Evaluating a policy of reduced consultant antenatal clinic visits for low risk multiparous women.
(49/10747)
OBJECTIVES: To evaluate a change in antenatal care policy to reduce antenatal clinic visits, whereby low risk multiparous women were managed by the primary care team and seen at booking and at 41 weeks' gestation at the consultant antenatal clinic. DESIGN: Comparative study of low risk multiparous women retrospectively identified through the Oxford obstetric data system and cared for by three consultants who changed their policy (group A) or three consultants who maintained their routine care (group B). SETTING: Oxfordshire Health District. SUBJECTS: 2153 low risk multiparous women (1079 group A, 1074 group B) booked for consultant care at John Radcliffe Maternity Hospital between August 1985 and July 1987. MAIN MEASURES: Comparison of pregnancy outcomes, satisfaction with care, and clinic waiting times, during one year before and after the policy change (year 1, year 2). RESULTS: The proportion of women in group A with only one or two consultant clinic visits increased from 19.9% to 57.9% between years 1 and 2 (p < 0.001). Clinic waiting times did not improve. Of five perinatal deaths in group A, one (from postmaturity) could possibly be attributed to the policy change. The proportion of women reaching 42 weeks' gestation rose from 4.7% to 9.2% (p < 0.01); the proportion fully satisfied with their care rose from 68.4% to 82.1% (p < 0.025). No such changes were seen in group B. CONCLUSIONS: The change in policy was successful in reducing hospital antenatal clinic visits. The exercise identified dilemmas around evaluating changes in antenatal care settings. IMPLICATIONS: Criteria to test policy objectives should be selected carefully and rare events assessed prospectively in order to detect problems early. (+info)
Incompleteness and retrieval of case notes in a case note audit of colorectal cancer.
(50/10747)
Hospital case notes are a crucial source of data but are subject to two major biases: incompleteness of data and non-retrieval. To assess these biases in relation to colorectal cancer a study was performed of all cases of colorectal cancer listed in the Thames cancer registry in patients resident in one of four districts in South Thames regions with a diagnosis in 1988. Five medical record sites were involved. Retrieval rate for all case notes for districts combined was 80%. In two districts the rates were too high for further investigation; in the other two respectively patient survival and whether treatment was given were positively associated with retrieval. Among the four districts incompleteness of notes ranged from 38% to 62% for staging, 8% to 40% for treatment, and 70% to 25% for diagnostic tests. Information about treatment was missing in 3% to 20%; survival data were omitted in less than 5%. In all districts completeness of case notes was inadequate and in some non-retrieval compounded the problem. Missing data reduce the quality of cancer registry data and potentially undermine interpretation of epidemiological studies and evaluation of care. Further research is warranted into the standards and resourcing of medical records departments and their effects on retrieval and data quality. Structured proformas could be applied across specialties to identify missing items in case notes, to identify areas where standards are required, or to audit notes where standards have already been agreed. A staging protocol to set standards for colorectal cancer has been adopted in one district, and a prospective audit is being established. (+info)
Audit of patients' awareness of ophthalmic diagnoses.
(51/10747)
Providing information to patients about their medical condition and treatment options is important in medical management. To assess patients' knowledge of their ocular disease, prognosis, and treatment a questionnaire based survey was performed. 219 patients selected by random systematic sampling during six months from patients attending general ophthalmic clinics in Selly Oak Hospital, Birmingham, were questioned and 217 questionnaires were analysed. The findings showed that patients' knowledge of their diagnosis depended on their condition: patients with common conditions such as glaucoma and cataract had a better understanding of their condition, its treatment, and prognosis compared with patients with rarer conditions such as retinal detachment or patients with multiple diagnoses. In all, 152 patients (70%) wanted more information about their condition; 49 (23%) did not (although 12 (25%) had attempted to obtain information); and 16 (7%) were undecided. In view of the few patients with a precise understanding of their ophthalmic diagnosis and prognosis and the majority's wish for access to further information, that access needs improvement and different modes of disseminating the information should be implemented. (+info)
Selection for oesophagectomy and postoperative outcome in a defined population.
