Guideline registries and libraries: a mixed-methods approach identified issues to be addressed with content: Guideline registries and libraries must address the tension between comprehensiveness, quality assurance and ease of use

OBJECTIVE

To establish what GIN guideline community members see as the desirable features of a guidelines library and registry of guidelines in development Study Design and Setting: An explorative mixed-methods study was undertaken, including scoping activity and semi-structured interviews with guideline developers and endorsers from nine member organisations of the Guidelines International Network.

RESULTS

A small number of desirable features of a guideline library were identified: comprehensiveness; single source of information to avoid searching multiple sites; inclusion of related materials; being up to date; searchability and ease of use. No existing library of guidelines was considered to have all of these features. A number of issues arose out of the desire to have a comprehensive library of guidelines, including inclusion of 'high quality guidelines' and limiting the scope to include only national guidelines. For registries of guidelines in development, the data set should be limited to avoid placing undue burden on those entering information.

CONCLUSION

Our findings identify ongoing issues for the guideline community, including the tension between comprehensiveness and ease of use, which can result in limited uptake, reporting of guideline quality and the need for clarity on the purpose of any library or registry.

Screening for thrombophilia in high-risk situations: systematic review and cost-effectiveness analysis. The Thrombosis: Risk and Economic Assessment of Thrombophilia Screening (TREATS) study

OBJECTIVES

To assess the risk of clinical complications associated with thrombophilia in three high-risk patient groups: women using oral oestrogen preparations, women during pregnancy and patients undergoing major orthopaedic surgery. To assess the effectiveness of prophylactic treatments in preventing venous thromboembolism (VTE) and adverse pregnancy outcomes in women with thrombophilia during pregnancy and VTE in patients with thrombophilia, undergoing major orthopaedic surgery. To evaluate the relative cost-effectiveness of universal and selective VTE history-based screening for thrombophilia compared with no screening in the three high-risk patient groups.

DATA SOURCES

Electronic databases including MEDLINE, EMBASE, and four other major databases were searched up to June 2003.

REVIEW METHODS

In order to assess the risk of clinical complications associated with thrombophilia, a systematic review of the literature on VTE and thrombophilia in women using oral oestrogen preparations and patients undergoing major orthopaedic surgery; and studies of VTE and adverse obstetric complications in women with thrombophilia during pregnancy was carried out. Meta-analysis was used to calculate pooled odds ratios (ORs) associated with individual clinical outcomes, stratified by thrombophilia type and were calculated for each patient group. To assess the effectiveness of prophylaxis, a systematic review was carried out on the use of prophylaxis in the prevention of VTE and pregnancy loss in pregnant women with thrombophilic defects and the use of thromboprophylaxis in the prevention of VTE in patients with thrombophilia undergoing major elective orthopaedic surgery. Relevant data were summarised according to the patient groups and stratified according to the types of prophylaxis. A narrative summary was provided; where appropriate, meta-analysis was conducted. An incremental cost-effectiveness analysis was then carried out, from the perspective of the NHS in the UK. A decision analytical model was developed to simulate the clinical consequences of four thrombophilia screening scenarios. Results from the meta-analyses, information from the literature and results of two Delphi studies of clinical management of VTE and adverse pregnancy complications were incorporated into the model. Only direct health service costs were measured and unit costs for all healthcare resources used were obtained from routinely collected data and the literature. Cost-effectiveness was expressed as incremental cost-effectiveness ratios (ICERs); an estimate of the cost per adverse clinical complication prevented, comparing screening with no screening, were calculated for each patient group.

