Reduction in the use of surgery for glue ear: did national guidelines have an impact?

Printed educational materials: effects on professional practice and healthcare outcomes

BACKGROUND

Printed educational materials are widely used dissemination strategies to improve the quality of healthcare professionals' practice and patient health outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. This is the fourth update of the review.

OBJECTIVES

To assess the effect of printed educational materials (PEMs) on the practice of healthcare professionals and patient health outcomes. To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on healthcare professionals' practice and patient health outcomes.

SEARCH METHODS

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and EPOC Register from their inception to 6 February 2019. We checked the reference lists of all included studies and relevant systematic reviews.

SELECTION CRITERIA

We included randomised trials (RTs), controlled before-after studies (CBAs) and interrupted time series studies (ITSs) that evaluated the impact of PEMs on healthcare professionals' practice or patient health outcomes. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. Any objective measure of professional practice (e.g. prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.

DATA COLLECTION AND ANALYSIS

Two reviewers undertook data extraction independently. Disagreements were resolved by discussion. For analyses, we grouped the included studies according to study design, type of outcome and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where data were available, we re-analysed the ITS studies by converting all data to a monthly basis and estimating the effect size from the change in the slope of the regression line between before and after implementation of the PEM. We reported median changes in slope for each outcome, for each study, and then across studies. We standardised all changes in slopes by their standard error, allowing comparisons and combination of different outcomes. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. We assessed the risks of bias of all the included studies.

MAIN RESULTS

We included 84 studies: 32 RTs, two CBAs and 50 ITS studies. Of the 32 RTs, 19 were cluster RTs that used various units of randomisation, such as practices, health centres, towns, or areas. The majority of the included studies (82/84) compared the effectiveness of PEMs to no intervention. Based on the RTs that provided moderate-certainty evidence, we found that PEMs distributed to healthcare professionals probably improve their practice, as measured with dichotomous variables, compared to no intervention (median absolute risk difference (ARD): 0.04; interquartile range (IQR): 0.01 to 0.09; 3,963 healthcare professionals randomised within 3073 units). We could not confirm this finding using the evidence gathered from continuous variables (standardised mean difference (SMD): 0.11; IQR: -0.16 to 0.52; 1631 healthcare professionals randomised within 1373 units ), from the ITS studies (standardised median change in slope = 0.69; 35 studies), or from the CBA study because the certainty of this evidence was very low. We also found, based on RTs that provided moderate-certainty evidence, that PEMs distributed to healthcare professionals probably make little or no difference to patient health as measured using dichotomous variables, compared to no intervention (ARD: 0.02; IQR: -0.005 to 0.09; 935,015 patients randomised within 959 units). The evidence gathered from continuous variables (SMD: 0.05; IQR: -0.12 to 0.09; 6,737 patients randomised within 594 units) or from ITS study results (standardised median change in slope = 1.12; 8 studies) do not strengthen these findings because the certainty of this evidence was very low. Two studies (a randomised trial and a CBA) compared a paper-based version to a computerised version of the same PEM. From the RT that provided evidence of low certainty, we found that PEM in computerised versions may make little or no difference to professionals' practice compared to PEM in printed versions (ARD: -0.02; IQR: -0.03 to 0.00; 139 healthcare professionals randomised individually). This finding was not strengthened by the CBA study that provided very low certainty evidence (SMD: 0.44; 32 healthcare professionals). The data gathered did not allow us to conclude which PEM characteristics influenced their effectiveness. The methodological quality of the included studies was variable. Half of the included RTs were at risk of selection bias. Most of the ITS studies were conducted retrospectively, without prespecifying the expected effect of the intervention, or acknowledging the presence of a secular trend.

