Inquiry into homicides by psychiatric patients: systematic audit should replace mandatory inquiries.

Inquiries into homicides committed by psychiatric patients are currently mandatory under Department of Health guidance. They are often broadly defined in their terms of reference and almost always address not only the cause of the incident but also professional skill, practice, and culpability. Concurrent pursuit of both purposes is unlikely to maximise "learning from experience." Also, since inquiries can set their own thresholds for culpability, doctors can potentially be judged to a higher standard than would be required by the General Medical Council or negligence law. Lack of strict legal process increases the inherent potential unfairness to doctors. Investigation of cause and culpability should be separated and inquiries restricted to the former. There should also be a standing secretariat for inquiries to set terms of reference and to collate and distribute findings of inquiries. Widespread mandatory systematic audit of professional practice and service efficiency concerning risk assessment and management should largely replace costly ad hoc mandatory inquiries after homicides.     

Effect of using protocols on medical care: randomised trial of three methods of taking an antenatal history.

OBJECTIVE--To compare the effectiveness of three methods of taking an antenatal history on the quality of obstetric care. DESIGN--Randomised controlled trial. SETTING--Antenatal clinic of St James''s University Hospital, Leeds. SUBJECTS--2424 women attending the hospital for the first (booking) visit. INTERVENTIONS--Histories were taken by midwives using an unstructured paper questionnaire, a structured paper questionnaire (incorporating a checklist), or an interactive computerised questionnaire (incorporating 101 clinical reminders). MAIN OUTCOME MEASURES--The number of clinical responses to factors arising from the antenatal booking history according to method of taking the history. Actions were categorised as medical and surgical, obstetric, personal, current symptoms and treatment, related to maternal age, and related to two common actions (cervical smear testing and dental hygiene) and were weighted for clinical importance by 10 obstetricians. RESULTS--Overall the unstructured questionnaire generated 1063 actions, the structured questionnaire 1146, and the computerised questionnaire 1122. The clinical importance of these actions was lowest for the unstructured questionnaire (overall total value score 1987 v 2182 and 2110 for the structured and computerised questionnaires respectively). The structured questionnaire was better than the computerised questionnaire in the medical and surgical (total value score 191 v 184), obstetric (275 v 241), and personal (430 v 360) categories but inferior in the current symptoms category (179 v 191). CONCLUSION--Structured questionnaires (computerised or paper) provide more and better information, and their use improves clinical response to risk factors. Computerised systems offer no further advantage in antenatal clinics.     

What did audit achieve? Lessons from preliminary evaluation of a year's medical audit.

OBJECTIVE--To evaluate the experience of a year''s audit of care of medical inpatients. DESIGN--Audit of physicians by monthly review of two randomly selected sets of patients'' notes by 12 reviewers using a detailed questionnaire dedicated to standards of medical records and to clinical management. Data were entered into a database and summary statistics presented quarterly at audit meetings. Assessment by improvement in questionnaire scores and by interviewing physicians. SETTING--1 District general hospital. PARTICIPANTS--About 40 consultant physicians, senior registrars, and junior staff dealing with 140 inpatient records. MAIN OUTCOME MEASURES--Median scores (range 1 to 9) for each item in the questionnaire; two sets of notes were discussed monthly at "general" audit meetings and clinical management of selected common conditions at separate monthly meetings. RESULTS--A significant overall increase in median scores for questions on record keeping occurred after the start of the audit (p less than 0.01), but interobserver variation was high. The parallel audit meetings on clinical management proved to be more successful than the general audits in auditing medical care and were also considered to be more useful by junior staff. CONCLUSIONS AND ACTION--Medical audit apparently resulted in appreciable improvements in aspects of care such as clerking and record keeping. Analysis of the scores of the general audits has led to the introduction of agreed standards that can be objectively measured and are being used in a further audit, and from the results of the audits of clinical management have been developed explicit guidelines, which are being further developed for criterion based audit.     

A total audit of preventive procedures in 45 practices caring for 430,000 patients.

