, but little is known about how they manage hypercholesterolaemia or whether they believe treatment will be of benefit. A questionnaire was sent to listed members of the Vascular Surgical Society of Great Britain and Ireland seeking responses to a range of questions on the measurement and management of raised TC. In all, 374 questionnaires were sent out. The response rate was 67%. Over 90% of respondents said they measured TC and considered a level below 5.5 mmol/l as normal. The cut-off for initiating drug therapy, referral to a dietician or to a lipid specialist varied from 5.5 to 7.5 mmol/l. Most (62%) believed that lowering TC improved coronary mortality, but fewer (26%) that it prevented worsening of claudication. Although most vascular surgeons check for raised TC, the level at which treatment begins and the form it takes varies; in many cases being at odds with recommendations. Few surgeons are convinced of the benefits of lowering TC for claudication and nearly one-fifth do not believe it improves coronary mortality. (+info)
Role of the surgical trainee in upper gastrointestinal resectional surgery.
(18/5672)
The 'New Deal' set out by the Department of Health in 1991, together with the introduction of specialist 6-year training grades by Calman in 1993, has resulted in a decrease in available training time for surgeons in the UK. There is also an emerging belief that surgical procedures performed by trainees might compromise patient outcome. This study examines the level of trainee experience in a specialist gastrointestinal unit and whether operation by a trainee surgeon adversely affects patient outcome. All patients in the University Department of Surgery, Royal Infirmary, Edinburgh, undergoing oesophagogastric, hepatic or pancreatic resection between January 1994 and December 1996 were entered into the study. The early clinical outcome (in-hospital mortality and morbidity, considered in three groups: anastomotic leak, other technique-related complications and non-technique-related complications) was evaluated with regard to the grade of surgeon (consultant or trainee) performing the operation. Of the 222 patients undergoing major upper gastrointestinal resection during the study period, 100 (45%) were operated on by trainees. Trainees were assisted and closely supervised by consultants in all but six resections. There was no major difference in mortality rate (consultant, 4.1% vs trainee, 5%), incidence of non-technique-related complications (consultant, 6.7% vs trainee, 7.1%), anastomotic leaks (consultant, 10.7% vs trainee, 5%) or technique-related complications (consultant, 18.9% vs trainee, 15%) between the two grades of surgeon. In a specialist unit, the early clinical outcome of patients undergoing major upper gastrointestinal resection by supervised trainees is no worse than in those operated on by consultants. Participation of trainees in such complex procedures enhances surgical training and does not jeopardise patient care. (+info)
Impact of a national campaign on GP education: an evaluation of the Defeat Depression Campaign.
(19/5672)
BACKGROUND: The Defeat Depression Campaign, which was run by the Royal College of Psychiatrists and the Royal College of General Practitioners (RCGP) from 1992 to 1996, aimed to educate general practitioners (GPs) to recognize and manage depression. AIM: To measure the educational impact on GPs of the Defeat Depression Campaign. METHOD: A postal survey using a structured questionnaire was distributed to 2046 GPs obtained by systematically sampling 1 in 14 GPs from alphabetical lists from family health services authorities (FHSAs) in England and Wales. The questionnaire covered awareness of the campaign, awareness and use of campaign materials, and ratings of the usefulness of the campaign in relation to other educational activities. RESULTS: Two-thirds of GPs were aware of the campaign and 40% had definitely or possibly made changes in practice as a result of it. Impact of materials was highest for a consensus statement on the recognition and management of depression in general practice and for guidelines derived from it, each of which had been read in detail by about one quarter of responders and was known of by an additional one third. Impact was low for the other materials. The campaign had the highest impact among younger GPs, members of the RCGP, and (less strongly) among those who had undertaken a six-month post in psychiatry, those who were working in larger practices and fundholding practices, and women; 56% of GPs had attended a teaching session on depression in the past three years. CONCLUSION: A national campaign of this kind can have a useful impact, but it needs to be supplemented by local and practice-based teaching activities. (+info)
Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions.
(20/5672)
OBJECTIVE: To investigate whether using a computer-based patient record (CPR) affects the completeness of documentation and appropriateness of documented clinical decisions. DESIGN: A blinded expert panel of four experienced internists evaluated 50 progress notes of patients who had chronic diseases and whose physicians used either a CPR or a traditional paper record. MEASUREMENTS: Completeness of problem and medication lists in progress notes, allergies noted in the entire record, consideration of relevant patient factors in the progress note's diagnostic and treatment plans, and appropriateness of documented clinical decisions. RESULTS: The expert reviewers rated the problem lists and medication lists in the CPR progress notes as more complete (1.79/2.00 vs 0.93/2.00, P < 0.001, and 1.75/2.00 vs. 0.91/2.00, P < 0.001, respectively) than those in the paper record. The allergy lists in both records were similar. Providers using a CPR documented consideration of more relevant patient factors when making their decisions (1.53/2.00 vs. 1.07/2.00, P < 0.001), and documented more appropriate clinical decisions (3.63/5.00 vs. 2.50/5.00, P < 0.001), compared with providers who used traditional paper records. CONCLUSIONS: Physicians in our study who used a CPR produced more complete documentation and documented more appropriate clinical decisions, as judged by an expert review panel. Because the physicians who used the CPR in our study volunteered to do so, further study is warranted to test whether the same conclusions would apply to all CPR users and whether the improvement in documentation leads to better clinical outcomes. (+info)
Influence of hospital and clinician workload on survival from colorectal cancer: cohort study.
