The impact of guidelines in clinical outpatient practice.
Explore the source record for details and available documents.
Diagnostic Services↗
Biomedical subjects
C J Roberts
Publications and source records attributed to C J Roberts.
Can the use of radiography of arms and legs in accident and emergency units be made more efficient?
The efficiency of the selection of patients with injured arms and legs for radiography was investigated. The analysis was based on data on presenting signs and symptoms collected in a multicentre study organised by the Royal College of Radiologists working party on the effective use of diagnostic radiology. The work was carried out in eight accident and emergency units in England and Wales. With the help of various computer simulation techniques a combination of signs and symptoms that might usefully improve present practice was sought. The results suggest that for injuries of arms and legs the clinical determinants of bony injury cannot be refined further to improve current selection for radiography. This study shows that existing clinical practice is probably as good as it can be.
Accidents↗
Clinical guidelines, medical litigation, and the current medical defence system.
The introduction into National Health Service medical practice of guidelines designed to achieve more effective use of clinical resources is likely to encounter opposition owing to the increasing fear of litigation amongst clinicians. Hospital doctors are unusual amongst salaried professionals in being required to bear the cost of indemnity insurance themselves. The advantages for doctors commonly attributed to this arrangement are insubstantial. A system of no-fault compensation is unlikely to be implemented in this country in the foreseeable future. If guidelines are to achieve wide acceptability amongst clinicians, health authorities must accept full legal and financial responsibility for the actions of doctors in their employment, as they currently do for other health service staff.
Cost Control↗
Study of the action of cicletanine in hyperuricemic patients.
The possibility that the drug cicletanine might offer diuresis and reduction in plasma uric acid has been investigated in patients recruited from the rheumatology and general medical clinics. Nine hyperuricemic patients received cicletanine 100 mg daily by mouth for 21 days. Urinary clearance studies and plasma biochemistry were measured twice before treatment, twice at the start of treatment, and twice at the end of the treatment period. No change was observed in the urine volume, absolute or fractional excretion of sodium in response to the drug. There was no measurable change in the plasma uric acid or urinary urate clearance. Creatinine clearance and potassium excretion also remained constant. No adverse effects were observed apart from a possibly drug-related elevation in serum aspartate amino transferase in one patient. The study provides no support for the postulated diuretic or hypouricemic effects of the drug.
Adult↗
Pharmacokinetics of nifedipine after oral administration in chronic liver disease.
Presented are the results of a study in which ten healthy subjects and seven patients with hepatic cirrhosis were given 10 mg nifedipine orally; plasma concentrations of the drug were measured over 24 hours. The drug was also administered intravenously, but those results were unsatisfactory for presentation. The rate of absorption and peak plasma concentrations were similar in the two groups. There was a fourfold increase in the elimination half-life (434 +/- 74 minutes in the cirrhotics compared with 102 +/- 11 minutes in the healthy subjects). A twofold increase in the area under the plasma concentration-time curve occurred in the cirrhotic group. The study confirmed that there is clinically significant alteration in the kinetics of nifedipine in patients who have hepatic cirrhosis and that there is considerable risk of accumulation. No adverse effects were observed despite high plasma levels of nifedipine.
Administration, Oral↗
A comparison of the radiation-induced mutation at the HGPRT locus in V79 and BHK cells.
Mutation response at the HGPRT locus has been compared in two differing cell lines: V79/4, an aneuploid Chinese-hamster fibroblast line with a complement of 20 chromosomes, and BHK21-C13, a diploid Syrian-hamster fibroblast line with a complement of 44 chromosomes. The data presented show that BHK is slightly more radiosensitive than V79/4; however, the toxicity curves and expression times are similar for both cell lines. If radiosensitivity is taken into account, a common line can be drawn for radiation mutagenesis. We conclude from the data that radiation-induced mutagenesis is broadly equivalent in the two cell lines examined, and is not dependent on the chromosome complement.
Animals↗
The cost of saving a life through cervical cytology screening: implications for health policy.