OBJECTIVE--To develop and report the results of a system of audit of computer records in general practice. DESIGN--A retrospective audit of records in practices using the same computer system. Information about recorded preventive procedures was collected by sending the same audit program to each practice on floppy disk. Other characteristics of the practices were determined by postal questionnaire. SETTING--Forty five general practices, widely distributed in England and Wales. SUBJECTS--All 430,901 patients registered with the practices. MAIN OUTCOME MEASURES--Within each practice the percentage of patients in specified age groups for whom certain preventive procedures were recorded as having been carried out. These measures were analysed in relation to practice characteristics. RESULTS--Practice characteristics and recording rates for preventive procedures varied over a wide range. Recording rates were higher in practices with computer terminals on every doctor''s desk. Only one practice achieved the new contract target of 90% coverage for recorded primary immunisations, and fewer than two thirds recorded 80% coverage for cervical cytology in the past five years. Practices holding clinics did no better than those without. Smaller partnerships and smaller doctors'' list sizes were associated with better performance. CONCLUSIONS--Centrally programmed audit of computerised records is a feasible method of providing data on a regular basis for epidemiological purposes and for performance review. The fact that practices with smaller list sizes had higher levels of recorded preventive care suggests that the trend towards larger lists promoted by the new contract might militate against the intended effect of better preventive care.     

Survey of general practice audit in Leeds.

OBJECTIVE--To determine general practitioners'' attitudes to medical audit and to establish what initiatives are already being undertaken; to define future ideas for audit and perceived difficulties in implementing audit in primary care. DESIGN--Analysis of responses to a self administered postal questionnaire. SETTING--Urban conurbation with a population of about 750,000. PARTICIPANTS--386 general practitioners on the general medical list of Leeds Family Practitioner Committee. MAIN OUTCOME MEASURES--Extent of recording of practice activity data and outcome measures and clinical data, use of data, and audit performed; ideas for audit and perceived difficulties. RESULTS--317 doctors responded to the questionnaire (individual response rate 82%) from 121 practices (practice response rate 88%). In all, 206 doctors thought that audit could improve the quality of care; 292 collected practice activity data, though 143 of them did not use it. A total of 111 doctors recorded some outcome measures, though half of them did not use them. Varying proportions of doctors had registers, for various diseases (136 had at least one register), disease management policies (60 doctors), and prescribing policies. In all, 184 doctors met monthly with other members of the primary health care team. CONCLUSIONS--Much poorly focused data collection is taking place. Some doctors have experience in setting up basic information systems and practice policies, and some audit is being performed. The family health services authorities need to take seriously the perceived difficulties of time, organisation, and resources concerned with audit.     

Audit of a surgical firm by microcomputer: five years' experience

From 1982 to 1986 inclusive work of one surgical firm was audited with a microcomputer. Data were recorded on 4336 patients having 3355 operations, who were under the care of one consultant in a general surgical unit; fifty items of information were recorded on each patient, allowing a wide range of analyses to be performed—for example, the number of admissions and operations, grades of operation, diagnostic grouping, complications, and complication rates associated with individual surgeons. Data collected for the audit provided a valuable baseline for the unit, defining aspects of practice that could be reviewed and improved. During the audit the overall rate of complications as a percentage of admissions fell significantly from 13% to 9% and the rate of postoperative complications decreased significantly from 16% in 1982 to 11% in 1986. The incidence of chest and wound infections also decreased significantly. The system was improved by using the data to produce discharge summaries as well as audit; the microcomputer thus became an integral part of the office work of the unit.     

Aspects of audit. 1. The background.

Methods of reviewing health care already exist in Britain, but the debate continues about how practical and acceptable such a review is. The many different terms used to describe review only confuse the issue. "Audit" is a useful term for describing the review of medical work by medical people. This can be divided into "internal audit," or peer review, and "external audit"--that is, review by organisations outside hospital and general practice. The concepts of internal and external audit have a great impact upon the attitudes held by the medical profession about audit. The shortcomings of audit by the professional standards review organisations in the United States are not inevitable in Britian.     

