Paul M. Taylor

Use of a Computerized Guideline for Glucose Regulation in the Intensive Care Unit Improved Both Guideline Adherence and Glucose Regulation

OBJECTIVE To measure the impact of a computerized guideline for glucose regulation in an ICU. DESIGN A randomized, controlled trial with an off-on-off design. METHODS We implemented a glucose regulation guideline in an intensive care unit in paper form during the first study period. During the second period, the guideline was randomly applied in either paper or computerized form. In the third period, the guideline was available only in paper form. MEASUREMENTS AND RESULTS We analyzed data for 484 patients. During the intervention period, the control group included 54 patients and the computerized intervention group included 66 patients. The two guideline-related outcome measures consisted of compliance with: (a) glucose measurement timing recommendations and (b) insulin dose advice. We measured clinical impact as the proportion of time that glucose levels fell within target range. In the first (paper-based) study period, 29.0% of samples occurred with optimal timing; during the second period, this increased to 35.5% for paper-based and to 40.2% for computerized protocols. The third study period timeliness scores reverted to the first period rates. Late (suboptimal) sampling occurred for 66% of glucose measurements in the first study period, for 42% of paper-based and 28% of computer-based protocol samples in the second period, and for 50.0% of samples in the third study period. In the first study period, insulin-dosing guideline compliance was 56.3%; in the second period, it was 64.2% for paper-based and 77.3% for computer-based protocols, and it fell to 42.4% in the third period. For the second study period, the time that a patients glucose values fell within target range improved for both the control (52.9%) and the computerized groups (54.2%) compared with the first study period (44.3%) and the third period (42.3%). CONCLUSION Implementing a computerized version of a guideline significantly improved timeliness of measurements and glucose level regulation for critically ill patients compared with implementing a paper-based version of the guideline.

Telemedicine in the NHS for the millennium and beyond.

This article defines telemedicine, discusses evidence of its effectiveness, looks at its advantages and disadvantages (and barriers to implementation), and considers its role in the NHS for the millennium and beyond.

An Ontology to Support Adaptive Training for Breast Radiologists

Medical education and training increasingly rely on computer-based tools. A number of initiatives incorporate digital libraries in tools to train radiologists. Our research involves the use of an informatics infrastructure to access a database of annotated images. We argue that an intelligent training tool requires a rich annotation of images in the database. In order to allow for the flexible querying of the database and intelligent feedback to trainees, those annotations must be organised using a clear and explicit model of the relevant concepts: an ontology. The paper reviews existing work on ontologies for mammography and outlines a new approach which is (a) derived from a detailed analysis of a large number of cases and (b) rich enough to meet the requirements of a training tool.

Construction of an odds model of coronary heart disease using published information: the Cardiovascular Health Improvement Model (CHIME)

BackgroundThere is a need for a new cardiovascular disease model that includes a wider range of relevant risk factors, in particular lifestyle factors, to aid targeting of interventions and improve population models of the impact of cardiovascular disease and preventive strategies. The model needs to be applicable to a wider population including different ethnic groups, different countries and to those with and without cardiovascular disease. This paper describes the construction of the Cardiovascular Health Improvement Model that aims to meet these requirements.MethodAn odds model is used. Information was taken from 2003 mortality statistics for England and Wales, the Health Survey for England 2003 and published data on relative risk in those with and without CVD and mean blood pressure values in hypertensives. The odds ratios used were taken from the INTERHEART study.ResultsA worked example is given calculating the 10-year coronary heart disease risk for a 57 year-old non-diabetic male with no personal or family history of cardiovascular disease, who smokes 30 cigarettes a day and has a systolic blood pressure of 137 mmHg, a total cholesterol (TC) of 6.2 mmol/l, a high density lipoprotein (HDL) of 1.3 mol/l, and a body mass index of 21. He neither drinks regularly nor exercises. He can give no reliable information about his mental health or fruit and vegetable intake. His 10-year risk of CHD death is 2.47%.ConclusionThis paper demonstrates a method for developing a CHD risk model. Further improvements could be made to the model with additional information. The method is applicable to other causes of death.

Two systematic reviews to compare effects of double reading and computer-aided detection on both cancer detection and recall rate

There are two competing methods for improving the accuracy of a single screening radiologist: use of a computer aid (CAD) or double reading. Bibliographic databases were searched for studies where either intervention was incorporated into routine screening work. Meta-analyses were performed to find overall estimates of the impacts of CAD and double reading on both the cancer detection rate and the recall rate. Ten studies were found comparing single reading with CAD to single reading. Seventeen studies were found comparing double reading to single reading. Double reading generally increases the cancer detection rate, but also the recall rate. However, double reading with arbitration increases the detection rate (95% CI = 1.02 to 1.15) and decreases the recall rate (95% CI = 0.92 to 0.96). CAD does not have a significant effect on the cancer detection rate (95% CI = 0.96 to 1.13) and increases the recall rate (95% CI = 1.09 to 1.12). However, there is considerable heterogeneity in the impact on the recall rate in both sets of studies. There is better evidence for an improvement in the cancer detection rate with a human second reader than with CAD. Arbitration where two readers disagree also delivers a reduced recall rate, whereas CAD increases the recall rate. There are therefore strong grounds for preferring double reading with arbitration to single reading with CAD.

Intelligent Learning Environment for Film Reading in Screening Mammography

We are developing a computer based training system to support breast cancer screening, designed for use in training new staff and also to help experienced readers enhance their skills. We discuss the design architectures used by computer based training systems, intelligent tutoring systems and intelligent learning environments. The basic skills involved in mammogram reading are investigated. Particular attention is given to the understanding of mammogram reading practices and the diversity of ways in which readers acquire their practical reading skills.

Impact of CAD with full field digital mammography on workflow and cost

The cost-effectiveness of single reading with CAD as an alternative to double reading was assessed in a national screening programme using CAD with full field digital mammography The impact of CAD on the time taken to read screening films (n=5710) and on the proportion of films referred for arbitration and for assessment was measured (n=3064) No evidence was found of a change in the time taken to read films and no evidence of a change in rates of referral or recall Estimates of the cost implications were made under three different scenarios for screening units We conclude that single reading with CAD is likely to be a cost-effective alternative to double reading in terms of radiologist time Published data however shows increased recall rates using CAD and no significant increase in sensitivity for CAD use over single reading Any decision to introduce CAD instead of double reading should take into account the impact of sensitivity and specificity on women attending for screening.