AUTHORS' CONCLUSIONS

The results of this review suggest that, when used alone and compared to no intervention, PEMs may slightly improve healthcare professionals' practice outcomes and patient health outcomes. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

Implementation of study results in guidelines and adherence to guidelines in clinical practice

Guidelines were introduced in hospital- and practice-based otorhinolaryngology in the 1990ies, and have been undergoing further development ever since. There are currently 20 guidelines on file at the German Society of Oto-Rhino-Laryngology, Head & Neck Surgery. The society has cooperated in further 34 guidelines. The quality of the guidelines has been continuously improved by concrete specifications put forward by the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V., AWMF). Since increasing digitalization has made access to scientific publications quicker and simpler, relevant study results can be incorporated in guidelines more easily today than in the analog world. S2e and S3 guidelines must be based on a formal literature search with subsequent evaluation of the evidence. The consensus procedure for S2k guidelines is also regulated. However, the implementation of guidelines in routine medical practice must still be considered inadequate, and there is still a considerable need for improvement in adherence to these guidelines.

Strategies for reducing regional variation in the use of surgery: a systematic review

OBJECTIVE

To review the literature evaluating the effect of practice guidelines and decision aids on use of surgery and regional variation.

BACKGROUND

The use of surgical procedures varies widely across geographic regions. Although practice guidelines and decision aids have been promoted for reducing variation, their true effectiveness is uncertain.

METHODS

Studies evaluating the influence of clinical practice guidelines or consensus statements, shared decision making and decision aids, or provider feedback of comparative utilization, on rates of surgical procedures were identified through literature searches of Ovid MEDLINE, EMBASE, and Web of Science.

RESULTS

A total of 1946 studies were identified and 27 were included in the final review. Of the 12 studies evaluating implementation of guidelines, 6 reported a significant effect. Those examining overall population-based rates had mixed effects, but all studies evaluating procedure choice described at least a small increase in use of recommended therapy. Three of 5 studies examining the effect of guidelines on regional variation reported a significant reduction after dissemination. Of the 15 studies examining decision aids, 5 revealed significant effects. Many studies of decision aids reported decreases in population-based procedure rates. Nearly all studies evaluating the impact of decision aids on procedure choice reported increases in rates of less invasive procedures. Only one study of decision aids assessed changes in regional variation and found mixed results.

CONCLUSIONS

Both practice guidelines and decision aids have been proven effective in many clinical contexts. Expanding the clinical scope of these tools and eliminating barriers to implementation will be essential to further efforts directed toward reducing regional variation in the use of surgery.

Strategies to reduce variation in the use of surgery

Provision rates for surgery vary widely in relation to identifiable need, suggesting that reduction of this variation might be appropriate. The definition of unwarranted variation is difficult because the boundaries of acceptable practice are wide, and information about patient preference is lacking. Very little direct research evidence exists on the modification of variations in surgery rates, so inferences must be drawn from research on the alteration of overall rates. The available evidence has large gaps, which suggests that some proposed strategies produce only marginal change. Micro-level interventions target decision making that affects individuals, whereas macro-level interventions target health-care systems with the use of financial, regulatory, or incentivisation strategies. Financial and regulatory changes can have major effects on provision rates, but these effects are often complex and can include unintended adverse effects. The net effects of micro-level strategies (such as improvement of evidence and dissemination of evidence, and support for shared decision making) can be smaller, but better directed. Further research is needed to identify what level of variation in surgery rates is appropriate in a specific context, and how variation can be reduced where desirable.

National Institute for Clinical Excellence guidelines on the surgical management of otitis media with effusion: are they being followed and have they changed practice?

OBJECTIVE

UK National Institute of Clinical Excellence (NICE) guidelines on surgical management of otitis media with effusion (OME) in children call for an initial 3 month period of observation, with ventilation tube (VT) insertion considered for children with persistent bilateral OME with a hearing level in better ear of 25-30 dB HL or worse ("core criteria"), or for children not meeting those audiologic criteria but when OME has significant impact on developmental, social or educational status (exceptional circumstances). We aimed to establish whether guidelines are followed and whether they have changed clinical practice.