RESULTS

In the review of risk of clinical complications, 81 studies were included, nine for oral oestrogen preparations, 72 for pregnancy and eight for orthopaedic surgery. For oral contraceptive use, significant associations of the risk of VTE were found in women with factor V Leiden (FVL); deficiencies of antithrombin, protein C, or protein S, elevated levels of factor VIIIc; and FVL and prothrombin G20210A. For hormone replacement therapy (HRT), a significant association was found in women with FVL. The highest risk in pregnancy was found for FVL and VTE, in particular, homozygous carriers of this mutation are 34 times more likely to develop VTE in pregnancy than non-carriers. Significant risks for individual thrombophilic defects were also established for early, recurrent and late pregnancy loss; preeclampsia; placental abruption; and intrauterine growth restriction. Significant associations were found between FVL and high factor VIIIc and postoperative VTE following elective hip or knee replacement surgery. Prothrombin G20210A was significantly associated with postoperative pulmonary embolism. However, antithrombin deficiency, MTHFR and hyperhomocysteinaemia were not associated with increased risk of postoperative VTE. In the review of the effectiveness of prophylaxis, based on available data from eight studies, low-dose aspirin and heparin was found to be the most effective in preventing pregnancy loss in thrombophilic women during pregnancy, while aspirin alone was the most effective in preventing minor bleeding. All the studies on thrombophilia and major elective orthopaedic surgery included in the review of risk complications were also used in the review of the effectiveness of thromboprophylaxis. However, there were insufficient data to determine the relative effectiveness of different thromboprophylaxis in preventing VTE in this patient group. For the cost-effectiveness analysis, of all the patient groups evaluated, universal screening of women prior to prescribing HRT was the most cost-effective (ICER pound6824). In contrast, universal screening of women prior to prescribing combined oral contraceptives was the least cost-effective strategy (ICER pound202,402). Selective thrombophilia screening based on previous personal and/or family history of VTE was more cost-effective than universal screening in all the patient groups evaluated.

CONCLUSIONS

Thrombophilia is associated with increased risks of VTE in women taking oral oestrogen preparations and patients undergoing major elective orthopaedic surgery, and of VTE and adverse pregnancy outcomes in women with thrombophilia during pregnancy. There is considerable difference in the magnitude of the risks among different patient groups with different thrombophilic defects. In women who are on combined oral contraceptives, the OR of VTE among those who are carriers of the FVL mutation was 15.62 (95% confidence interval 8.66 to 28.15). However, in view of the prevalence of thrombophilia and the low prevalence of VTE in non-users of combined oral contraceptives, the absolute risk remains low. Significant risks for VTE and adverse pregnancy outcomes have been established with individual thrombophilic defects. Thrombophilic defects including FVL, high plasma factor VIIIc levels and prothrombin G20210A are associated with the occurrence of postoperative VTE in elective hip or knee replacement therapy. These associations are observed in patients who were given preoperative thromboprophylaxis and are, therefore, of clinical significance. Universal thrombophilia screening in women prior to prescribing oral oestrogen preparations, in women during pregnancy and in patients undergoing major orthopaedic surgery is not supported by current evidence. The findings from this study show that selective screening based on prior VTE history is more cost-effective than universal screening. Large prospective studies should be undertaken to refine the risks and establish the associations of thrombophilias with VTE among hormone users and in patients undergoing orthopaedic surgery. The relative value of a thrombophilia screening programme to other healthcare programmes needs to be established.

Thrombophilia in pregnancy: a systematic review

Growing evidence suggests that thrombophilia is associated with venous thromboembolism (VTE) and adverse pregnancy outcomes. However, methodological limitations have made it difficult to obtain a clear overview of the overall risks. We conducted a systematic review to determine the risk of VTE and adverse pregnancy outcomes associated with thrombophilia in pregnancy. The effectiveness of prophylactic interventions during pregnancy was also evaluated. Major electronic databases were searched, relevant data abstracted and study quality assessed by two independent reviewers. Odds ratios (ORs) stratified by thrombophilia type were calculated for each outcome. A total of 79 studies were included in our review. The risks for individual thrombophilic defects were determined for VTE (ORs, 0.74-34.40); early pregnancy loss (ORs, 1.40-6.25); late pregnancy loss (ORs, 1.31-20.09); pre-eclampsia (ORs, 1.37-3.49); placental abruption (ORs, 1.42-7.71) and intrauterine growth restriction (ORs, 1.24-2.92). Low-dose aspirin plus heparin was the most effective in preventing pregnancy loss in thrombophilic women (OR, 1.62). Our findings confirm that women with thrombophilia are at risk of developing VTE and complications in pregnancy. However, despite the increase in relative risk, the absolute risk of VTE and adverse outcomes remains low. There is also a lack of controlled trials of antithrombotic intervention to prevent pregnancy complications. Thus, at present, universal screening for thrombophilia in pregnancy cannot be justified clinically.

Clinical practice guidelines

This paper introduces the concepts of evidence-based clinical practice guidelines. It describes the key elements of guideline development, using examples from the Scottish Intercollegiate Guidelines Network (SIGN), and then goes on to discuss how practitioners in Singapore and other countries can find and use guidelines from other areas of the world. It concludes with a short section on the future direction of guideline development.