Influence of the Royal College of Radiologists' guidelines on hospital practice: a multicentre study. Royal College of Radiologists Working Party.

OBJECTIVE--To measure the effect on hospital radiology referral practice of introducing a strategy for change involving guidelines of good practice, monitoring, and peer review. DESIGN--Prospective data collection over a continuous 21-24 month period at each centre some time between January 1987 and December 1990. SETTING--Five district general hospitals and one district health authority. SUBJECTS--314,663 inpatient discharges, deaths, and day cases and 1,706,781 outpatient attendances under the care of 722 consultants from 25 clinical specialties. MAIN OUTCOME MEASURES--Number of referrals for x ray examination per 100 inpatient discharges, deaths, and day cases and per 100 new outpatient attenders. RESULTS--Most doctors were prepared to accept standards of clinical practice set by peers and also the monitoring and review of their practice with respect to these standards by local colleagues. 18% of firms were identified before guidelines were instituted as having persistently high referral rates. Appreciable, and often dramatic reductions in referral rates for individual x ray examinations were recorded by a substantial number of firms in every centre and in every specialty after guidelines were instituted. The major part of this reduction was achieved by some of the firms whose initial practice did not meet "high referral" criteria. Important variations in compliance with agreed standards of good practice were observed. CONCLUSIONS--The study offers strong experimental evidence to support a recent suggestion that at least a fifth of radiological examinations carried out in NHS hospitals are clinically unhelpful. The problem of how to assure compliance with agreed standards of practice needs to be resolved. Until this happens medical audit alone is unlikely to translate good practice into common practice.     

Effects of feedback of information on clinical practice: a review.

OBJECTIVE--To establish what is known about the role of feedback of statistical information in changing clinical practice. DESIGN--Review of 36 studies of interventions entailing the use of statistical information for audit or practice review, which used a formal research design. SUBJECTS--Papers identified from computer searches of medical and health service management publications, of which 36 describing studies of interventions designed to influence clinical care and including information feedback from clinical or administrative data systems were reviewed. MAIN OUTCOME MEASURES--Evidence for effect of information feedback on change in clinical practice. RESULTS--Information feedback was most likely to influence clinical practice if it was part of strategy to target decision makers who had already agreed to review their practice. A more direct effect was discernable if the information was presented close to the time of decision making. The questions of the optimum layout and quantity of information were not addressed; the 36 papers were insufficient for defining good formats for information to be used for audit or quality assurance. CONCLUSIONS--Given the cost of information processing and the current emphasis on closing the audit loop in the health services, it is important that the use of information in the audit process should be critically evaluated.     

Local confidential inquiry into avoidable factors in deaths from stroke and hypertensive disease.

OBJECTIVE--To audit avoidable deaths from stroke and hypertensive disease. DESIGN--Details of care before death were obtained from general practitioners and other doctors, anonymised, and assessed by two experts against agreed minimum standards of good practice for detecting and managing hypertension. SETTING--Health authority with population of 250,000. SUBJECTS--All patients under 75 years who died of stroke, hypertensive disease, or hypertension related causes during November 1990 to October 1991. MAIN OUTCOME MEASURES--Presence of important avoidable factors and departures from minimum standards of good practice. RESULTS--Adequate information was obtained for 88% (123/139) of eligible cases. Agreement between the assessors was mostly satisfactory. 29% (36/123, 95% confidence interval 21% to 37%) of all cases and 44% (36/81, 34% to 55%) of those with definite hypertension had avoidable factors that may have contributed to death. These were most commonly failures of follow up and continuing smoking. Assessment against standards of minimum good practice showed that care was inadequate but not necessarily deemed to have contributed to death, in a large proportion of patients with definite hypertension. Common shortcomings were inadequate follow up, clinical investigation, and recording of smoking and other relevant risk behaviours. CONCLUSIONS--This method of audit can identify shortcomings in care of patients dying of hypertension related disease.     