METHODS

Retrospective case-notes review in five different centres, analysing practice in accordance with guidelines in all children having first VT insertion before (July-December 06) and after (July-December 08) guidelines introduction.

RESULTS

Records of 319 children were studied, 173 before and 146 after guidelines introduction. There were no significant differences in practice according to guidelines before and after their introduction with respect to having 2 audiograms 3 months apart (57.8 vs. 54.8%), OME persisting at least 3 months (94.8 vs. 92.5%), or fulfilment of the 25 dB audiometric criteria (68.2 vs. 61.0%). Practice in accordance with the core criteria fell significantly from 43.9 to 32.2% (Chi squared p=0.032). However, if the exceptional cases were included there was no significant difference (85.5 vs. 87.0%), as the proportion of exceptional cases rose from 48.3 to 62.2% (Chi squared p=0.021).

CONCLUSION

This study shows that 87.0% of children have VTs inserted in accordance with NICE guidelines providing exceptional cases are included, but only 32.2% comply with the core criteria. A significant number have surgery due to the invoking of exceptional criteria, suggesting that clinicians are personalising the treatment to each individual child.

Printed educational materials: effects on professional practice and healthcare outcomes

BACKGROUND

Printed educational materials are widely used passive dissemination strategies to improve the quality of clinical practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines.

OBJECTIVES

To assess the effect of printed educational materials on the practice of healthcare professionals and patient health outcomes.To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on professional practice and patient outcomes.

SEARCH METHODS

For this update, search strategies were rewritten and substantially changed from those published in the original review in order to refocus the search from published material to printed material and to expand terminology describing printed materials. Given the significant changes, all databases were searched from start date to June 2011. We searched: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and the EPOC Register.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised trials, controlled before and after studies (CBAs) and interrupted time series (ITS) analyses that evaluated the impact of printed educational materials (PEMs) on healthcare professionals' practice or patient outcomes, or both. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. There was no language restriction. Any objective measure of professional practice (e.g. number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.

DATA COLLECTION AND ANALYSIS

Two review authors undertook data extraction independently, and any disagreement was resolved by discussion among the review authors. For analyses, the included studies were grouped according to study design, type of outcome (professional practice or patient outcome, continuous or dichotomous) and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where the data were available, we re-analysed the ITS studies and reported median differences in slope and in level for each outcome, across outcomes for each study, and then across studies. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format.

MAIN RESULTS

The review includes 45 studies: 14 RCTs and 31 ITS studies. Almost all the included studies (44/45) compared the effectiveness of PEM to no intervention. One single study compared paper-based PEM to the same document delivered on CD-ROM. Based on seven RCTs and 54 outcomes, the median absolute risk difference in categorical practice outcomes was 0.02 when PEMs were compared to no intervention (range from 0 to +0.11). Based on three RCTs and eight outcomes, the median improvement in standardised mean difference for continuous profession practice outcomes was 0.13 when PEMs were compared to no intervention (range from -0.16 to +0.36). Only two RCTs and two ITS studies reported patient outcomes. In addition, we re-analysed 54 outcomes from 25 ITS studies, using time series regression and observed statistically significant improvement in level or in slope in 27 outcomes. From the ITS studies, we calculated improvements in professional practice outcomes across studies after PEM dissemination (standardised median change in level = 1.69). From the data gathered, we could not comment on which PEM characteristic influenced their effectiveness.

AUTHORS' CONCLUSIONS

The results of this review suggest that when used alone and compared to no intervention, PEMs may have a small beneficial effect on professional practice outcomes. There is insufficient information to reliably estimate the effect of PEMs on patient outcomes, and clinical significance of the observed effect sizes is not known. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

Interventions to improve the use of systematic reviews in decision-making by health system managers, policy makers and clinicians

BACKGROUND

Systematic reviews provide a transparent and robust summary of existing research. However, health system managers, national and local policy makers and healthcare professionals can face several obstacles when attempting to utilise this evidence. These include constraints operating within the health system, dealing with a large volume of research evidence and difficulties in adapting evidence from systematic reviews so that it is locally relevant. In an attempt to increase the use of systematic review evidence in decision-making a number of interventions have been developed. These include summaries of systematic review evidence that are designed to improve the accessibility of the findings of systematic reviews (often referred to as information products) and changes to organisational structures, such as employing specialist groups to synthesise the evidence to inform local decision-making.

