Biomedical subjects
I K Crombie
Publications and source records attributed to I K Crombie.
Controlled trial of an audit facilitator in diagnosis and treatment of childhood asthma in general practice.
OBJECTIVE: To test whether an audit facilitator could alter the pattern of diagnosis and treatment of childhood asthma. DESIGN: Randomised stratified controlled trial. SETTING: 12 general practices in Tayside. SUBJECTS: 3373 children aged 1-15 inclusive who had symptoms suggestive of asthma or possible asthma drawn from a systematic review of 10,725 general practice case records. INTERVENTION: Children were targeted for a clinical review by their general practitioner or practice nurses. MAIN OUTCOME MEASURES: Asthma related consultations, prescriptions, hospital attendances, and health service costs 12 months before and after study. RESULTS: Compared with controls (n = 1563) the intervention group (n = 1585) had more practice initiated consultations for asthma (relative risk 2.18 (95% confidence interval 1.74 to 2.73)), new diagnoses of asthma (2.83 (2.26 to 3.54)), and past diagnoses reaffirmed (1.30 (1.08 to 1.58)), and they were more frequently prescribed inhaled cromoglycate (1.52 (1.02 to 2.25)). Hospital inpatient day rates fell from 152 to 122 in the intervention group and rose from 69 to 117 in the control group between the year before and the year after study. Total primary care costs rose from 30,118 pounds to 37,243 pounds in the intervention group and fell from 29,131 pounds to 27,990 pounds in the control group. Hospital care cost fell in the intervention group from 25,406 pounds to 20,727 pounds and rose in the control group from 12,699 pounds to 19,650 pounds. CONCLUSION: An audit facilitator can favourably influence the pattern of diagnosis and treatment of childhood asthma in general practice. This may have an impact on health service costs.
Women's experiences at cervical screening.
Concerns about attendance for cervical screening has focussed on determining the reasons why some women never attend. Less attention has been paid to whether women continue to attend for further smears, although this is essential for further screening. This study investigated women's experiences of cervical screening and their views on subsequent attendance. Three hundred and thirty nine women aged 20-64 were identified from a computerised register of cervical smears as having had a smear test within the previous three years. They were interviewed at home about their most recent experience of screening. Just over half of the women (53%) recalled being anxious before the test, and about one fifth reported embarrassment (19%) or pain (20%) during it. The frequencies of discomfort were higher amongst those who were anxious about the test, although 24% of those who were embarrassed and 28% who had pain reported being unconcerned beforehand. The frequencies of pain and embarrassment were only slightly higher when the smear taker was male. Many women (22%) reported being concerned about the test result although only 10% of those who were concerned were recalled for further assessment. Although a number of women had unpleasant experiences, almost all (95%) who were under 60 years of age said they were likely to attend for a subsequent smear. Taking cervical smears is often an unpleasant experience for women, although some of the distressing events could easily have been avoided. Attention to technique and to the concerns of individual patients, especially ensuring privacy, could reduce the extent of the problem. The uptake of subsequent smears should be monitored to ensure that women are not being discouraged from attendance.
The use of children's medical records to predict the risk of asthma attack.
Using a large data base of respiratory morbidity in children the opportunity arose to explore the link between what was written in general practice case records and the subsequent risk of a child developing an asthma attack or hospital admission due to asthma. Children with five or more consultations in one year for respiratory symptoms had a 33% risk of experiencing an asthma attack or 7.1% risk of admission in the following year. Twenty seven percent of children who received antibiotics for "respiratory infections" subsequently had an asthma attack. The potential exists to review past and present symptoms and thus attempt to predict future morbidity. Childhood asthma is an example where the quality of care offered by general practitioners could be improved if a precise estimate of risk could be used to modify clinical management.
The cost effectiveness of amoxicillin/clavulanic acid as antibacterial prophylaxis in abdominal and gynaecological surgery.
