Ethics committees and health services research

Ethics committees in Britain were set up to consider clinical research. Increasingly, however, they are receiving applications for health services research which often involves several or many centres. The performance of 23 ethics committees was examined through a case-study of an application for a multi-centre non-experimental study of prostatectomy. Although all the committees approved the study, long delays occurred (mean 11.5 weeks, range 3-32 weeks), particularly in teaching districts which dealt with large numbers of applications. The composition of the committee and the frequency with which it met were not associated with the time taken to reach a decision. Some delays might be reduced by improving the design of the application forms and ensuring that at least one member of the committee has an understanding of health services research methods. Although such measures might improve the performance of committees, applicants are likely to remain in a logistic trap between funding bodies, clinicians, and ethics committees. In addition, until committees temper their concern for individualistic medical ethics with a collective ethic of the common good, health services research may continue to experience delays and difficulties.

A regional computerised surgical audit project

This paper describes a computerised surgical audit project which has been developed in the North West Thames region of the British National Health Service. The need for such a project and the reasons for the approach adopted are explained. The key feature is the capacity both for local audit within hospitals and for global audit between hospitals. Progress with implementing the project is reported. The uses of global audit are described and possible future developments outlined.

Volume and outcome in hospital care: evidence, explanations and implications

The relationship between the volume of work undertaken in a hospital and the outcome of care has assumed increasing importance in recent years. A review of the literature reveals that most studies have been carried out in the USA and have largely been confined to six specific areas of health care. There is evidence that better outcomes are obtained at higher volumes for several surgical operations, cardiac catheterisation and care of the severely injured. As yet there is no clear association for coronary, neo-natal and burn care. There are two competing hypotheses to explain any association -- 'practice-makes-perfect' and 'selective referral'. These are discussed and implications for the future provision of hospital services considered.

The effectiveness of adenoidectomy in the treatment of glue ear: a randomized controlled trial

One hundred children with glue ear, in whom surgical treatment was indicated, were randomly allocated to 1 of 4 treatment groups. Children in 2 of the groups underwent adenoidectomy plus various combinations of ear operations while in the other 2 groups surgery was confined to the ears. The effect of adenoidectomy was assessed 6 weeks, 6 months and 1 year after surgery by means of audiometry, impedance tympanometry and parental opinion. Improvements in hearing were greater in those children who underwent an adenoidectomy than in those who did not (4.0 dB at 6 weeks; 2.4 dB at 6 months; 0.7 dB at 1 year). However, these differences are of little clinical significance and were only statistically significant (P less than 0.05) 6 weeks after surgery. Middle ear function, measured by tympanometry, revealed a similar pattern of response to treatment. Despite this, 6 months after surgery a higher proportion of parents were satisfied with their child's condition if an adenoidectomy had been performed. Possible explanations of this discrepancy between clinical and parental assessments of outcome are discussed.

The 'health culture' of families as an influence on the use of surgery for glue ear: a case-control study

The influence of elements of a family's health culture (its health beliefs, attitudes and behaviour) on the decision for children to undergo surgery for glue ear was investigated by means of a case-control study. One hundred and forty-two children who had undergone such surgery were compared with the same number of children from their school class. Data derived from a structured questionnaire administered to the parents in their own homes revealed that the families were similar with regard to most biosocial factors. However, there were clear differences in the labelling of middle ear disease. Children in case families were more likely to be diagnosed as suffering from glue ear rather than recurrent acute otitis media, particularly if an older sibling of the same sex had previously been so diagnosed (for boys RR 6.68; for girls RR 4.55). This influence of the family's health culture was supported by the findings that parents tended to view their children as having presented more developmental problems; and to be more conscious themselves of health promoting activities. Further studies employing different methodologies are required to confirm these findings.

Causes of glue ear. An historical review of theories and evidence

Over the past one hundred years medical views on the cause of glue ear have frequently changed. The medical literature was reviewed to see if these changes reflected advances in the level of scientific support for different causes. This revealed that only a few of the many proposed causes command any scientific support. An explanation for the changing pattern of views on the aetiology of glue ear was therefore sought by considering secular changes in medical knowledge and belief in general. This suggested that the views held on the cause of glue ear at any given time are influenced and largely determined by the prevailing knowledge and beliefs of medicine as a whole. This phenomenon is not peculiar to glue ear--though conditions about which there is considerable uncertainty are probably more susceptible to such influences.

Geographical variations in use of surgery for glue ear

Study of geographical variations in the rate of surgery for glue ear reveals striking differences both between English health regions and between health districts. There are two-fold differences between regions and up to seven-fold differences between districts. Analysis of these differences at different levels of population aggregation reveals that professional uncertainty about the indications and value of surgery for this condition is the major factor responsible. In addition, the availability of otolaryngologists influences the surgical rate at district though not at regional level. The method used in this study is unable to determine the part played by geographical variation in patient expectation and morbidity rate. In contrast to the lack of consensus among otolaryngologists regarding the use of surgery for glue ear, there appears to be a high degree of agreement as regards tonsillectomy. The latter has coincided with the end of the decline in the tonsillectomy rate in the late 1970s.

The aetiology of glue ear--a case-control study

A case-control study was carried out to investigate many of the proposed causes of glue ear in childhood. One hundred and fifty cases with two matched controls were found to be remarkably similar in nearly all medical and social aspects of their past and present lives, thus providing no support for many of the currently held views on the aetiology of glue ear. Of the 5 factors which were found to increase the risk of a child undergoing surgery for glue ear, only one of these is thought to be related to the development of the condition, rather than to the chances of its detection. This factor was parental smoking (RR 1.64). The 4 other risk factors appear to influence the chance of glue ear being detected, diagnosed and referred for surgical treatment - the child's mother being employed outside the home, but only if the father is employed in non-manual work (RR 3.0); attending pre-school day-care (RR 2.00); having an older sibling who had been diagnosed as suffering from glue ear (RR 1.84); and having been born locally (in Oxfordshire) (RR 1.89). Possible explanations for these social and behavioural factors are discussed.

Glue ear: the new dyslexia?

Several factors have led to the current epidemic of surgery for glue ear in children, including the widespread introduction of audiometry; greater recognition of the presence of fluid in the middle ear by general practitioners; the availability of more otolaryngologists; and technical advances such as the availability of antibiotics to treat postoperative infections and of flanged tympanostomy tubes (grommets). The need of surgeons to fill the vacuum caused by the decline in the number of adenotonsillectomies, and the fact that a diagnosis of glue ear legitimises the continued use of these operations, may also have contributed to the increase. Finally, glue ear may provide parents with a medical explanation of their children's poor educational performance, as the term dyslexia did in the past. The high social and public costs of this operation demand a reappraisal of its increasing use.

Surgery for glue ear--a modern epidemic

Analysis of routine hospital statistics confirms anecdotal reports of an epidemic of surgery for glue ear. The surgical rate rose by 74% in Oxford Region between 1975 and 1981. The peak ages for surgery are 5-7 years, and the rates are higher in boys than in girls (1.4:1.00). The relative risk is high in social class I (1.16) and low in social class V (0.61). Although the prevalence of glue ear is hard to ascertain, the current surgical epidemic probably reflects an increase in apparent prevalence rather than a real increase in morbidity.