OBJECTIVES

To identify and assess the effects of information products based on the findings of systematic review evidence and organisational supports and processes designed to support the uptake of systematic review evidence by health system managers, policy makers and healthcare professionals.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, Web of Science, and Health Economic Evaluations Database. We also handsearched two journals (Implementation Science and Evidence and Policy), Cochrane Colloquium abstracts, websites of key organisations and reference lists of studies considered for inclusion. Searches were run from 1992 to March 2011 on all databases, an update search to March 2012 was run on MEDLINE only.

SELECTION CRITERIA

Randomised controlled trials (RCTs), interrupted time-series (ITS) and controlled before-after studies (CBA) of interventions designed to aid the use of systematic reviews in healthcare decision-making were considered.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed the study quality. We extracted the median value across similar outcomes for each study and reported the range of values for each median value. We calculated the median of the two middlemost values if an even number of outcomes were reported.

MAIN RESULTS

We included eight studies evaluating the effectiveness of different interventions designed to support the uptake of systematic review evidence. The overall quality of the evidence was very low to moderate.Two cluster RCTs evaluated the effectiveness of multifaceted interventions, which contained access to systematic reviews relevant to reproductive health, to change obstetric care; the high baseline performance in some of the key clinical indicators limited the findings of these studies. There were no statistically significant effects on clinical practice for all but one of the clinical indicators in selected obstetric units in Thailand (median effect size 4.2%, range -11.2% to 18.2%) and none in Mexico (median effect size 3.5%, range 0.1% to 19.0%). In the second cluster RCT there were no statistically significant differences in selected obstetric units in the UK (median effect RR 0.92; range RR 0.57 to RR 1.10). One RCT evaluated the perceived understanding and ease of use of summary of findings tables in Cochrane Reviews. The median effect of the differences in responses for the acceptability of including summary of findings tables in Cochrane Reviews versus not including them was 16%, range 1% to 28%. One RCT evaluated the effect of an analgesic league table, derived from systematic review evidence, and there was no statistically significant effect on self-reported pain. Only one RCT evaluated an organisational intervention (which included a knowledge broker, access to a repository of systematic reviews and provision of tailored messages), and reported no statistically significant difference in evidence informed programme planning.Three interrupted time series studies evaluated the dissemination of printed bulletins based on evidence from systematic reviews. A statistically significant reduction in the rates of surgery for glue ear in children under 10 years (mean annual decline of -10.1%; 95% CI -7.9 to -12.3) and in children under 15 years (quarterly reduction -0.044; 95% CI -0.080 to -0.011) was reported. The distribution to general practitioners of a bulletin on the treatment of depression was associated with a statistically significant lower prescribing rate each quarter than that predicted by the rates of prescribing observed before the distribution of the bulletin (8.2%; P = 0.005).

AUTHORS' CONCLUSIONS

Mass mailing a printed bulletin which summarises systematic review evidence may improve evidence-based practice when there is a single clear message, if the change is relatively simple to accomplish, and there is a growing awareness by users of the evidence that a change in practice is required. If the intention is to develop awareness and knowledge of systematic review evidence, and the skills for implementing this evidence, a multifaceted intervention that addresses each of these aims may be required, though there is insufficient evidence to support this approach.

What features of educational interventions lead to competence in aseptic insertion and maintenance of CV catheters in acute care? BEME Guide No. 15

BACKGROUND

Up to 6000 patients per year in England acquire a central venous catheter (CVC)-related bloodstream infection (Shapey et al. 2008 ). Implementation of Department of Health guidelines through educational interventions has resulted in significant and sustained reductions in CVC-related blood stream infections (Pronovost et al. 2002), and cost (Hu et al. 2004 ).