(52/10747)
OBJECTIVE: To measure the extent of use of, and perioperative mortality from, oesophagectomy for carcinoma of the oesophagus, and to examine the association between oesophagectomy and long term survival. DESIGN: Retrospective cohort study of cases of oesophageal carcinoma notified to the Thames Cancer Registry. SETTING: South East Thames and South West Thames health regions. PATIENTS: 3273 patients first registered with carcinoma of the oesophagus during 1985-9, 789 of whom were excluded because of incomplete data, leaving 2484 (75.9%) for further analysis. MAIN MEASURES: Treatment of oesophagectomy, mortality within 30 days of oesophagectomy, and duration of survival from date of diagnosis to death, according to patient and tumour characteristics. RESULTS: Oesophagectomy was performed in 571(23.0%) patients. Its use decreased with increasing age (odds ratio (95% confidence interval) 0.935(0.925 to 0.944) per year) and was less common for tumours of the middle or upper third of the oesophagus than the lower third (0.56(0.42 to 0.75)). The proportion of patients undergoing oesophagectomy varied threefold among the 28 districts of residence. The perioperative mortality rate was 15.1(86/571) (12% to 18%); it increased with age (odds ratio 1.05(1.02 to 1.08) per year) and for tumours of the middle or upper third of the oesophagus compared with the lower third (2.52(1.31 to 4.84)). Long term survival was slightly higher for patients undergoing oesophagectomy (0.5% v 0.2%). CONCLUSIONS: Despite a high perioperative mortality rate patients selected for oesophagectomy showed better long term survival than those who were not, suggesting that clinical judgements used in selection were independent markers of a better prognosis. The nature of this selection needs to be more completely characterised to permit a valid evaluation of outcome of oesophagectomy. (+info)
Safe working practices and HIV infection: knowledge, attitudes, perception of risk, and policy in hospital.
(53/10747)
OBJECTIVES--To assess the knowledge, attitudes, and perceptions of risk of occupational HIV transmission in hospital in relation to existing guidelines. DESIGN--Cross sectional anonymous questionnaire survey of all occupational groups. SETTING--One large inner city teaching hospital. SUBJECTS--All 1530 staff working in the hospital in October 1991 and 22 managers. MAIN MEASURES--Knowledge of safe working practices and hospital guidelines; attitudes towards patients with AIDS; perception of risk of occupational transmission of HIV; availability of guidelines. RESULTS--The response rate in the questionnaire survey was 63% (958/1530). Although staff across all occupational groups knew of the potential risk of infection from needlestick injury (98%, 904/922), significantly more non-clinical staff (ambulance, catering, and domestic staff) than clinical staff (doctors, nurses, and paramedics) thought HIV could be transmitted by giving blood (38%, 153/404 v 12%, 40/346; chi 2 = 66.1 p < 0.001); one in ten clinical staff believed this. Except for midwives, half of staff in most occupational groups and 19% (17/91) of doctors and 22% (28/125) of nurses thought gloves should be worn in all contacts with people with AIDS. Most staff (62%, 593/958), including 38% (36/94) of doctors and 52% (67/128) of nurses thought patients should be routinely tested on admission, 17% of doctors and 19% of nurses thought they should be isolated in hospital. One in three staff perceived themselves at risk of HIV. Midwives, nurses, and theatre technicians were most aware of guidelines for safe working compared with only half of doctors, ambulance, and paramedical staff and no incinerator staff. CONCLUSIONS--Policy guidelines for safe working practices for patients with HIV infection and AIDS need to be disseminated across all occupational groups to reduce negative staff attitudes, improve knowledge of occupational transmission, establish an appropriate perception of risk, and create a supportive and caring hospital environment for people with HIV. IMPLICATIONS--Managers need to disseminate policy guidelines and information to all staff on an ongoing basis. (+info)
Assessing introduction of spinal anaesthesia for obstetric procedures.
