Aileen McIntosh

Effectiveness of screening and monitoring tests for diabetic retinopathy--a systematic review.

SUMMARY

A systematic review of foot ulcer in patients with Type 2 diabetes mellitus. I: prevention

Aim To evaluate the role of preventative strategies in reducing foot ulcers in patients with Type 2 diabetes mellitus, both in the general population and those identified to be at a raised risk.

Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System

Background: Internationally, there is increasing recognition of the need to collect and analyse data on patient safety incidents, to facilitate learning and develop solutions. The National Patient Safety Agency (NPSA) for England and Wales has been capturing incident data from acute hospitals since November 2003. Objectives: This study analyses patterns in reporting of patient safety incidents from all acute hospitals in England to the NPSA National Reporting and Learning System, and explores the link between reporting rates, hospital characteristics, and other safety and quality datasets. Methods: Reporting rates to the NPSA National Reporting and Learning System were analysed as trends over time, from the point at which each hospital became connected to the system. The relationships between reporting rates and other safety and quality datasets were assessed using correlation and regression analyses. Results: Reporting rates increased steadily over the 18 months analysed. Higher reporting rates correlated with positive data on safety culture and incident reporting from the NHS Staff Survey, and with better risk-management ratings from the NHS Litigation Authority. Hospitals with higher overall reporting rates had a lower proportion of their reports in the “slips, trips and falls” category, suggesting that these hospitals were reporting higher numbers of other types of incident. There was no apparent association between reporting rates and the following data: standardised mortality ratios, data from other safety-related reporting systems, hospital size, average patient age or length of stay. Conclusions: Incident reporting rates from acute hospitals increase with time from connection to the national reporting system, and are positively correlated with independently defined measures of safety culture, higher reporting rates being associated with a more positive safety culture.

Use of a safety climate questionnaire in UK health care: factor structure, reliability and usability

Aim: To explore the factor structure, reliability, and potential usefulness of a patient safety climate questionnaire in UK health care. Setting: Four acute hospital trusts and nine primary care trusts in England. Methods: The questionnaire used was the 27 item Teamwork and Safety Climate Survey. Thirty three healthcare staff commented on the wording and relevance. The questionnaire was then sent to 3650 staff within the 13 NHS trusts, seeking to achieve at least 600 responses as the basis for the factor analysis. 1307 questionnaires were returned (36% response). Factor analyses and reliability analyses were carried out on 897 responses from staff involved in direct patient care, to explore how consistently the questions measured the underlying constructs of safety climate and teamwork. Results: Some questionnaire items related to multiple factors or did not relate strongly to any factor. Five items were discarded. Two teamwork factors were derived from the remaining 11 teamwork items and three safety climate factors were derived from the remaining 11 safety items. Internal consistency reliabilities were satisfactory to good (Cronbach’s alpha ⩾0.69 for all five factors). Conclusions: This is one of the few studies to undertake a detailed evaluation of a patient safety climate questionnaire in UK health care and possibly the first to do so in primary as well as secondary care. The results indicate that a 22 item version of this safety climate questionnaire is useable as a research instrument in both settings, but also demonstrates a more general need for thorough validation of safety climate questionnaires before widespread usage.

Modelling the Expected Net Benefits of Interventions to Reduce the Burden of Medication Errors

Objectives The aim of this study is to estimate the potential costs and benefits of three key interventions (computerized physician order entry [CPOE], additional ward pharmacists and bar coding) to help prioritize research to reduce medication errors. Methods A generic model structure was developed to describe the incidence and impacts of medication errors in hospitals. The model follows pathways from medication error points at alternative stages of the medication pathway through to the outcomes of undetected errors. The model was populated from a systematic review of the medication errors literature combined with novel probabilistic calibration methods. Cost ranges were applied to the interventions, the treatment of preventable adverse drug events (pADEs), and the value of the health lost as a result of an ADE. Results The model predicts annual health service costs of between £0.3 million and £1 million for the treatment of pADEs in a 400-bed acute hospital in the UK. Including only health service costs, it is uncertain whether any of the three interventions will produce positive net benefits, particularly if high intervention costs are assumed. When the monetary value of lost health is included, all three interventions have a high probability of producing positive net benefits with a mean estimate of around £31.5 million for CPOE over a five-year time horizon. Conclusions The results identify the potential cost-effectiveness of interventions aimed at medication errors, as well as identifying key drivers of cost-effectiveness that should be specifically addressed in the design of primary evaluations of medication error interventions.