AIM

This review aimed to determine the features of structured educational interventions that impact on competence in aseptic insertion technique and maintenance of CV catheters by healthcare workers.

METHODS

We looked at changes in infection control behaviour of healthcare workers, and considered changes in service delivery and the clinical welfare of patients involved, provided they were related directly to the delivery method of the educational intervention.

RESULTS

A total of 9968 articles were reviewed, of which 47 articles met the inclusion criteria.

CONCLUSIONS

Findings suggest implications for practice: First, educational interventions appear to have the most prolonged and profound effect when used in conjunction with audit, feedback, and availability of new clinical supplies consistent with the content of the education provided. Second, educational interventions will have a greater impact if baseline compliance to best practice is low. Third, repeated sessions, fed into daily practice, using practical participation appear to have a small, additional effect on practice change when compared to education alone. Active involvement from healthcare staff, in conjunction with the provision of formal responsibilities and motivation for change, may change healthcare worker practice.

Overuse of tympanostomy tubes in New York metropolitan area: evidence from five hospital cohort

OBJECTIVES

To compare tympanostomy tube insertion for children with otitis media in 2002 with the recommendations of two sets of expert guidelines.

DESIGN

Retrospective cohort study.

SETTING

New York metropolitan area practices associated with five diverse hospitals.

PARTICIPANTS

682 of 1046 children who received tympanostomy tubes in the five hospitals for whom charts from the hospital, primary care physician, and otolaryngologist could be accessed.

RESULTS

The mean age was 3.8 years. On average, children with acute otitis media had fewer than four infections in the year before surgery. Children with otitis media with effusion had less than 30 consecutive days of effusion at the time of surgery. Concordance with recommendations was very low: 30.3% (n=207) of all tympanostomies were concordant with the explicit criteria developed for this study and 7.5% (n=13) with the 1994 guideline from the American Academy of Pediatrics, American Academy of Family Medicine, and American Academy of Otolaryngology-Head and Neck Surgery. Children who had previously had tympanostomy tube surgery, who were having a concomitant procedure, or who had "at risk conditions" were more likely to be discordant.

CONCLUSIONS

A significant majority of tympanostomy tube insertions in the largest and most populous metropolitan area in the United States were inappropriate according to the explicit criteria and not recommended according to both guidelines. Regardless of whether current practice represents a substantial overuse of surgery or the guidelines are overly restrictive, the persistent discrepancy between guidelines and practice cannot be good for children or for people interested in improving their health care.

Printed educational materials: effects on professional practice and health care outcomes

BACKGROUND

Printed educational materials (PEMs) are widely used passive dissemination strategies to improve knowledge, awareness, attitudes, skills, professional practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines and appear to be the most frequently adopted method for disseminating information.

OBJECTIVES

To determine the effectiveness of PEMs in improving process outcomes (including the behaviour of healthcare professionals) and patient outcomes. To explore whether the effect of characteristics of PEMs (e.g., source, content, format, mode of delivery, timing/frequency, complexity of targeted behaviour change) can influence process outcomes (including the behaviour of healthcare professionals and patient outcomes).

SEARCH STRATEGY

The following electronic databases were searched up to July 2006: (a) The EPOC Group Specialised Register (including the database of studies awaiting assessment (see 'Specialised Register'under 'Group Details'); (b) The Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness; (c) MEDLINE, EMBASE, CINAHL and CAB Health. An updated search of MEDLINE was done in March 2007.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) , controlled clinical trials (CCT), controlled before and after studies (CBAs) and interrupted time series analyses (ITS) that evaluated the impact of printed educational materials on healthcare professionals' practice and/or patient outcomes. There was no language restriction. Any objective measure of professional performance (sch as number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g., blood pressure, number of caesarean sections) were included.

