Should breast reduction surgery be rationed? A comparison of the health status of patients before and after treatment: postal questionnaire survey.

OBJECTIVES: To assess the health status of patients before and after breast reduction surgery and to make comparisons with the health status of women in the general population. DESIGN: Postal questionnaire survey sent to patients before and six months after surgery. SETTING: The three plastic surgery departments in the Oxford Regional Health Authority, during April to August 1993. SUBJECTS: 166 women (over the age of 16 years) referred for breast reduction; scores from the "short form 36" (SF-36) health questionnaire completed by women in the 1991-2 Oxford healthy life survey. MAIN OUTCOME MEASURES: Health status of breast reduction patients before and after surgery as assessed by the SF-36, the 28 item general health questionnaire, and Rosenberg''s self esteem scale; comparisons between the health status of breast reduction patients and that of women in the general population; outcome of surgery as assessed retrospectively by patients. RESULTS: Differences between the health status of breast reduction patients and that of women in the general population were detected by the SF-36 both before and after surgery. Breast reduction surgery produced substantial change in patients'' physical, social, and psychological function. The proportion of cases of possible psychiatric morbidity according to the general health questionnaire fell from 41% (22/54) before surgery to 11% (6/54) six months after treatment. Eighty six per cent (50/58) of patients expressed great satisfaction with the surgical result postoperatively. CONCLUSION: The study provides empirical evidence that supports the inclusion of breast reduction surgery in NHS purchasing contracts.     

Urine cytology: appropriate usage maximizes sensitivity and reduces cost

OBJECTIVE: Urine cytology is costly because of the skilled manpower required for analysis. Inappropriate requests are a significant drain both financially and on the cytopathologist's time. The present study aimed at identifying the extent and cause of this misuse and reduce it. METHODS: An audit of urine cytology usage was undertaken using the hospital results reporting system to identify requests. Patient case notes were then obtained to gain further clinical information. Initially a 2-week period was analysed, following which departmental guidelines for requesting urine cytology were produced and circulated. The audit loop was then closed. RESULTS: Over the initial 2-week period, 117 urine cytology requests were received. Thirty-three per cent were inappropriate, either because they were from patients with benign disease or because of duplication. Following the education programme this number fell to 6%. Expenditure on unnecessary samples thus decreased from pounds 2418 to only pounds 310, giving an annual overall saving of pounds 55,000. CONCLUSION: Significant cost and time savings can be made if urine cytology is sent appropriately. Simple guidelines and staff education are the key to reducing inefficiency. Our findings have implications not just for cytopathology costs but for laboratory and radiology requests in general.     

Effect of feedback on test ordering behaviour of general practitioners.

OBJECTIVE--To assess the effect of feedback on the test ordering behaviour of general practitioners. DESIGN--Comparison of requests at two diagnostic centres, and internal comparison between tests which were discussed in feedback and tests which were not. SETTING--A diagnostic centre in Maastricht giving feedback and another elsewhere in the Netherlands (laboratory A) not giving feedback. SUBJECTS--All 85 general practitioners in the region of Maastricht, and all general practitioners in the region of laboratory A. MAIN OUTCOME MEASURES--Numbers of tests requested by general practitioners. RESULTS--Requests at the Maastricht diagnostic centre decreased soon after the onset of feedback whereas there was a persistent increase in requests at laboratory A. Tests that were discussed showed the strongest decrease (maximum 40%), though tests that were not discussed decreased as well (maximum 27%). CONCLUSIONS--Feedback on diagnostic requests may exert a strong influence on request behaviour. Four years after the onset of feedback the effects were still noticeable.     

Quality improvement report: Linking guideline to regular feedback to increase appropriate requests for clinical tests: blood gas analysis in intensive care

Problem Need to decrease the number of requests for arterial blood gas analysis and increase their appropriateness to reduce the amount of blood drawn from patients, the time wasted by nurses, and the related cost.DesignAssessment of the impact of a multifaceted intervention aimed at changing requests for arterial blood gas analysis in a before and after study.

Background and setting

Twenty bed surgical intensive care unit of a tertiary university affiliated hospital, receiving 1500 patients per year.

Key measures for improvement

Number of tests per patient day, proportion of tests complying with current guideline, and safety indicators (mortality, incident rate, length of stay). Comparison of three 10 month periods corresponding to baseline, pilot (first version of the guideline), and consolidated (second version of the guideline) periods from March 1997 to August 1999.

Strategies for change

Multifaceted intervention combining a new guideline developed by a multidisciplinary group, educational sessions, and monthly feedback about adherence to the guideline and use of blood gas analysis.