(21/5672)
OBJECTIVE: To determine whether clinician or hospital caseload affects mortality from colorectal cancer. DESIGN: Cohort study of cases ascertained between 1990 and 1994 by a region-wide colorectal cancer register. OUTCOME MEASURES: Mortality within a median follow up period of 54 months after diagnosis. RESULTS: Of the 3217 new patients registered over the period, 1512 (48%) died before 31 December 1996. Strong predictors of survival both in a logistic regression (fixed follow up) and in a Cox's proportional hazards model (variable follow up) were Duke's stage, the degree of tumour differentiation, whether the liver was deemed clear of cancer by the surgeon at operation, and the type of intervention (elective or emergency and curative or palliative intent). In a multilevel model, surgeon's caseload had no significant effect on mortality at 2 years. Hospital workload, however, had a significant impact on survival. The odds ratio for death within 2 years for cases managed in a hospital with a caseload of between 33 and 46 cases per year, 47 and 54 cases per year, and >/=55 cases per year (compared to one with +info)
Primary care physicians' decisions to perform flexible sigmoidoscopy.
(22/5672)
OBJECTIVE: This study was designed to identify factors that influence primary care physicians' willingness to perform flexible sigmoidoscopy. MEASUREMENTS: Using a mailed questionnaire, we surveyed all 161 primary care physicians participating in a large health care system. We obtained information on training, current practice patterns, beliefs about screening for colorectal cancer, and the influence of various factors on their decision whether or not to perform flexible sigmoidoscopy in practice. MAIN RESULTS: Of the 131 physicians included in the analysis, 68 (52%) reported training in flexible sigmoidoscopy, of whom 36 (53%) were currently performing flexible sigmoidoscopy in practice. Time required to perform flexible sigmoidoscopy, availability of adequately trained staff, and availability of flexible sigmoidoscopy services provided by other clinicians were identified most often as reasons not to perform the procedure in practice. Male physicians were more likely than female physicians to report either performing flexible sigmoidoscopy or desiring to train to perform flexible sigmoidoscopy (odds ratio 2.61; 95% confidence interval 1.10, 6.23). This observed difference appears to be mediated through different weighting of decision criteria by male and female physicians. CONCLUSIONS: Approximately half of these primary care physicians trained in flexible sigmoidoscopy chose not to perform this procedure in practice. Self-perceived inefficiency in performing office-based flexible sigmoidoscopy deterred many of these physicians from providing this service for their patients. (+info)
Effect of clinical guidelines in nursing, midwifery, and the therapies: a systematic review of evaluations.
(23/5672)
BACKGROUND: Although nursing, midwifery, and professions allied to medicine are increasingly using clinical guidelines to reduce inappropriate variations in practice and ensure higher quality care, there have been no rigorous overviews of their effectiveness, 18 evaluations of guidelines were identified that meet Cochrane criteria for scientific rigor. METHODS: Guideline evaluations conducted since 1975 which used a randomised controlled trial, controlled before and after, or interrupted time series design were identified through a combination of database and hand searching. RESULTS: 18 studies met the inclusion criteria. Three studies evaluated guideline dissemination or implementation strategies, nine compared use of a guideline with a no guideline state; six studies examined skill substitution: performance of nurses operating according to a guideline were compared with standard care, generally provided by a physician. Significant changes in the process of care were found in six out of eight studies measuring process and in which guidelines were expected to have a positive impact on performance. In seven of the nine studies measuring outcomes of care, significant differences in favour of the intervention group were found. Skill substitution studies generally supported the hypothesis of no difference between protocol driven by nurses and care by a physician. Only one study included a formal economic evaluation, with equivocal findings. CONCLUSIONS: Findings from the review provide some evidence that care driven by a guideline can be effective in changing the process and outcome of care. However, many studies fell short of the criteria of the Cochrane Effective Practice and Organisation of Care Group (EPOC) for methodological quality. (+info)
The association between hospital volume and survival after acute myocardial infarction in elderly patients.
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BACKGROUND: Patients with chest pain thought to be due to acute coronary ischemia are typically taken by ambulance to the nearest hospital. The potential benefit of field triage directly to a hospital that treats a large number of patients with myocardial infarction is unknown. METHODS: We conducted a retrospective cohort study of the relation between the number of Medicare patients with myocardial infarction that each hospital in the study treated (hospital volume) and long-term survival among 98,898 Medicare patients 65 years of age or older. We used proportional-hazards methods to adjust for clinical, demographic, and health-system-related variables, including the availability of invasive procedures, the specialty of the attending physician, and the area of residence of the patient (rural, urban, or metropolitan). RESULTS: The patients in the quartile admitted to hospitals with the lowest volume were 17 percent more likely to die within 30 days after admission than patients in the quartile admitted to hospitals with the highest volume (hazard ratio, 1.17; 95 percent confidence interval, 1.09 to 1.26; P<0.001), which resulted in 2.3 more deaths per 100 patients. The crude mortality rate at one year was 29.8 percent among the patients admitted to the lowest-volume hospitals, as compared with 27.0 percent among those admitted to the highest-volume hospitals. There was a continuous inverse dose-response relation between hospital volume and the risk of death. In an analysis of subgroups defined according to age, history of cardiac disease, Killip class of infarction, presence or absence of contraindications to thrombolytic therapy, and time from the onset of symptoms, survival at high-volume hospitals was consistently better than at low-volume hospitals. The availability of technology for angioplasty and bypass surgery was not independently associated with overall mortality. CONCLUSIONS: Patients with acute myocardial infarction who are admitted directly to hospitals that have more experience treating myocardial infarction, as reflected by their case volume, are more likely to survive than are patients admitted to low-volume hospitals. (+info)