Community surveillance of complications after hernia surgery.

OBJECTIVE--To assess the effect of a programme of postoperative community surveillance on the rate of detection of wound complications after operation for inguinal hernia. DESIGN--Prospective audit of wound complications including complications recorded in case notes and those discovered by community surveillance. SETTING--Academic surgical unit of three consultant surgeons. PATIENTS--510 patients undergoing elective inguinal hernia repair between June 1985 and August 1989. RESULTS--The wound infection rate recorded in the hospital notes was 3% compared with 9% when additional information was obtained from community surveillance. Wound complications were detected in 143 (28%) patients by community surveillance compared with a complication rate of 7% in the case records for the same patients. CONCLUSIONS--Wound complications are common after clean surgery in patients discharged home early. Complication rates are a reflection not only of the standards of surgical practice but also the rigour with which they are sought. Before national comparative audit data are published the method of collection must be standardised. For short stay surgery this should include meaningful community surveillance.     

Where have all the pennies gone? The work of Manchester Medical Audit Advisory Group.

Medical audit has its critics, who point to the large sums of NHS cash that seem to be disappearing down a medical plughole. These criticisms are recognised by medical audit advisory groups but there are many reasons why the work of these groups has not yet resulted in many publications in journals or bumped up health indicators. After discussing the criticism this article describes the work of the medical audit advisory group in Manchester. Real changes in cooperative working with general practice teams and between practices are taking place, and improved relationships between general practice and the hospitals are being helped by joint audit work. The Manchester group is also working to help in setting standards and to cooperate with purchasing. The work of the group is changing as it develops.     

Auditing audits: use and development of the Oxfordshire Medical Audit Advisory Group rating system.

OBJECTIVES--To assess the value of the Oxfordshire Medical Audit Advisory Group rating system in monitoring and stimulating audit activity, and to implement a development of the system. DESIGN--Use of the rating system for assessment of practice audits on three annual visits in Oxfordshire; development and use of an "audit grid" as a refinement of the system; questionnaire to all medical audit advisory groups in England and Wales. SETTING--All 85 general practices in Oxfordshire; all 95 medical audit advisory groups in England and Wales. MAIN OUTCOME MEASURES--Level of practices'' audit activity as measured by rating scale and grid. Use of scale nationally together with perceptions of strengths and weaknesses as perceived by chairs of medical audit advisory groups. RESULTS--After one year Oxfordshire practices more than attained the target standards set in 1991, with 72% doing audit involving setting target standards or implementing change; by 1993 this had risen to 78%. Most audits were confined to chronic disease management, preventive care, and appointments. 38 of 92 medical audit advisory groups used the Oxfordshire group''s rating scale. Its main weaknesses were insensitivity in assessing the quality of audits and failure to measure team involvement. CONCLUSIONS--The rating system is effective educationally in helping practices improve and summatively for providing feedback to family health service authorities. The grid showed up weakness in the breadth of audit topics studied. IMPLICATIONS AND ACTION--Oxfordshire practices achieved targets set for 1991-2 but need to broaden the scope of their audits and the topics studied. The advisory group''s targets for 1994-5 are for 50% of practices to achieve an audit in each of the areas of clinical care, access, communication, and professional values and for 80% of audits to include setting targets or implementing change.     

From passive diffusion to active cellular migration in mathematical models of tumour invasion

Mathematical models of tumour invasion appear as interesting tools for connecting the information extracted from medical imaging techniques and the large amount of data collected at the cellular and molecular levels. Most of the recent studies have used stochastic models of cell translocation for the comparison of computer simulations with histological solid tumour sections in order to discriminate and characterise expansive growth and active cell movements during host tissue invasion. This paper describes how a deterministic approach based on reaction-diffusion models and their generalisation in the mechano-chemical framework developed in the study of biological morphogenesis can be an alternative for analysing tumour morphological patterns. We support these considerations by reviewing two studies. In the first example, successful comparison of simulated brain tumour growth with a time sequence of computerised tomography (CT) scans leads to a quantification of the clinical parameters describing the invasion process and the therapy. The second example considers minimal hypotheses relating cell motility and cell traction forces. Using this model, we can simulate the bifurcation from an homogeneous distribution of cells at the tumour surface toward a nonhomogeneous density pattern which could characterise a pre-invasive stage at the tumour-host tissue interface.     

