A co-designed evaluation study to identify Breastfeeding Knowledge of General Practitioners' and Practice Nurses'

The World Health Organization and American Academy of Paediatrics recommend exclusive breastfeeding until 6 months of age, with continued breastfeeding along with complementary solid foods for up to 2 years and beyond. Despite the well-established importance of breastfeeding, Irish rates remain the lowest in Europe. Healthcare professionals' breastfeeding knowledge and skills have a positive impact on increasing breastfeeding rates. There is limited evidence of the knowledge, attitudes or practices of general practitioners (GPs) and general practice nurses (GPNs), which is essential to breastfeeding in Ireland. The aim of this study was to evaluate the breastfeeding knowledge, attitudes and practices of GPs and GPNs in one community healthcare organisation (CHO) in Ireland. A co-designed evaluation study was used following low-risk ethical exemption (LS-LR-22-161). A modified version of a validated breastfeeding questionnaire was developed. A Project Steering Committee was established that included patient, and public involvement stakeholders. The anonymised survey was distributed via online Qualtrics platform (November 2022-February 2023). STROBE Guidelines were utilised. The overall response rate was 25.9% (n = 121) and valid responses were reported in the article. The total population size was n = 468 (GPs n = 290 and GPNs n = 178). Our pilot study identified that 42.7% (n = 47/110) of respondents never attended a breastfeeding education programme, and 53.9% (n = 55/102) identified that their knowledge could be improved. The majority of respondents, 92.9% (n = 92/99) wish to complete further education in breastfeeding. The results of this pilot study in one CHO in Ireland indicate a gap in knowledge and a need for specific breastfeeding and lactation theoretical and skills training for GPs and GPNs working in primary care to support, promote and protect breastfeeding.

Factors associated with informal human milk sharing among donors and recipients: A mixed-methods systematic review

BACKGROUND

The multiple benefits associated with the provision of human milk exceed individual health outcomes, engendering substantial economic, societal and environmental domains. Human milk is the absolute, unparalleled source of nutrition for infants. Informal human milk sharing is a modernistic and rapidly progressing practice. No systematic review of the factors associated with this contemporary practice among donors and recipients of informal human milk sharing exists.

AIM

The aim of this review was to identify, evaluate, synthesize and integrate the evidence on the factors associated with informal human milk sharing among donors and recipients.

METHODS

A mixed methods systematic review was conducted according to the Joanna Briggs Institute methodological guidance utilizing a convergent integrated approach. The following databases were systematically searched: CINAHL, Scopus, Medline and Embase and Web of Science between inception to August 2023. A grey literature search was conducted using multiple techniques. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Twenty-four studies were included in this review. Ten integrated findings relating to the factors associated with informal human milk sharing among donors and recipients were identified. The four integrated findings pertaining to donors included: altruistic motivation and value, resistance to commercialization and overcoming inaccessibility, uniting digital and personal connectedness and lack of awareness and acceptance of informal human milk sharing in healthcare settings. The six integrated findings relating to recipients included: maternal or infant factors, superiority and advantageous impact of breastmilk, human milk bank influences, digital connections and transparency, healthcare professional facilitation of informal human milk sharing, and professional and logistical implications.

CONCLUSION

This review highlighted a multitude of factors that motivate, facilitate and impede the practice of informal human milk sharing. Future research is required to explore these factors further within broader geographical locations to enhance the generalizability and rigor of the body of knowledge. Further studies should consider the exploration of the experiences and psychological impact of informal human milk sharing on donors and recipients. The provision of human milk to all infants is an imperative public health endeavor and thus positioning this as a key benchmark for research and practice is crucial.

Perspectives and factors associated with informal human milk sharing: a mixed-methods systematic review protocol

Background

The practice of informal human milk sharing is a relatively new phenomenon and poses significant questions in the domain of infant feeding. Informal human milk sharing is a means of donating human milk from another lactating individual who is not the child's biological parent, in a casual manner, that is, without the involvement of health professionals or agencies. The advent of digital technology has facilitated the donation and receipt of human milk through digital online platforms and thus has amplified this modern practice. This research aims to comprehensively examine and synthesize evidence about the motivations, barriers, facilitators and experiences of individuals who both donate (donors) and the primary care givers of the infants who receive (recipients) human milk informally to provide to infants.