Effects of change

Substantial decrease in the number of tests per patient day (from 8.2 to 4.8; P<0.0001), associated with increased adherence to the guideline (from 53% to 80%, P<0.0001). No significant variation of safety indicators.

Lessons learnt

A multifaceted intervention can substantially decrease the number of requests for arterial blood gas analysis and increase their appropriateness without affecting patient safety.     

Reductions in Inpatient Mortality following Interventions to Improve Emergency Hospital Care in Freetown,Sierra Leone

Background

The demand for high quality hospital care for children in low resource countries is not being met. This paper describes a number of strategies to improve emergency care at a children''s hospital and evaluates the impact of these on inpatient mortality. In addition, the cost-effectiveness of improving emergency care is estimated.

Methods and Findings

A team of local and international staff developed a plan to improve emergency care for children arriving at The Ola During Children''s Hospital, Freetown, Sierra Leone. Following focus group discussions, five priority areas were identified to improve emergency care; staff training, hospital layout, staff allocation, medical equipment, and medical record keeping. A team of international volunteers worked with local staff for six months to design and implement improvements in these five priority areas. The improvements were evaluated collectively rather than individually. Before the intervention, the inpatient mortality rate was 12.4%. After the intervention this improved to 5.9%. The relative risk of dying was 47% (95% CI 0.369–0.607) lower after the intervention. The estimated number of lives saved in the first two months after the intervention was 103. The total cost of the intervention was USD 29 714, the estimated cost per death averted was USD 148. There are two main limitation of the study. Firstly, the brevity of the study and secondly, the assumed homogeneity of the clinical cases that presented to the hospital before and after the intervention.

Conclusions

This study demonstarted a signficant reductuion in inpatient mortality rate after an intervention to improve emergency hospital care If the findings of this paper could be reproduced in a larger more rigorous study, improving the quality of care in hospitals would be a very cost effective strategy to save children''s lives in low resource settings.     

Effects of danazol on incidence of progesterone and oestrogen receptors in benign breast disease.

Results from a continuing clinical trial in benign breast disease indicate that danazol may induce progesterone receptors and that this effect persists after treatment. In women given danazol the number of biopsy specimens that were positive for progesterone receptors rose from 14 out of 31 before treatment to 23 out of 30 at the end of six months'' treatment and remained raised at 21 out of 31 six months later. The number of biopsy specimens that were positive for oestrogen receptors rose transiently from eight out of 31 to 12 out of 30 and then fell to six out of 31. A satisfactory clinical response was achieved in 26 of the 31 patients but was maintained in only 11 six months or more after the end of treatment. It was only in this group that a significant and long-standing increase in progesterone receptors was observed. These findings suggest that in some women with benign breast disease who have been treated with danazol changes occur that may have long term benefit.     

Impact of nurse practitioners on workload of general practitioners: randomised controlled trial

Objective To examine the impact on general practitioners'' workload of adding nurse practitioners to the general practice team.Design Randomised controlled trial with measurements before and after the introduction of nurse practitioners.Setting 34 general practices in a southern region of the Netherlands.Participants 48 general practitioners.Intervention Five nurses were randomly allocated to general practitioners to undertake specific elements of care according to agreed guidelines. The control group received no nurse.Main outcome measures Objective workload, derived from 28 day diaries, included the number of contacts per day for each of three conditions (chronic obstructive pulmonary disease or asthma, dementia, cancer), by type of consultation (in practice, telephone, home visit), and by time of day (surgery hours, out of hours). Subjective workload was measured by using a validated questionnaire. Outcomes were measured six months before and 18 months after the intervention.Results The number of contacts during surgery hours increased in the intervention group compared with the control group (P < 0.06), particularly for patients with chronic obstructive pulmonary disease or asthma (P < 0.01). The number of consultations out of hours declined slightly in the intervention group compared with the control group, but this difference did not reach significance. No significant changes became apparent in subjective workload.Conclusion Adding nurse practitioners to general practice teams did not reduce the workload of general practitioners, at least in the short term. This implies that nurse practitioners are used as supplements, rather than substitutes, for care given by general practitioners.     

Effect of Psychiatric Intervention in Attempted Suicide: A Controlled Study

All patients presenting at the casualty department of King''s College Hospital during the first six months of 1968 with deliberate self-poisoning or self-injury were followed up. Of 211 patients 204 (97%) were traced after a mean interval of 18 months (range one to two years). Despite official hospital policy, 22% had not been seen by a psychiatrist before discharge; these 44 untreated patients were compared with the remaining 160 who had received either brief (one or two interviews) or more prolonged psychiatric and social help.Subsequent suicidal attempts occurred significantly more often among untreated than among treated patients, prolonged treatment being associated with the best prognosis. The same trend was observed in respect of actual suicide, though the numbers were small and differences did not reach statistical significance. These findings held good when the untreated and treated groups were controlled for other variables which were found to be correlated with outcome. These results indicate that psychiatric intervention is associated with a significant reduction in subsequent suicidal behaviour.     