Through a review of the published literature on routine cervical cytology screening, this paper seeks to establish a likely range for the cost of saving a life through this screening programme as presently organised in England and Wales. The current performance of the programme may be expressed in several ways: a cost of 270,000 pounds to 285,000 pounds per life saved, 40,000 smears and 200 excision biopsies per death averted, or 1000 to 1500 avoidable deaths annually in England and Wales alone. The policy problems are thus of two kinds. First, there is a substantial misallocation of the limited resources available to an insurance based system of health care. Further, the money which is spent on this service does not avoid the mortality and morbidity which could reasonably be expected if the system were performing adequately. It is suggested that substantial improvements in the performance of the programme may well be possible if managers are appointed. Nevertheless a deeper policy issue is raised: to be delivered efficiently, any service based on population rather than individual considerations will require some acceptance by the medical profession of a limit to their traditional view of clinical freedom. The unresolved clash between population and individual considerations which poses such a fundamental challenge for policy making in insurance based health services is particularly well illustrated by the dilemma of publicly funded cervical cytology screening.
Costs and Cost Analysis↗
Compliance with the Royal College of Radiologists' guidelines on the use of pre-operative chest radiographs.
Clinical compliance with the Royal College of Radiologists' guidelines on the use of pre-operative chest radiology was examined in a random sample of patients in four hospitals in England and Wales. Pre-operative clinical data were abstracted from medical reports and, in one hospital, from special chest radiograph request forms completed by clinicians. Seventy-five per cent of patients had clinical indications warranting a pre-operative chest radiograph. This level of compliance is compatible with that found with other guidelines and would suggest that the pre-operative chest radiograph guidelines are suitable for wider implementation in the National Health Service.
Health Planning Guidelines↗
The production of chromosome aberration in Chinese hamster fibroblasts exposed to 24 keV neutrons.
A filtered reactor beam, consisting mainly of 24 keV neutrons, was used to study the induction of chromosome aberrations in the V79/4(AH1) Chinese hamster cell line. The yields of both dicentrics and acentrics were linear with dose and the value of relative biological effectiveness (RBE) for dicentrics at low doses was 6.5 +/- 1.4. This value was similar to that found previously for a neutron spectrum with mean energy 2.1 MeV, and suggests that the RBE of neutrons does not increase to very high values in the energy region below 100 keV. This result does not support the suggestions of Davy (1969) and Key (1971) that the neutron RBE rises to very high values in the intermediate energy range.
Animals↗
The effect of 238Pu alpha-particles on the mouse fibroblast cell line C3H 10T1/2: characterization of source and RBE for cell survival.
Considerable interest has been aroused in recent years by reports that the transforming and carcinogenic effectiveness of low doses of high LET radiations can be increased by reducing the dose rate, especially for transformation of 10T1/2 cells in vitro by fission-spectrum neutrons. We report on conditions which have been established for irradiation of 10T1/2 cells with high LET monoenergetic alpha-particles (energy of 3.2 MeV, LET of 124 keV microns-1) from 238Pu. The alpha-particle irradiator allows convenient irradiation of multiple dishes of cells at selectable high or low dose rates and temperatures. The survival curves of irradiated cells showed that the mean lethal dose of alpha-particles was 0.6 Gy and corresponded to an RBE, at high dose rates, of 7.9 at 80 per cent survival and 4.6 at 5 per cent survival, relative to 60Co gamma-rays. The mean areas of the 10T1/2 nuclei, perpendicular to the incident alpha-particles, was measured as 201 microns2, from which it follows that, on average, only one in six of the alpha-particle traversals through a cell nucleus is lethal. Under the well-characterized conditions of these experiments the event frequency of alpha-particle traversals through cell nuclei is 9.8 Gy-1.
Alpha Particles↗
Variation in repeat rates between 18 radiology departments.
A comprehensive analysis of repeat rates has been obtained from an observational study of radiological practice in diagnostic X-ray departments throughout Wales. Interdepartmental and intradepartmental repeat rates are investigated for chest, abdomen, pelvis, sinus, lumbar spine, cervical spine and intravenous pyelographic examinations. The confounding effects upon observed repeat rates of trainee practitioners and automatic exposure control devices are also considered. The overall proportions of total film cost and patient exposure attributable to repeat radiographs are estimated to be 10% and 14% respectively.
Hospital Departments↗
Out-of-hours radiology: a suitable case for audit?