An economic analysis of surgical wound infection

Audit of surgical wound infection is not only an outcome indicator, but also an important aspect of infection control. The literature suggests an expensive 'gold standard' involving a full-time audit nurse collecting prospective data, including a 30-day follow-up into the community.Our study indicates that the cost of surgical wound infection is three-fold: cost to the hospital, the community services and the patient. Although the greatest costs were due to prolonged stay or re-admission to hospital (just under pound90 000), costs to the community and patient cannot be ignored. Hospital expenditure varied according to the type of operation. The study clearly demonstrated the potential cost savings to be highlighted by this type of audit.

Pragmatic randomised controlled trial to evaluate guidelines for the management of infertility across the primary care-secondary care interface

OBJECTIVE

To investigate the effect of clinical guidelines on the management of infertility across the primary care-secondary care interface.

DESIGN

Cluster randomised controlled trial.

SETTING

General practices and NHS hospitals accepting referrals for infertility in the Greater Glasgow Health Board area.

PARTICIPANTS

All 221 general practices in Glasgow; 214 completed the trial.

INTERVENTION

General practices in the intervention arm received clinical guidelines developed locally. Control practices received them one year later. Dissemination of the guidelines included educational meetings.

MAIN OUTCOME MEASURES

The time from presentation to referral, investigations completed in general practice, the number and content of visits as a hospital outpatient, the time to reach a management plan, and costs for referrals from the two groups.

RESULTS

Data on 689 referrals were collected. No significant difference was found in referral rates for infertility. Fewer than 1% of couples were referred inappropriately early. Referrals from intervention practices were significantly more likely to have all relevant investigations carried out (odds ratio 1.32, 95% confidence interval 1.00 to 1.75, P=0.025). 70% of measurements of serum progesterone concentrations during the midluteal phase and 34% of semen analyses were repeated at least once in hospital, despite having been recorded as normal when checked in general practice. No difference was found in the proportion of referrals in which a management plan was reached within one year or in the mean duration between first appointment and date of management plan. NHS costs were not significantly affected.

CONCLUSIONS

Dissemination of infertility guidelines by commonly used methods results in a modest increase in referrals having recommended investigations completed in general practice, but there are no detectable differences in outcome for patients or reduction in costs. Clinicians in secondary care tended to fail to respond to changes in referral practice by doctors. Guidelines that aim to improve the referral process need to be disseminated and implemented so as to lead to changes in both primary care and secondary care.

A randomised comparison and economic evaluation of laparoscopic-assisted hysterectomy and abdominal hysterectomy

OBJECTIVES

To determine the safety, cost effectiveness and effect on quality of life of laparoscopic-assisted vaginal hysterectomy (LAVH) compared with total abdominal hysterectomy (TAH) in the management of benign gynaecological disease.

DESIGN

Randomised controlled trial and economic evaluation.

SETTING

Three hospitals in the West of Scotland.

PARTICIPANTS

Two hundred women scheduled for an abdominal hysterectomy for benign gynaecological disease.

MAIN OUTCOME MEASURES

Conversion rate of LAVH to TAH, complication rates, NHS resource use and costs, quality of life using EuroQol 5 D visual analogue scale, and achievement of milestones.

RESULTS

The overall incidence of operative complications was 14% in the TAH group and 8% in the LAVH group, with an 8% conversion rate. Length of operation was significantly greater in the women having LAVH at 81 +/- 30 min vs 47 +/- 16 min (P < 0.001). There was no difference in analgesic requirements between the groups although there was a significantly shorter hospital stay for those having LAVH. The rate of post-surgery recovery, satisfaction with operation and quality of life at four weeks post-operative were similar in the two groups of women. LAVH was significantly more expensive than TAH and remained more expensive for all but the most extreme scenario.

CONCLUSIONS

This study demonstrates that despite the decreased length of hospital stay, LAVH is more expensive than TAH. In addition, recovery following operation and patient satisfaction were not affected by the route chosen. It is unlikely that LAVH represents an efficient use of NHS resources.