Supplementary prescribing by community and primary care pharmacists: an analysis of PACT data, 2004–2006

Background and objective:  Pharmacist prescribing is a relatively new intiative in the extension of prescribing responsibilities to non‐medical healthcare professionals. Pharmacist supplementary prescribing was introduced in 2003 and allowed prescribing in accordance with a clinical management plan agreed with a medical practitioner and patient to improve patient access to medicines and better utilize the skills of healthcare professionals. The objective of this research was to examine the volume, cost and trends in pharmacist prescribing in community and primary care using Prescription Analysis and Cost (PACT) data and to suggest possible reasons for the trends.

Complications of diabetes: renal disease and promotion of self-management

This paper is an edited version of Effective Health Care volume 6 number 1,1 which summarises information originally derived from systematic reviews undertaken to inform national clinical practice guidelines,23 supplemented and re-analysed by the NHS Centre for Reviews and Dissemination. Raised blood glucose levels and related microvascular disease are associated with progressive damage to the kidneys. This damage becomes detectable when protein (primarily albumin) is excreted in the urine in higher concentrations than normal. As the severity of the damage increases, the quantity of protein in the urine also increases. When the level of albumin in the urine is fairly low, the condition is known as microalbuminuria or incipient nephropathy; higher albumin excretion is described as proteinuria. Eventually the condition can lead to renal failure.2 Epidemiological studies report prevalence rates of microalbuminuria in patients with type 2 diabetes ranging from 8% to 32% with most estimates being around 25%.4–15 Prevalence estimates for proteinuria range from 5% to 19% with most studies giving rates of around 15%.569–111516 This variation may be a product of the criteria used to define the condition, the stage of the disease, and the methods used to assess it. Figures from the UK Prospective Diabetes Study (UKPDS), based on 3867 patients, suggest that about 12% have microalbuminuria (although using a high threshold) and 1.9% have proteinuria at the time of diagnosis of diabetes.17 A US study which followed 794 patients with type 2 diabetes who were initially free from proteinuria (defined as ≥30 μg protein/l urine) found that 1.3% developed renal failure within 10 years.18 A substantial proportion of patients treated in renal units in the UK have diabetes. Diabetic nephropathy is the most common single cause of renal failure among …

Comparison of case note review methods for evaluating quality and safety in health care