The objective of this study was to compare the cost effectiveness of amoxicillin/clavulanic acid with other antibacterial regimens for prophylaxis of infection after elective abdominal or gynaecological surgery. Data from 21 previously published comparative clinical trials were used to calculate statistical confidence intervals for differences in postoperative wound infection rate. A simple model was used to produce a tabular sensitivity analysis of cost effectiveness over a wide range of costs of wound infection and potential differences in efficacy. For more expensive comparator regimens, including combination regimens utilising gentamicin and metronidazole, amoxicillin/clavulanic acid was either likely to be more cost effective or equally cost effective. For example, in trials of colonic surgery the comparators were on average 11.39 pounds more expensive than amoxicillin/clavulanic acid, which was > 95% likely to be more cost effective unless the cost of wound infection was estimated to be > 1519 pounds. Amoxicillin/clavulanic acid was more expensive than only 2 of the 21 comparators. Furthermore, in one of these 2 trials it was also significantly more effective than the comparator. In this trial, amoxicillin/clavulanic acid was > 95% likely to be more cost effective as prophylaxis in hysterectomy than rectal metronidazole, provided that the cost of wound infection was estimated to be > 179 pounds. In conclusion, this analysis shows that amoxicillin/clavulanic acid, given as monotherapy, is likely to be equally or more cost effective than a wide range of comparator regimens for prophylaxis of elective abdominal or gynaecological surgery.
Entering the loop: assessing the contribution of pain clinics in northern Britain.
A survey of patients attending ten outpatient pain clinics throughout northern Britain was undertaken to identify opportunities for improving the treatment of pain patients. A short data collection form was designed to obtain information at every patient consultation. The patients were found to be a diverse group, many with complex pain problems. For many patients meaningful diagnoses could not be obtained. The focus of the study was altered to address a selected group of patients: those with neurogenic pain. This group was selected because it was comparatively easy to define, and previous studies suggested that nerve damage pain might not always be well managed. Many patients were found not to have had adequate trials of potentially effective therapies prior to attendance at the pain clinics. Some of these therapies, such as antidepressants and anticonvulsants, could have been prescribed by general practitioners. However, there were also substantial differences between the clinics in the proportion of patients receiving particular therapies. Finally, although many patients had psychological morbidity few were offered psychological assessment and management. These studies have shown that the pain clinics provide a range of therapies which patients are unlikely to receive elsewhere. But there is scope for improvement in the management of patients in pain clinics and efforts are currently being directed towards this.
Waiting in pain. Delays between referral and consultation in outpatient pain clinics.
Patients with chronic pain may benefit from referral to a pain specialist. This study describes the delay between referral and first appointment of 3386 new referrals seen in ten outpatient pain clinics between 1990 and 1992. We then assess the follow-up patterns of the pain clinics and how these relate to waiting times. Patients wait in pain for long periods before being seen in a pain clinic. In 1992 about half of patients waited more than 3 months for an appointment at a teaching hospital pain clinic; and half waited 9 weeks or longer to be seen at a district general hospital pain clinic. In many clinics the situation is worsening. Pain clinics differ widely in their patient follow-up, with patients averaging more than twice as many visits in some clinics than others. Clinic practice on reappointing patients largely determines the number of new referrals who can be accepted for management, and hence affects waiting lists. Thus our data suggest that pain clinics themselves can help reduce waiting times, by changing the extent and nature of patient follow-up. Ultimately, however, additional consultant sessions may be needed to enable pain clinics to meet the increasing demands placed on them.
The photosensitivity dermatitis and actinic reticuloid syndrome: no association with lymphoreticular malignancy.