Medical audit in general practice. I: Effects on doctors' clinical behaviour for common childhood conditions. North of England Study of Standards and Performance in General Practice.

OBJECTIVE--To estimate the effects of medical audit, particularly setting clinical standards, on general practitioners'' clinical behaviour. DESIGN--Before and after study strengthened by a replicated Latin square. SETTING--62 training general practices in the north of England. SUBJECTS--92 general practitioner trainers, 84 (91%) of whom completed the study; random sample of 3500 children consulting one of these trainers for any of five conditions--acute cough, acute vomiting, bedwetting, itchy rash, and recurrent wheezy chest--stratified by doctor consulted, condition, and age. INTERVENTIONS--Clinical standard set by each of 10 small groups of general practitioner trainers for one randomly selected childhood condition. Each group also experienced a different type of medical audit, randomly selected, for each of the four other study conditions (receiving a clinical standard set by another trainer group, tabulated data comparing clinical performance with that of all other groups, tabulated data from only their own group, and nothing ("control" condition)). MAIN MEASURES--Content of initial consultation divided into: history, examination, investigation, diagnosis, and management (abstracted from medical records and "enhancement forms" completed by doctors). RESULTS--There was increased prescribing of bronchodilators for acute cough, oral rehydration fluids for acute vomiting, antibiotics for itchy rash, and bronchodilators and oral steroids for recurrent wheezy chest and reduced prescribing of antibiotics for acute cough and recurrent wheezy chest and tricyclic antidepressants for bedwetting. Fewer children were "discharged." Each change was consistent with the standard and either limited to doctors who set a standard for that condition or significantly greater for them than all other doctors. CONCLUSION--Setting clinical standards improved prescribing and follow up.     

Relation between night visit rates and deprivation measures in one general practice.

OBJECTIVE--To compare night visit rates in different electoral wards of one general practice with the Jarman and Townsend deprivation scores and unemployment rates. DESIGN--Analysis of computerised workload data. SETTING--General practice in centre of Mansfield, Nottinghamshire. OUTCOME MEASURE--Visits made in 588 nights to the 11,998 patients on the practice list. RESULTS--Night visit rates in 15 electoral wards varied from 19.6 to 55.3 visits per 1000 patients per year. The rates showed a significant association with the Townsend score (p = 0.004) and the unemployment rate (p = 0.03) but not with the Jarman score (p = 0.3). The Townsend score explained 49% of the variability; unemployment explained 31% and the Jarman score explained 9%. CONCLUSIONS--Even in a general practice not eligible for deprivation payments there was a 2.8-fold variation in night visit rates between wards. In this practice the Townsend score was significantly better at predicting night visit rates than the Jarman score. This method of looking at internal variation in workloads in computerised practices could give more direct data on the relation between deprivation and general practice workload than has previously been available.     

Internal quality audit and quality standards as a method of quality improvement at the Department of Ophthalmology, University Hospital

Quality assessment of clinical health care with the programme of quality standard is a method of health management, through which better efficiency and safety of health outcomes can be achieved. In the period from 2002 to 2004, a pilot program of quality has been carried out on the Department of Ophthalmology, University Hospital Center in Zagreb. Seven internal audit teams of hospital commission and teams of hospital departments were evaluating introducing practice for quality standards every three months. In the period of two years improvement in all standards of quality has been noticed (expressed in percent of progress towards the ideal result of 100%): personnel 20%, patient rights 15%, medical equipment 40%, quality of emergency service 60%, implementation of clinical guidelines and criteria for elective admission 55%, quality of risk prevention 70%, quality of medical records 60%. The two-years-improvement dynamics of about 46%, first year 24%.