OBJECTIVES To determine which of two methods of case note review--holistic (implicit) and criterion-based (explicit)--provides the most useful and reliable information for quality and safety of care, and the level of agreement within and between groups of health-care professionals when they use the two methods to review the same record. To explore the process-outcome relationship between holistic and criterion-based quality-of-care measures and hospital-level outcome indicators. DATA SOURCES Case notes of patients at randomly selected hospitals in England. REVIEW METHODS In the first part of the study, retrospective multiple reviews of 684 case notes were undertaken at nine acute hospitals using both holistic and criterion-based review methods. Quality-of-care measures included evidence-based review criteria and a quality-of-care rating scale. Textual commentary on the quality of care was provided as a component of holistic review. Review teams comprised combinations of: doctors (n = 16), specialist nurses (n = 10) and clinically trained audit staff (n = 3) and non-clinical audit staff (n = 9). In the second part of the study, process (quality and safety) of care data were collected from the case notes of 1565 people with either chronic obstructive pulmonary disease (COPD) or heart failure in 20 hospitals. Doctors collected criterion-based data from case notes and used implicit review methods to derive textual comments on the quality of care provided and score the care overall. Data were analysed for intrarater consistency, inter-rater reliability between pairs of staff using intraclass correlation coefficients (ICCs) and completeness of criterion data capture, and comparisons were made within and between staff groups and between review methods. To explore the process-outcome relationship, a range of publicly available health-care indicator data were used as proxy outcomes in a multilevel analysis. RESULTS Overall, 1473 holistic and 1389 criterion-based reviews were undertaken in the first part of the study. When same staff-type reviewer pairs/groups reviewed the same record, holistic scale score inter-rater reliability was moderate within each of the three staff groups [intraclass correlation coefficient (ICC) 0.46-0.52], and inter-rater reliability for criterion-based scores was moderate to good (ICC 0.61-0.88). When different staff-type pairs/groups reviewed the same record, agreement between the reviewer pairs/groups was weak to moderate for overall care (ICC 0.24-0.43). Comparison of holistic review score and criterion-based score of case notes reviewed by doctors and by non-clinical audit staff showed a reasonable level of agreement (p-values for difference 0.406 and 0.223, respectively), although results from all three staff types showed no overall level of agreement (p-value for difference 0.057). Detailed qualitative analysis of the textual data indicated that the three staff types tended to provide different forms of commentary on quality of care, although there was some overlap between some groups. In the process-outcome study there generally were high criterion-based scores for all hospitals, whereas there was more interhospital variation between the holistic review overall scale scores. Textual commentary on the quality of care verified the holistic scale scores. Differences among hospitals with regard to the relationship between mortality and quality of care were not statistically significant. CONCLUSIONS Using the holistic approach, the three groups of staff appeared to interpret the recorded care differently when they each reviewed the same record. When the same clinical record was reviewed by doctors and non-clinical audit staff, there was no significant difference between the assessments of quality of care generated by the two groups. All three staff groups performed reasonably well when using criterion-based review, although the quality and type of information provided by doctors was of greater value. Therefore, when measuring quality of care from case notes, consideration needs to be given to the method of review, the type of staff undertaking the review, and the methods of analysis available to the review team. Review can be enhanced using a combination of both criterion-based and structured holistic methods with textual commentary, and variation in quality of care can best be identified from a combination of holistic scale scores and textual data review.

Complications of diabetes: screening for retinopathy and management of foot ulcers

1which is based on two systematic reviews undertaken to inform national clinical practice guidelines for type 2 diabetes. 23 The first part of the article looks at screening for diabetic retinopathy and the second at the prevention and treatment of diabetic foot ulcers. Two of the most common complications of diabetes are visual problems caused by retinopathy, and problems with the feet, particularly persistent ulcers. These result from microvascular and macrovascular complications, often exacerbated by chronically raised blood glucose levels. Around 2% of the UK population are believed to have diabetes, of whom perhaps 200 000 have type 1 (insulin dependent) diabetes, and more than a million have type 2 (non-insulin dependent) diabetes. 4

Assessing quality of care from hospital case notes: comparison of reliability of two methods

Objectives To determine which of the two methods of case note review provide the most useful and reliable information for reviewing quality of care. Design Retrospective, multiple reviews of 692 case notes were undertaken using both holistic (implicit) and criterion-based (explicit) review methods. Quality measures were evidence-based review criteria and a quality of care rating scale. Setting Nine randomly selected acute hospitals in England. Participants Sixteen doctors, 11 specialist nurses and three clinically trained audit staff, and eight non-clinical audit staff. Analysis Methods Intrarater consistency, inter-rater reliability between pairs of staff using intraclass correlation coefficients (ICCs), completeness of criterion data capture and between-staff group comparison. Results A total of 1473 holistic reviews and 1389 criterion-based reviews were undertaken. When the three same staff types reviewed the same record, holistic scale score inter-rater reliability was moderate within each group (ICC 0.46 to 0.52). Inter-rater reliability for criterion-based scores was moderate to good (ICC 0.61 to 0.88). Comparison of holistic review score and criterion-based score of case notes reviewed by doctors and by non-clinical audit staff showed a reasonable level of agreement between the two methods. Conclusions Using a holistic approach to review case notes, same staff groups can achieve reasonable repeatability within their professional groups. When the same clinical record was reviewed twice by the doctors, and by the non-clinical audit staff, using both holistic and criterion-based methods, there are close similarities between the quality of care scores generated by the two methods. When using retrospective review of case notes to examine quality of care, a clear view is required of the purpose and the expected outputs of the project.