In the management of photosensitivity dermatitis/actinic reticuloid syndrome (PD/AR) (syn. chronic actinic dermatitis), a chronic and often severe photodermatosis, there has been concern that patients may be predisposed to the development of lymphoreticular malignancy. A follow-up study of 231 patients with PD/AR who had been investigated at the Photobiology Unit, Ninewells Hospital, Dundee, between 1971 and 1991, was undertaken to determine (i) the incidence and type of malignancies (ii) the causes of any deaths. This information was obtained from three sources: (a) National Cancer Registry data, (b) death certificates, (c) when possible or practical, by casenote review. Thirty-eight malignancies had occurred (in 37 of the 231 patients). Although six of the 38 malignancies were lymphoma registrations, it emerged from a review of casenotes, pathology reports and death certificates that five of the six were incorrect: two were labelled 'mycosis fungoides' prior to diagnosis of PD/AR; a case of dermatopathic lymphadenopathy was initially reported as Hodgkin's disease; clerical errors had occurred in two cases. The remaining case was a true B-cell lymphoma. The occurrence of one lymphoreticular malignancy is not significantly different from the number expected in a normal population (0.96), when applying 5-year age-, sex-, and site-specific incidence rates to the cumulative patient years of risk [standardized incidence ratio 1.04 (95% CI 0.03-5.79)]. There was also no significant increase in the risk of non-lymphoma malignancies in the PD/AR subjects. Since diagnosis, 83 patients have died, the majority from cardiorespiratory or cerebrovascular diseases, or the reported malignancies, a pattern expected in an elderly population.(ABSTRACT TRUNCATED AT 250 WORDS)
Failure of cigarette smoking to explain international differences in mortality from chronic obstructive pulmonary disease.
STUDY OBJECTIVE: The study aimed to explain international differences in rates and trends of chronic obstructive pulmonary disease (COPD) using two measurements of cigarette smoking, the major risk factor for this disease. DESIGN: Mortality data for COPD were obtained from the World Health Organisation for 31 countries from 1979 to 1988. Smoking data were obtained for most countries. COPD rates were compared to the percentage of current smokers and past levels of cigarette consumption. COPD trends were compared to past consumption trends. MAIN RESULTS: In men, Romania had the highest COPD mortality and Greece the lowest throughout the period. English speaking countries occupy most of the other top positions, and southern European countries and Japan the low positions. Women show a similar ranking to men (r = 0.75; p < 0.01 (1988)). Mortality rates in men are, in general, two to four times those in women. Most countries show either a decrease or no change in COPD mortality over the period. In women the opposite is true--no clear relationships are seen when comparing rates and trends of COPD with measures of smoking. CONCLUSION: This failure to explain international COPD differences suggests that national data on COPD may be unreliable or national cigarette smoking data are inadequate, or both.
Cervical screening: the optimum visit plan for contacting users and non-users in Scotland.
OBJECTIVE: To investigate the numbers of visits required to obtain interviews with users and non-users of cervical screening, and to determine the workload involved to enable an optimum visit plan to be developed. DESIGN: Case-control study of users and non-users of cervical screening using a flexible visit plan that involved up to eight attempts at contact. Visits were made in mornings, afternoons, and evenings, the visit pattern being determined by information gained from local sources. PATIENTS: Altogether 660 non-users of cervical screening (cases), aged 20-64 and registered with 23 randomly selected general practitioners (GPs), were identified from the Tayside computerised register of cervical smears. These women were selected from the computerised lists of 18 GPs in Dundee and five in Perth. A total of 417 women recorded as having a smear within the previous three years (controls), matched by age and GP, were also identified from the computerised register. RESULTS: Altogether 1834 attempts were made to contact the cases, of whom 339 were interviewed, giving a workload of 18 interviews per 100 attempts. For the controls 1359 attempts were made at contact to yield 339 interviews, a workload of 25 interviews per 100 attempts. Refusals (19%) and incorrect addresses (23%) were the two major reasons for failing to achieve interview. Only for four (0.6%) of the cases and one (0.2%) of the controls was no information gained. The proportion of attempts which led to interview remained constant with increasing numbers of call-backs (up to six for the cases and eight for the controls). CONCLUSIONS: A flexible approach to visit scheduling that takes account of local knowledge can lead to interviews with 66% of non-users of health screening, when incorrect addresses are removed. It is preferable to plan for many (up to six) visits to achieve interview. This will minimise non-response bias without increasing the workload per successful interview.
The importance of being systematic.
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Why use a pain clinic? Management of neurogenic pain before and after referral.