Clinical and economic consequences of a reimbursement restriction of nebulised respiratory therapy in adults: direct comparison of randomised and observational evaluations

Objective To compare the results of a randomised and an observational evaluation of the same policy that restricted reimbursement for nebulised respiratory medications in adult patients in a community setting.Designs Cluster randomised controlled trial and observational time series with historical controls.Setting Pharmacare, the government funded drug benefits plan for elderly people and patients receiving social assistance in British Columbia, Canada.Participants In the randomised controlled trial 104 clusters of medical practices, pair matched by geography and approximately by practice size, were randomised to the intervention group (449 patients affected by the policy on 1 March 1999), and the control group (offered a six month exemption, affecting 386 patients). The observational analysis included all Pharmacare beneficiaries (excluding the 386 exempt patients) who had used any nebulised drugs six months before the policy (4624 patients).Intervention Pharmacare restricted reimbursement for nebulised bronchodilators, steroids, and cromoglycate to patients whose doctors applied for an individual patient''s exemption, giving an appropriate clinical reason.Main outcome measures Number of contacts with doctors and services, emergency admissions to hospital, and utilisation of and expenditure for respiratory drugs in databases of British Columbia''s Ministry of Health.Results Contacts with doctors or emergency admissions to hospital did not increase in association with the restriction, regardless of the analytical approach. In the observational analysis, we found a reduction of $C24 per patient month in all nebulised drug use (95% confidence interval 19 to 29) and an increase of $C3 per patient month in all expenditure for inhalers (1.4 to 4.5). The randomised evaluation found savings of $C8 per patient month for nebulisers (P = 0.24) and no increase in spending on inhalers (P = 0.79). Correcting for 60% non-compliance by exempt doctors in a sensitivity analysis yielded similar results as the observational evaluation.Conclusions Observational as well as randomised analyses found moderate net savings and no increase in unintended healthcare outcomes after restricting reimbursement for nebulised respiratory drugs. Randomised policy trials are feasible and, if carefully implemented, likely to be concordant with observational evaluations.     

Self testing for diabetes mellitus.

OBJECTIVE--To develop a simple, economically viable, and effective means of population screening for diabetes mellitus. DESIGN--A postal request system for self testing for glycosuria with foil wrapped dipsticks. Preprandial and postprandial tests were compared with a single postprandial test. The subjects were instructed how to test, and a result card was supplied on which to record and return the result. All those recording a positive test result and 50 people recording a negative result were invited for an oral glucose tolerance test. SETTING--General practice in east Suffolk, list size 11534. PATIENTS--All subjects aged 45-70 years registered with the practice were identified by Suffolk Family Health Services Authority (n = 3057). The 73 subjects known to have diabetes from the practice''s register were excluded, leaving 2984 subjects, 2363 (79.2%) of whom responded. 1167 subjects completed the single test and 1196 the two tests. MAIN OUTCOME MEASURES--Response rate and number of patients with glycosuria. Sensitivity, specificity, and positive predictive value of a single postprandial test and preprandial and postprandial tests. Number of new cases of diabetes identified and cost of screening. RESULTS--Of the patients completing the single postprandial test, 29 had a positive result, an oral glucose tolerance test showed that eight (28%) had diabetes, six (21%) impaired glucose tolerance, and 14 (48%) normal glucose tolerance. 44 of the group who tested before and after eating had a positive result; nine (20%) had diabetes, five (11%) impaired tolerance, and 26 (11%) normal tolerance. Screening cost 59p per subject and 81 pounds per case detected. Of the 17 people with previously undiagnosed diabetes, eight were asymptomatic and 11 had not visited their general practitioner in the past three months. CONCLUSIONS--A postal request system for self testing for postprandial glycosuria in people aged 45-70 is a simple and effective method of population screening for diabetes mellitus.     

Photostatic Reporting in a Hospital Bacteriology Laboratory

A method of reporting results of tests performed in a hospital bacteriological laboratory is described in which a modified commercially available electrostatic copier is used. This device was designed for a hispital system in which more than one report per specimen is issued and in which rubber stamps are widely used and frequently changed. It has been working satisfactorily for more than six months. It increases accuracy and saves time and money. Attention to the clarity of reproduction is necessary. It is suggested that this system could be modified for other laboratory reporting systems.     