DATA COLLECTION AND ANALYSIS

Four reviewers undertook data abstraction independently using a modified version of the EPOC data collection checklist. Any disagreement was resolved by discussion among the reviewers and arbitrators. Statistical analysis was based upon consideration of dichotomous process outcomes, continuous process outcomes, patient outcome dichotomous measures and patient outcome continuous measures. We presented the results for all comparisons using a standard method of presentation where possible. We reported separately for each study the median effect size for each type of outcome, and the median of these effect sizes across studies.

MAIN RESULTS

Twenty-three studies were included for this review. Evidence from this review showed that PEMs appear to have small beneficial effects on professional practice. RCTs comparing PEMs to no intervention observed an absolute risk difference median: +4.3% on categorical process outcomes (e.g., x-ray requests, prescribing and smoking cessation activities) (range -8.0% to +9.6%, 6 studies), and a relative risk difference +13.6% on continuous process outcomes (e.g., medication change, x-rays requests per practice) (range -5.0% to +26.6%, 4 studies). These findings are similar to those reported for the ITS studies, although significantly larger effect sizes were observed (relative risk difference range from 0.07% to 31%). In contrast, the median effect size was -4.3% for patient outcome categorical measures (e.g., screening, return to work, quit smoking) (range -0.4% to -4.6%, 3 studies)). Two studies reported deteriorations in continuous patient outcome data (e.g., depression score, smoking cessation attempts) of -10.0% and -20.5%. One study comparing PEMs with educational workshops observed minimal differences. Two studies comparing PEMs and education outreach did not have statistically significant differences between the groups. It was not possible to explore potential effect modifiers across studies.

AUTHORS' CONCLUSIONS

The results of this review suggest that when compared to no intervention, PEMs when used alone may have a beneficial effect on process outcomes but not on patient outcomes. Despite this wide of range of effects reported for PEMs, clinical significance of the observed effect sizes is not known. There is insufficient information about how to optimise educational materials. The effectiveness of educational materials compared to other interventions is uncertain.

A community based questionnaire study on the association between symptoms suggestive of otitis media with effusion, rhinitis and asthma in primary school children

OBJECTIVES

To evaluate the association between symptoms suggestive of otitis media with effusion (OME), rhinitis and asthma in an unselected population of primary school children and investigate whether our previous observation of such an association in a secondary care setting was valid in the community.

METHODOLOGY

A specifically designed questionnaire was administered to 332 new entrant primary school children across 11 state and independent primary schools in the East Berkshire district between March and June 1996. It had six sections, to ascertain symptoms suggestive of OME, rhinitis, asthma, other atopic features, treatment for any of these, and a possible family history of atopy. Within the first three sections, each question was scored and weighted depending on the importance of each in establishing the possible diagnoses, with three scoring bands: '0' indicating the absence; '1-5' the possibility and '> or =6' a strong likelihood that the above conditions were present. The outcome measures were the number of children with or without symptoms suggestive of OME, rhinitis, asthma, and the correlation of these symptom scores with each other and OME with eczema, other atopic manifestations, family history of atopy and educational system.

RESULTS

Thirty two point eight percent, thirty six point six percent and twenty four percent had symptoms suggestive of OME, rhinitis and asthma, respectively with scores of either 1-5 or > or =6. There was a highly significant correlation between otological (OME) and nasal scores (p=0.00000), particularly obstructive nasal symptoms (p=0.00000) and > or =6 upper respiratory tract infections/year (p=0.00000); otological and chest scores suggestive of asthma (p=0.00001), and a family history of asthma (p=0.00178). No association was found between scores for OME and eczema, urticaria, food or drug allergies. No differences were noted between the sexes or educational systems.

CONCLUSION

The highly significant association between the symptom scores suggestive of OME and rhinitis in this unselected population, indicates the importance of enquiring about nasal symptoms in children with chronic OME, as appropriate treatment of rhinitis may improve the child's quality of life, reduce health care utilisation and possibly reduce the need for OME surgery.