Evaluation of a nurse-led continence service in the south-west of Glasgow, Scotland

This paper reports the results of a pilot study of a nurse-led continence promotion service in both the community and a local nursing home. Telephone and written referrals were made to the service from 28 primary care teams in Glasgow, Scotland. In the nursing home all patients were assessed and an appropriate management plan implemented. A full assessment was carried out in all community patients, including an appraisal of contributory factors, urinalysis and diaries of food and drink intake. A management plan suited to the patient was then implemented. Patients' levels of incontinence in both arms of the study were assessed objectively using the Lagro-Janssen method. The cost incurred in both arms of the study were measured. There was a 69% improvement in the level of incontinence in the community group compared with 30% in the residents wing and 13% in the hospital wing. The savings in the nursing home amounted to Pounds 4152 in the residents' wing and Pounds 1959 in the hospital wing. In summary, a nurse dedicated to urinary incontinence in the community allows improved management, a greater level of awareness and results in resource savings, whilst increasing patient accessibility to a service.

Randomised, controlled trial of efficacy of midwife-managed care

BACKGROUND

Midwife-managed programmes of care are being widely implemented although there has been little investigation of their efficacy. We have compared midwife-managed care with shared care (ie, care divided among midwives, hospital doctors, and general practitioners) in terms of clinical efficacy and women's satisfaction.

METHODS

We carried out a randomised controlled trial of 1299 pregnant women who had no adverse characteristics at booking (consent rate 81.9%). 648 women were assigned midwife-managed care and 651 shared care. The research hypothesis was that compared with shared care, midwife-managed care would produce fewer interventions, similar (or more favourable) outcomes, similar complications, and greater satisfaction with care. Data were collected by retrospective review of case records and self-report questionnaires. Analysis was by intention to treat.

FINDINGS

Interventions were similar in the two groups or lower with midwife-managed care. For example, women in the midwife-managed group were less likely than women in shared care to have induction of labour (146 [23.9%] vs 199 [33.3%]; 95% CI for difference 4.4-14.5). Women in the midwife-managed group were more likely to have an intact perineum and less likely to have had an episiotomy (p = 0.02), with no significant difference in perineal tears. Complication rates were similar. Overall, 32.8% of women were permanently transferred from midwife-managed care (28.7% for clinical reasons, 3.7% for non-clinical reasons). Women in both groups reported satisfaction with their care but the midwife-managed group were significantly more satisfied with their antenatal (difference in mean scores 0.48 [95% CI 0.41-0.55]), intrapartum (0.28 [0.18-0.37]), hospital-based postnatal care (0.57 [0.45-0.70]), and home-based postnatal care (0.33 [0.25-0.42]).

INTERPRETATION

We conclude that midwife-managed care for healthy women, integrated within existing services, is clinically effective and enhances women's satisfaction with maternity care.

Programme budgeting and marginal analysis: application within programmes to assist purchasing in Greater Glasgow Health Board

Recent NHS policy statements advocate the use of 'knowledge-based' purchasing. This paper describes an attempt to use an economic method to inform the purchasing process. The approach of programme budgeting and marginal analysis (PBMA) offers information on current service provision and provides a framework in which changes in a service can be evaluated and agreed within the context of a fixed budget. This has been applied to gynaecology services in Greater Glasgow Health Board and, following positive reaction to the results of this exercise, is now being extended into other areas. The process of carrying out the exercise is described. Additionally, limitations of the approach and the advantages of using PBMA in achieving knowledge-based purchasing are discussed.

Day care for women with high-risk pregnancies

This report describes a study carried out at Glasgow Royal Maternity Hospital which examined women's perceptions of the care they received for hypertension during pregnancy at a day care unit. Thirty women were asked about the advantages and disadvantages of day care. Additionally, they were asked to assess how often they would be willing to attend day care each week, to avoid a seven-day admission. The overwhelming view of day care was positive. None of the women would rather be an in-patient than attend day care, and the majority would attend day care five times a week to avoid admission. Information of this type is of use to staff in such units, since it is very important that women with complications during pregnancy are confident about the care they are receiving.

Moving towards a common understanding in maternity services

There is a need to ensure that there is a common understanding of what is meant by the terminology surrounding the organisation and provision of maternity services. This is especially important with the development of purchaser/provider contracts in the National Health Service (NHS) in the UK. It is vitally important that terms specified in contracts are not ambiguous. It is also important that practitioners and researchers are working from a common base. Information on local definitions used in Scottish health boards was obtained through questionnaires sent to Heads of Midwifery Services in consultant units. The findings show that for some terms the definitions were fairly standard, but for others there were considerable differences in how the terms were interpreted. In light of these differences, and given the necessity for clearly defined terms within the new NHS, professionally agreed definitions were produced by the Royal College of Midwives. It is recommended that these definitions be adopted as standard by relevant individuals and groups.