Pain arising from damage or malfunction of the nervous system (for example postherpetic neuralgia, peripheral nerve injuries and the neuropathies) is often severe and resistant to standard analgesics. These patients are commonly seen in pain clinics where they receive a variety of treatments including psychotropic drugs (such as antidepressants and anticonvulsants), nerve blocks and stimulation. There is concern that the management of these difficult patients may be less than optimal where they are not seen by pain specialists. We examined a cohort of 703 patients with long-established nerve-damage pain seen in ten outpatient pain clinics. We compared their use of treatments prior to referral with the management given in the pain clinic. The majority of patients (79%) had had their pain for over 1 year before being seen in the pain clinic, yet many had not tried simple and effective treatments prior to referral. Less than a quarter had received an adequate trial of antidepressants; only one in seven had been appropriately treated with anticonvulsants; and only one in 10 had tried a nerve stimulator. All these treatments were frequently provided in the pain clinic. Referral of patients with nerve-damage pain to a pain clinic may greatly increase their access to therapies of proven value.
Waiting time for first outpatient appointment.
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Trends in morbidity and mortality from peptic ulcer disease: Tayside versus Scotland.
Recent studies have shown that the prophylactic use of H2-receptor antagonists reduces both ulcer recurrence and the risk of ulcer complications. Despite these results, epidemiological studies have failed to show any evidence of an effect of gastric anti-secretory drugs on complicated ulcer disease in the community. Since 1979, it has been the policy of the gastroenterology department at Ninewells Hospital in Tayside to recommend long-term, continuous therapy with H2-receptor antagonists for patients with peptic ulcer; in contrast, prophylactic therapy is less commonly used in the rest of Scotland. The difference in the management of peptic ulcer between Tayside and Scotland presented an opportunity to study the population effects of the widespread use of continuous H2-receptor antagonists on the morbidity and mortality from ulcer disease. This study compared the trends in hospital admissions, gastric surgery, haemorrhage, perforation and mortality from ulcer disease using data supplied by the Information and Statistics Division of the Common Services Agency, Scottish Health Service, Edinburgh. During the 1980s, hospital admissions for peptic ulcer declined significantly in Tayside, whereas in Scotland there was no obvious downward trend. Gastric surgery for ulcer disease declined throughout Scotland although the fall was significantly steeper in Tayside than in the rest of Scotland. For the population in general, the rate of perforation decreased faster in Tayside than in the rest of Scotland, although the difference was not significant. The rate of admissions for ulcer haemorrhage declined substantially in Tayside whereas there was little change in Scotland as a whole. The decrease in mortality from ulcer disease in all groups except younger females was more marked in Tayside than in Scotland, although the differences were not significant. The magnitude of the differences between Tayside and Scotland, and in particular the consistency of these results across a broad range of indicators of ulcer disease, suggests that the policy of prescribing long-term, continuous therapy with H2-receptor antagonists has reduced both uncomplicated and complicated peptic ulcer in the community in Tayside.
Missing link in the audit cycle.
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Unnecessary hospitalisation in a psychiatric rehabilitation unit.
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Diagnosis and treatment of asthma in children: usefulness of a review of medical records.
In order to tackle the problems of underdiagnosis and undertreatment of asthma in childhood general practitioners need to be aware of which children in their practices have or might have asthma. In an effort to identify a cohort of asthmatic or potentially asthmatic children a trained audit facilitator studied all the medical records of children aged between one year and 15 years who were registered with 12 Tayside general practices. From a total of 10,685 medical records the frequency of 'key items' sometimes associated with asthma were as follows: one or more episodes of bronchospasm or wheeze 23.7% of children, persistent cough 23.2%, treatment with anti-asthma therapy in the past 20.0%, exercise induced cough or wheeze 5.2% and history of 'wheezy bronchitis' 4.6%. However, in only 896 children (8.4%) had a formal diagnosis of asthma been made. Of all the children, 5.4% had received a prescription for anti-asthma medication within the past three months. Only 1.2% were taking an inhaled corticosteroid and 1.0% sodium cromoglycate, but many more were taking inhaled bronchodilators (3.1%) and oral bronchodilators (1.7%). The findings suggest that a systematic review of medical records by a trained facilitator can identify those children who could benefit from clinical review. Practices who wish to know which of their children have or might have asthma should consider using medical record review to search for key items associated with asthma.
Computers in audit: servants or sirens?
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