Audits can improve neurosurgical practice--illustrated by endoscopic third ventriculostomy

OBJECTIVE

A single-center, retrospective study was performed to evaluate the effect of audit on the patient selection for endoscopic third ventriculostomy (ETV).

MATERIALS AND METHODS

Between 01.01.99 and 07.31.01, 134 patients underwent ETV (group 1). During this period, there was no consensus within the neurosurgical community as to patient selection criteria for ETV. A review of our clinical practice in August 2001 demonstrated significantly lower ETV success rates for patients <6 months of age, patients with communicating hydrocephalus (HC) and for patients with prior shunt surgery. Thus, stricter patient selection criteria were established. Between 08.01.01 and 12.31.02, 54 patients were operated (group 2). The two groups were compared with respect to age, type of HC, previous shunt surgeries and ETV success rates. The primary outcome event was ETV malfunction, defined as symptoms and/or signs of increased intracranial pressure leading to repeat ETV or shunt implantation. Follow-up was done through outpatient clinics and telephone interviews. Average follow-up time was 12 months (range 0-44 months). No patient was lost to follow-up.

RESULTS

The overall 1-year ETV success rate in group 2 (65%) was significantly higher than in group 1 (53%) (p < 0.04). Group 2 had a significantly higher proportion of patients >6 months of age (p = 0.013) and with obstructive HC (p = 0.001).

CONCLUSION

Patient selection criteria critically affect the overall ETV success rate. An audit of our results led to a significant change in clinical practice, thereby improving the ETV success rates and patient care.

Increased rates of ENT surgery among young children: have clinical guidelines made a difference?

OBJECTIVES

To examine the association between introduction of paediatric ear, nose and throat (ENT) surgery guidelines and population procedure rates. To determine changes in children's risk of undergoing ENT surgery.

METHODS

Trend analysis of incidence of myringotomy, tonsillectomy and adenoidectomy among New South Wales (NSW) children aged 0-14 between 1981 and mid 1999. Poisson regression models were used to estimate annual rates of change pre and postguidelines introduction and age/gender specific rates, and lifetable methods to determine risk of undergoing an ENT procedure by age 15.

RESULTS

ENT surgery rates increased by 21% over the study period. Children's risk of surgery increased from 17.9% in 1981 to 20.2% in 1998/99. Guideline introduction was associated with moderate short-term decreases in rates. For tonsillectomy, rates decreased between 1981 and 1983, but then rose continually until the introduction of myringotomy guidelines in 1993, when they fell, only to recommence rising until the end of the study period. For myringotomy, rates rose annually from 1981 to 1992/93 and fell in the 3 years following guideline introduction, after which they rose again. Increases were almost exclusively restricted to children aged 0-4 and correspond with increased use of formal childcare. The prevalence of myringotomy by the age of 5 years rose from 5.6% of children born in 1988/89 to 6.4% of those born in 1994/95, and the prevalence of tonsillectomy from 2.4% to 2.7%.

CONCLUSIONS

The risk of young Australian children undergoing ENT surgery increased significantly over the last two decades despite the introduction of guidelines and no evidence of an increase in otitis media, one condition prompting surgery. Surgery increased most among the very young. We hypothesize this is related to increasing use of childcare.

Secondary use of personal data for health and health services research: why identifiable data are essential

Databases provide a powerful and essential resource for health and health services research. There are seven reasons why the identification of individuals may be needed: linkage within a database; linkage between databases; ensuring comparisons are meaningful; ensuring completeness of recruitment; investigation of social factors; analysis of trends over time; and assessing the applicability of primary research findings. Examples of recent British research studies for which identifiable data were essential are described to illustrate six research applications: to understand the natural history and development of disease; to identify causes of disease; to evaluate health care interventions; to assess equity of care; to describe trends in health care utilisation; and to ensure the methodological rigour of research. Given the benefits to the public of such research activities, methods need to be found to ensure the continuation of such research while meeting legitimate concerns about individual privacy and confidentiality.