Methods

A mixed-methods systematic review will be undertaken. This review will consider qualitative, quantitative and primary mixed-methods studies which report on the factors associated with informal milk sharing, and on donors' and recipients' experiences of the practice. Primary mixed-method studies will be included if the individual qualitative and quantitative components can be extracted. Five databases will be searched for studies on informal human milk sharing published from inception of the database. Study quality will be evaluated using the standardized JBI critical appraisal tools, selected based on the methodology in each individual study. Data extraction will be conducted using the JBI mixed methods data extraction form followed by data transformation, synthesis and integration. This mixed-methods systematic review will follow a convergent integrated approach in accordance with JBI guidance.

Discussion

Informal human milk sharing is a novel practice in the domain of infant feeding. This review will enable a thorough understanding of this practice from both the donors and recipients' perspective and will have implications for healthcare professionals, policy and future clinical decision-making.

Protocol registration number

PROSPERO CRD42023405653.

Surgical nurses in teaching hospitals in Ireland: understanding pain

BACKGROUND

Nurses play a crucial role in pain management and must be highly knowledgeable to ensure their practices are of a high standard.

AIM

The purpose of this study was to determine the baseline level of knowledge and attitudes regarding pain of nurses working in three teaching hospitals in Dublin.

METHODS

This descriptive study explored the knowledge and attitudes of nurses regarding pain management. A modified version of the 'Knowledge and Attitudes Survey Regarding Pain' tool was used to collect data. The sample comprised a convenience sample of 94 nurses working in the acute surgical wards of three hospitals.

FINDINGS

Three per cent of respondents achieved a passing score of 80% or greater. Results revealed that the mean percentage score overall was 65.7%. Widespread knowledge deficits were noted in this study, particularly in the domain of pharmacological management of pain. Further analysis revealed respondents had an inaccurate self-evaluation of their pain management knowledge.

CONCLUSION

The results of this study support the concern of inadequate knowledge and attitudes of nurses regarding pain. Educational and quality improvement initiatives in pain management should be used, which could foster and enhance nurses' knowledge base in the area of pain and possibly improve practices.

The British Labour government's reform of the National Health Service

The recent general election in Britain saw healthcare as the dominant issue amongst voters. The victorious Labour Party responded to this concern with a set of reforms designed to introduce greater private-sector involvement in the delivery of healthcare. These reforms are ill-thought-out. The standard of care in British private hospitals is below that found in public hospitals, whilst new contracting arrangements are likely to increase the administration costs within the system. Faith in private-sector management techniques is misplaced at a time when the real problem facing the NHS is that of capacity. The Labour Party is also committed to redefining some aspects of healthcare as a personal responsibility and not a right, moving Britain towards a more market-based healthcare system.

Reducing DCO registrations through electronic matching of cancer registry data and routine hospital data

The Thames Cancer Registry (TCR) has registered a high proportion of tumours from death certificate information only (DCO) registrations. This paper describes the results of a study set up to establish whether this proportion could be reduced by linking cancer registrations with routine hospital data from the Hospital Episodes Statistics (HES) data set using computerized matching. A total of 67752 registrations were identified from the TCR. Matches were found in the HES data set for 66%. The proportion of cases retrieved for each tumour site was: 72% for colorectal cancer; 62% for cancer of the lung, trachea or bronchus; and 65% for female breast cancer. For all three tumour sites the proportion of matches found for patients registered from hospital case notes was higher than the proportion found for patients registered as DCOs (P < 0.0001 for all three tumour sites). Among matched DCO cases, 58% had at least one procedure recorded. DCO rates might be reduced by as much as 43% (from 17% of total registrations to less than 10%) for the three most common cancers if the method of electronic matching outlined here was used. Younger age groups, prognosis of tumour site and residence in North Thames region were all positively associated with successful matching (P < 0.0001 in all three cases). Many matched DCO cases were found to have had more than one admission for cancer. Among ordinary in-patient admissions, admissions to patients ratios of 1.5, 1.4 and 1.9 were found for colorectal, lung and breast cancers respectively. Of 5190 matched DCOs a procedure was recorded for 3013 (58%). HES data offer a useful aid to follow-up of case notes on patients identified to the registry by death certificates. Doubts about the completeness and accuracy of HES data mean case notes must remain the 'gold standard'.