An outline of radiological activity outside normal working hours over a 2-month period in a teaching hospital is presented. A 100-fold variation between specialties in the number of requests per 100 discharges and deaths is shown. Specialties with a high out-of-hours radiology demand also tended to have a high overall demand. Chest and abdomen radiographs accounted for approximately 82% of all investigations undertaken during the period of observation. Six radiological investigations--chest and abdomen radiographs, computed tomography, skull radiographs, intravenous urography and cardiac catheterisation--accounted for approximately 94% of all out-of-hours investigations. There was a 5.6-fold variation between investigations in the time taken to carry out one standard unit of work. In the health authority studied, it was estimated that pounds 93,000 was spent on radiographers' out-of-hours payments in 1984/85, of which almost 90% was directly related to the number of radiological procedures undertaken. It is suggested that the wide variation in rates of out-of-hours radiology usage between specialties requires more detailed examination. The limited range of procedures accounting for the great majority of the out-of-hours work makes a study feasible. The very marked variation in the time taken for one unit of work may result in important financial distortions if clinical budgeting becomes more widespread. The large excess cost of out-of-hours radiological investigations, which may be as much as pounds 16,000,000 per annum in England and Wales, offers the possibility of substantial savings if some of the investigations are shown to be of little clinical value outside normal working hours.
Appointments and Schedules↗
Multicentre trial of four strategies to reduce use of a radiological test.
The Royal College of Radiologists' guidelines on the use of pre-operative chest X-rays were implemented for 1 year in four hospitals in England and Wales. The strategies adopted were: (1) the appointment of a utilisation review committee; (2) getting feedback on use to consultants; (3) the introduction of a new chest X-ray request form; or (4) the concurrent reviewing of chest X-ray requests by the radiology department. The lowest level of use (8.5 pre-operative chest X-rays per 100 elective operations) was achieved with the utilisation review committee after it displayed the guidelines in surgical wards. Information feedback produced a consistent reduction from 29.4 to 13.3 X-rays per 100 operations. Both the new request form and concurrent review had a moderate and intermittent effect. No change in practice occurred in a control hospital.
England↗
Admission guidelines for head injuries: variance with clinical practice in accident and emergency units in the UK.
Guidelines for the initial management of head injuries were formulated by neurosurgeons and a multidisciplinary group of clinicians and administrators attending a seminar convened by the UK Department of Health and Social Security (DHSS). Analysis of data collected previously by the Royal College of Radiologists in nine accident and emergency units in the UK shows that admitting practice varied between centres and was very different from that recommended subsequently in the guidelines. Only 49 per cent (range 22 to 71 per cent) of patients who had skull X-rays and possessed symptoms and signs warranting admission were admitted to hospital and 14 per cent (range 1 to 20 per cent) of those without appropriate symptoms and signs were admitted. Rates of admission for patients with a history of unconsciousness, which according to the guidelines is not a criterion for admission, were up to ten-fold higher than for comparable patients with no such history. Implementation of the guidelines could have a substantial effect on clinical practice and could reduce admissions of patients who had skull X-rays by up to 46 per cent.
Adult↗
A critical comparison of the micronucleus yield from high and low LET irradiation of plateau-phase cell populations.
Experimental data are presented which cast doubt on the usefulness of micronucleus assays as a quantitative measure of radiation damage. Synchronised (G1) Syrian hamster fibroblasts (BHK21 C13) were exposed to doses of gamma- or neutron radiation which yielded equivalent survival response. The cultures were examined at intervals during a 120-h post-irradiation incubation, for the appearance of micronuclei. Dose-response curves for the micronucleus yield constructed at a single sample time of 30 h were compared with those for the peak yield, irrespective of sampling time at each dose. When the total production of acentric fragments was compared with the peak yield of micronuclei no clear correlation could be seen. Qualitative hypotheses have been suggested to account for the various features of the data. The production and expression of micronuclei has been found to be a very complicated relationship and is a warning against too simplistic an interpretation of micronuclei data.
Animals↗
Inactivation of Chinese hamster V79/4(AH1) and HeLa cells by 24 keV neutrons.
Cell survival studies have been carried out with a filtered neutron beam providing a nearly pure, high intensity source of 24 keV neutrons. These suggest that 24 keV neutrons behave as high LET radiation. The RBE at 37 per cent survival was approximately 2.2 for V79 Chinese hamster cells while HeLa cells gave a value of 2.9.
Animals↗
Making NHS services more affordable.
Explore the source record for details and available documents.
Costs and Cost Analysis↗