(54/10747)
To assess the impact of introducing spinal anaesthesia for obstetric operative procedures on use of general anaesthesia and quality of regional anaesthesia in a unit with an established epidural service a retrospective analysis of routinely collected data on method of anaesthesia, efficacy, and complications was carried out. Data were collected from 1988 to 1991 on 1670 obstetric patients requiring an operative procedure. The introduction of spinal anaesthesia in 1989 significantly reduced the proportion of operative procedures performed under general anaesthesia, from 60% (234/390) in 1988 to 30% (124/414) in 1991. The decrease was most pronounced for manual removal of the placenta (88%, 48/55 v 9%, 3/34) and emergency caesarean section (67%, 129/193) v 38%, 87/229). Epidural anaesthesia decreased in use most significantly for elective caesarean section (65%, 77/118 v 3% 3/113; x2=139, p<0.0001). The incidence of severe pain and need for conversion to general anaesthesia was significantly less with spinal anaesthesia (0%, 0/207 v 3%, 5/156; p<0.05). Hypotension was not a problem, and the incidence of headache after spinal anaesthetic decreased over the period studied. Introducing spinal anaesthesia therefore reduced the need for general anaesthesia and improved the quality of regional anaesthesia. (+info)
Problems with implementing guidelines: a randomised controlled trial of consensus management of dyspepsia.
(55/10747)
OBJECTIVE: To determine the feasibility and benefit of developing guidelines for managing dyspepsia by consensus between general practitioners (GPs) and specialists and to evaluate their introduction on GPs' prescribing, use of investigations, and referrals. DESIGN: Randomised controlled trial of effect of consensus guidelines agreed between GPs and specialists on GPs' behaviour. SETTING: Southampton and South West Hampshire Health District, United Kingdom. SUBJECTS: 179 GPs working in 45 practices in Southampton district out of 254 eligible GPs, 107 in the control group and 78 in the study group. MAIN MEASURES: Rates of referral and investigation and costs of prescribing for dyspepsia in the six months before and after introduction of the guidelines. RESULTS: Consensus guidelines were produced relatively easily. After their introduction referral rates for upper gastrointestinal symptoms fell significantly in both study and control groups, but no significant change occurred in either group in the use of endoscopy or radiology, either in terms of referral rates, patient selection, or findings on investigation. No difference was observed between the control and study group in the number of items prescribed, but prescribing costs rose by 25% (from 2634 pounds to 3215 pounds per GP) in the study group, almost entirely due to an increased rate of prescription of ulcer-healing agents. CONCLUSION: Developing district guidelines for managing dyspepsia by consensus between GPs and specialists was feasible. However, their acceptance and adoption was variable and their measured effects on some aspects of clinical behaviour were relatively weak and not necessarily associated with either decreased costs or improved quality of care. (+info)
Evidence for validity of a health status measure in assessing short term outcomes of cholecystectomy.
(56/10747)
OBJECTIVE: To assess the validity of the Nottingham health profile (NHP) as an indicator of short term outcome of cholecystectomy. DESIGN: Prospective assessment of outcome. SETTING: One teaching hospital. Patients--161 consecutive patients admitted for cholecystectomy between January 1989 and September 1990. MAIN MEASURES: Patients' reported symptoms and self assessed NHP scores before cholecystectomy and at follow up at three and 12 months (76 patients); assessment before admission (19). RESULTS: Complete data were obtained preoperatively and at three months' follow up from 154 patients; seven did not respond to the follow up questionnaire. 76/84(90%) patients in the study 12 months or more answered the 12 month follow up questionnaire; eight did not respond. Significant changes in score before and at three months after the operation were observed for four of the six dimensions: energy (35.34 v 19.53, p < 0.0001), pain (27.38 v 9.8, p < 0.0001), sleep (26.99 v 17.51, p = 0.0002), and emotional reactions (16.12 v 7.56, p = 0.001). The mean scores for 76 patients followed up at three and 12 months showed little subsequent change. Scores in readmitted patients were all significantly higher, suggesting poor health. Patients with five reported symptoms had significantly worse scores for all dimensions. Scores were similar before cholecystectomy whether the questionnaire was completed before or after admission. CONCLUSION: The NHP is an appropriate tool for monitoring changes in health after cholecystectomy. (+info)