An evaluation of postnatal care individualised to the needs of the woman

Traditionally, in Scotland women have been visited daily in their own home until the 10th postnatal day. There has been concern about the ability of such a service to offer continuity of care. A 'before and after' study was undertaken at Glasgow Royal Maternity Hospital to assess the effects of introducing individualised postnatal care. In the first stage information was collected on 106 women to obtain baseline information. In the second stage information was collected on 114 women who had experienced individualised care. The women in the two stages were not significantly different in terms of age, parity, mode of delivery and problems encountered. The average number of midwives visiting during the postnatal period fell from 3.7 to 2.5 and the average number of visits fell from 6.5 to 5.7 visits. Both forms of care, standard and individualised, were popular with women, but the proportion who felt a daily visit necessary dropped significantly. Continuity of care was improved with individualising care to the needs of the woman and women were satisfied with this type of care. The change is likely to be cost effective, since a higher quality of care can be provided for the same, or slightly less cost.

An economic evaluation of daycare in the management of hypertension in pregnancy

OBJECTIVE

To evaluate the efficiency of daycare in the management of hypertension in pregnancy compared with inpatient management with prior domiciliary visits.

DESIGN

Comparative study.

SETTING

Two maternity teaching hospitals, Glasgow Royal Maternity Hospital which has an established daycare unit and Aberdeen Maternity Hospital with no daycare unit.

MAIN OUTCOME MEASURES

Pregnancy outcomes in terms of maternal hypertensive complications, gestation at delivery, mode of delivery, birthweight, Apgar scores, admission rates and length of admission to special care baby unit.

RESULTS

There was no significant difference in any of the measured pregnancy outcomes between the two hospitals. The average cost of treating a women with mild hypertension was 154.91 pounds in Glasgow and 136.59 pounds in Aberdeen. The average cost of treating women with a single episode of hypertension and women with a past history of hypertension was 88.65 pounds and 214.12 pounds in Glasgow and 31.18 pounds and 28.28 pounds in Aberdeen, respectively. If these two groups are excluded, the average cost of treating women with mild hypertension was 172.32 pounds in Glasgow and 201.13 pounds in Aberdeen. The majority of women were willing to attend daycare five times per week to avoid admission.

CONCLUSION

Daycare management of hypertension in pregnancy is more efficient than inpatient care with prior domiciliary visits for most women, but less efficient for women with transient or previous hypertension. It is very acceptable to women. Domiciliary checking of women with hypertension found at outpatient clinics would reduce resource use.

Screening and surveillance of pregnancy hypertension--an economic approach to the use of daycare

Frequent measurement of blood pressure is an accepted part of routine outpatient antenatal care. Women found to have mild hypertension may be further monitored for signs of progressive disease, while women with proteinuria or severe hypertension may be admitted for more intensive surveillance or treatment. In practice, the course and ultimate severity of this disorder are unpredictable and women with mild hypertension are frequently admitted. Recently, daycare has grown as an option for assessing women with hypertension as it offers the advantage of more extensive evaluation than is possible at an outpatient clinic and is widely assumed to be more cost-effective than conventional management. However, its use in obstetrics has not been subject to a formal economic appraisal. Such an evaluation is currently being carried out in two hospitals in Scotland, one of which uses daycare and inpatient admissions in the management of hypertension and one of which uses domiciliary midwife visits as well as hospital beds. Preliminary results suggest that the pregnancy outcome in terms of birthweight, gestation at delivery, admission to a special unit, etc., are the same in the two units for women with mild hypertension (diastolic 90-99 mmHg, no proteinuria). The costs per patient were less in the hospital with a daycare unit. These lower individual costs, however, do not mean that the overall costs to the health service are less in a hospital with daycare. This will depend on the average number of visits to daycare for women with mild hypertension, the proportion of hypertensive women receiving daycare, whether freed inpatient beds are closed or redeployed, and the capital costs of establishing a day unit. Data has also been collected on women's costs and views which will ultimately be presented and should play a part in any decision to implement or continue daycare.