Abortion Act in Somerset

A survey conducted with a sample of 20% of general practitioners over six months in 1972 disclosed a request rate for termination approaching 10% of all pregnancies. The attitude and performance of the practitioner were considered to be important in the patient''s requests for this, and patients were thought to know about these. This implies that in three-quarters of the practices there was a sizeable demand for abortion which remained latent.Altogether, 20% of specialist consultations were made privately and in none of these cases was abortion refused. Under the Health Service the refusal rate was 19%, but 7 of the 12 women refused N.H.S. abortions subsequently obtained it privately.     

Effect of stress management on blood pressure in mild primary hypertension.

OBJECTIVE--To establish whether stress management had a larger effect than a control treatment on resting blood pressure, ambulatory blood pressure, and left ventricular mass. DESIGN--A 12 week baseline period of habituation to measurement of blood pressure was followed by randomisation to either stress management or mild exercise for six months and follow up six months later. SETTING--General practice, district general hospital, and medical school. PATIENTS--Of the 184 patients aged under 60 with mild primary hypertension who entered the baseline habituation period, 88 were excluded because they failed to meet the entry criteria or they withdrew from the study. The remaining 46 men and 50 women underwent treatment. INTERVENTIONS--10 clinical sessions and daily practice at home of either stress management based on relaxation or non-aerobic stretching exercises. Mildly stressful 15 minute interviews before and after treatment. MAIN OUTCOME MEASURES--Diastolic and systolic blood pressure in the clinic and during 12 hours of ambulatory recording, and left ventricular mass measured by echocardiography. RESULTS--The patients'' blood pressure fell during habituation (systolic pressure from 152 mmHg to 140 mmHg, diastolic pressure from 98 to 93 mm Hg), but neither resting nor ambulatory blood pressure was changed by the treatments. Left ventricular mass was also unchanged. Blood pressure rose during the stressful interview, but this rise was reduced by stress management (systolic pressure rose by 7.4 mmHg before treatment and by 3.7 mmHg after treatment). CONCLUSION--Stress management of a type advocated for treating mild primary hypertension is ineffective in lowering blood pressure in patients who are well habituated to measuring blood pressure.     

How tumor markers are used in the routine follow-up of breast and colorectal cancer. A survey of 29 Italian hospitals

The impact of tumor markers on the outcome of several malignancies is still under debate. This relative uncertainty leads to a subjective approach to their use. Monitoring the use of tumor markers is a valuable tool to identify the need for educational policies. We conducted a survey to evaluate how tumor markers are routinely used in the follow-up of patients with breast, colorectal and ovarian carcinoma. The former two malignancies are considered in the present paper. We surveyed 35 Italian hospitals; 29 (83%, accounting for 26,622 hospital beds) filled in and returned the questionnaire. Overall, 467,361 tumor marker requests were scrutinized by the surveyed hospitals. We found a wide variability in the type and number of routinely used markers, the cutoff points chosen, and the clinical decisions taken on the basis of marker results. In addition, we observed a relative lack of communication between clinicians and clinical pathologists in around 50% of the surveyed hospitals. In these cases clinical information was not provided to the laboratory and methodological aspects were not communicated to clinicians. From the findings of the present study we conclude that the cooperation between clinicians and clinical pathologists must improve before guidelines for the use of tumor marker assays can be framed and the compliance with these guidelines can be checked. Request forms for tumor marker assays should therefore be designed to contain clinical information and the quality of filling in request forms with clinical data should be carefully monitored.     

Benefits of swimming pools in two remote Aboriginal communities in Western Australia: intervention study

Objective To determine the health impact of swimming pools built with the aim of improving quality of life and reducing high rates of pyoderma and otitis media.Design Intervention study assessing prevalence of ear disease and skin infections before and at six monthly intervals after opening of swimming pools.Setting Two remote Aboriginal communities in Western Australia.Participants 84 boys and 78 girls aged < 17 years.Main outcome measures Changes in prevalence and severity of pyoderma and perforation of tympanic membranes with or without otorrhoea over 18 months after opening of pools.Results In community A, 61 children were seen before the pool was opened, and 41, 46, and 33 children were seen at the second, third, and fourth surveys. Equivalent figures for community B were 60, 35, 39, and 45. Prevalence of pyoderma declined significantly from 62% to 18% in community A and from 70% to 20% in community B during the 18 months after the pools opened. Over the same period, prevalence of severe pyoderma fell from 30% to 15% in community A and from 48% to 0% in community B. Prevalence of perforations of the tympanic membrane fell from 32% in both communities to 13% in community A and 18% in community B. School attendance improved in community A.Conclusion Swimming pools in remote communities were associated with reduction in prevalence of pyoderma and tympanic membrane perforations, which could result in long term benefits through reduction in chronic disease burden and improved educational and social outcomes.