Improving the quality of communicable disease control: the example of meningococcal disease

Improving the quality of health services is central to current attempts to reform the National Health Service. The main approaches to quality improvement in communicable disease control to date have been the development of practice guidelines and audit projects. Descriptions of the impact of quality initiatives in public health generally and communicable disease in particular have been limited, objective measures of quality are rare and few reports outline improvements that have been achieved in practice. We describe a project to develop a set of quality indicators for meningococcal disease control. A set of candidate indicators was developed and screened using standard approaches based on local consensus. We outline how they could be further tested and used to promote quality improvement.

The performance of the Rose angina questionnaire in South Asian and European origin populations: a comparative study in Newcastle, UK

BACKGROUND

The Rose angina questionnaire has been extensively used in different cultural settings, but may not perform consistently in different ethnic groups. We set out to assess the performance of the Rose angina questionnaire in UK South Asians compared with Europeans.

METHODS

Data on major ECG abnormalities, possible or definite Rose questionnaire angina and diagnosed angina were collected from an age- and sex-stratified random sample of 1509 adults from European, Indian, Pakistani and Bangladeshi ethnic groups.

RESULTS

The ECG abnormalities were commoner in South Asians than Europeans (6% versus 2% in men). The prevalence in both South Asian and European men of possible Rose angina and diagnosed angina was 18% and 8%, respectively, but definite Rose angina was less common in South Asians (3% versus 6%). Definite Rose angina showed lower sensitivity for other measures in South Asians than in Europeans: sensitivity for a doctor's diagnosis was 21% in South Asian and 37% in European men. For possible Rose angina, the corresponding figures were 81% and 84%. Similar patterns were seen in women.

CONCLUSIONS

The performance of the Rose angina questionnaire was sufficiently inconsistent to warrant further work to achieve greater cross-cultural validity. Possible Rose angina performed more consistently across ethnic groups than definite Rose angina and pending further validation studies may be the most appropriate form to use.

Use of a journal club and letter-writing exercise to teach critical appraisal to medical undergraduates

INTRODUCTION

There is growing interest in methods of teaching critical appraisal skills at undergraduate and postgraduate levels. We describe an approach using a journal club and subsequent letter writing to teach critical appraisal and writing skills to medical undergraduates.

METHODS

The exercise occurs during a 3-week public health medicine attachment in the third year of the undergraduate curriculum. Students work in small groups to appraise a recently published research paper, present their findings to their peers in a journal club, and draft a letter to the journal editor. Evaluation took place through: informal and formal feedback from students; number of letters written, submitted and published, and a comparison of marks obtained by students submitting a literature review assignment with and without critical appraisal teaching during the public health attachment.

RESULTS

Feedback from students was overwhelmingly positive. In the first 3(1/2) years, 26 letters have been published or accepted for publication, and 58 letters published on the Internet. There were no significant differences in overall marks or marks for the critical appraisal component of the literature review assignments between the two student groups.

DISCUSSION

We believe our approach is an innovative and enjoyable method for teaching critical appraisal and writing skills to medical students. Lack of difference in marks in the literature review between the student groups may reflect its insensitivity as an outcome measure, contamination by other critical appraisal teaching, or true ineffectiveness.

Impact of laparoscopic cholecystectomy: a population-based study

BACKGROUND

We assessed the effect of the introduction of laparoscopic cholecystectomy on surgical outcomes in routine practice.

METHODS

Hospital discharge and death-certificate data were linked for all patients undergoing cholecystectomy (n=85120) in Scottish public-sector hospitals (n=51) between January, 1981, and June, 1999. The primary endpoints were cholecystectomy rate, hospital stay, and postoperative mortality. Regression methods were used to examine the effect of laparoscopic experience and surgeon caseload on postoperative mortality and hospital stay.

FINDINGS

From 1989 to 1999, the proportion of cholecystectomies done laparoscopically rose from none to 80%, and the age-standardised cholecystectomy rate increased by 20% (95% CI 15-26). Postoperative mortality did not change in the 1990s (odds ratio 0.99 [0.7-1.4], p=0.99). The mean postoperative hospital stay fell from 8.0 (SD 3.7) to 2.9 (3.2) days. There was wide variation between hospitals in the proportion of cholecystectomies done laparoscopically and in average hospital stay. For individual surgeons, increasing laparoscopic experience and annual caseload were associated with higher proportions of laparoscopic procedures and shorter hospital stays. Postoperative mortality was higher during the first ten laparoscopic cholecystectomies done by a surgeon (compared with >200 procedures, odds ratio 2.3 [1.2-4.6], p=0.015).

INTERPRETATION

The laparoscopic method reduced hospital stay but had no overall effect on postoperative mortality. Studies to assess the appropriateness of the increased cholecystectomy rate are merited. The wide variation in the proportion done laparoscopically, together with evidence of better results for surgeons doing more procedures, suggests scope for further reductions in hospital stay and morbidity.

An exploratory population-based case-control study of primary biliary cirrhosis

Primary biliary cirrhosis (PBC) is a disease of unknown etiology, with unexplained geographical variation. Various exposures have been suggested as triggers for disease development-possibly in susceptible individuals, but the evidence was not always well founded. We therefore conducted a population-based case-control study in Northeast England to investigate these and other exposures. All cases incident during 1993 to 1995 in a defined area of Northeast England were identified, and age- and sex-matched population controls were identified from primary care population registers. Cases and controls were sent postal self-completion questionnaires covering medical history and lifestyle. Information was received from 100 cases and 223 controls. The familial tendency of PBC was found to be less marked than has been claimed: Only weak associations were found with other autoimmune diseases. Among factors considered previously, no significant associations were found with surgical procedures, events in pregnancy, past infections, vaccinations, and medications. No significant associations were found for previously unconsidered lifestyle factors (drinking alcohol, previous pets, or stressful events), but there was an unexpected association with past smoking (ever smoked: 76% in cases vs. 57% in controls, odds ratio 2.4; smoked for 20 years or more: 64% vs. 35%, odds ratio 3.5). There were also unexpected significant associations with psoriasis (13% in cases vs. 3% in controls, odds ratio 4.6) and eczema (3% in cases vs. 11% in controls, odds ratio 0. 13). These findings merit further investigation.

Non-invasive blood glucose monitoring by means of near infrared spectroscopy: methods for improving the reliability of the calibration models

The feasibility of using near infrared reflection spectroscopy for non-invasive blood glucose monitoring is discussed. Spectra were obtained using a diode-array spectrometer with a fiberoptic measuring head with a wavelength ranging from 800 nm to 1350 nm. Calibration was performed using partial least-squares regression and radial basis function networks. The results of different methods used to evaluate the quality of the recorded spectra in order to improve the reliability of the calibration models, are presented.

Varicella and life-threatening streptococcal infection

Four children with varicella who subsequently developed life-threatening infection with Streptococcus pyogenes are reported. The need for increased awareness of this potentially lethal complication of what is usually a benign exanthem is stressed.