Deprivation and emergency admissions for cancers of colorectum, lung, and breast in south east England: ecological study

OBJECTIVES

To examine the relation between deprivation and acute emergency admissions for cancers of the colon, rectum, lung, and breast in south east England.

DESIGN

Ecological analysis with data from hospital episode statistics and 1991 census.

SETTING

North and South Thames Regional Health Authorities (population about 14 million), divided into 10 aggregations of 31 470 census enumeration districts (median population 462).

SUBJECTS

146 639 admissions relating to 76 552 patients aged <100 years on admission, resident in the Thames regions, admitted between 1 April 1992 and 31 March 1995.

RESULTS

Residents living in deprived areas were more likely to be admitted as emergencies and has ordinary inpatient admissions and less likely to be admitted as day cases. Adjusted odds of ordinary admissions from the most deprived tenth occurring as emergencies (relative to admissions from the most affluent tenth) were 2.29 (95% confidence interval 2.09 to 2.52) for colorectal cancer, 2.20 (1.99 to 2.43) for lung cancer, and 2.41 (2.17 to 2.67) for female breast cancer; adjusted odds of admissions as day cases were 0.70 (0.64 to 0.76), 0.50 (0.44 to 0.56), and 0.56 (0.50 to 0. 62), respectively. Patients from deprived areas with lung or breast cancers were less likely to be recorded as having surgical interventions. Adjusted odds of patients from the most deprived tenth receiving surgery were 0.88 (0.78 to 1.00), 0.58 (0.48 to 0. 70), and 0.63 (0.56 to 0.71), respectively. Admissions for colorectal cancer from the most deprived areas were less likely to be to hospitals admitting 100 or more new patients a year; the opposite held true for breast cancer admissions. No association was found for lung cancer admissions.

CONCLUSIONS

Earlier diagnostic and referral procedures in primary care in deprived areas are required if there are to be significant reductions in mortality from these cancers. A national information strategy is required to ensure the continued availability of population based data on NHS patients and to mandate standardised datasets from the private sector. Rationalisation of acute services, hospital mergers, and plans for bed closures must take into account the increased healthcare needs and inequities in access to treatment and care of residents in areas with high levels of deprivation. Health authorities and primary care groups should re-examine their purchasing intentions, service reviews, and monitoring arrangements in the light of these findings.

Trends in colorectal cancer care in southern England, 1989-1993: using HES data to inform cancer services reviews

BACKGROUND

This paper describes trends in hospital activity, hospital admissions, and treatments for colorectal cancer on residents of the South Thames regions (population 8 million) between 1989-1993 against the background of the Calman Report on the future of cancer services in England and Wales.

METHODS

The analyses are derived from UK hospital data, which are collected as finished consultant episodes (FCEs). These are defined as episodes "where a patient has completed a period of care under a consultant and is either transferred to another consultant or is discharged." Probability matching was used to derive patient-based records, matching FCEs to admissions. A total of 18,542 South Thames residents aged 40-99 were admitted for colorectal cancer between 1 January 1989 and 31 December 1993. Time trends were analysed for procedures, FCEs, admissions, and patient numbers by admission type (ordinary admissions and day case admissions).

RESULTS

Between 1989 and 1993 inclusive colorectal cancer admissions doubled (98% increase p (trend) < 0.0001). These admissions were a result of a 6.4-fold increase in day case admissions and a 41% increase in ordinary admissions. The proportion of patients having a day case admission rose from 9% in 1989 to 18% in 1993 (p < 0.0001). Overall, 2894 (16%) patients had a day case admission; 1894 of these (65%) were also admitted as ordinary admissions. The number of FCEs and admissions per patient rose from 1.37 and 1.28 respectively in 1989 to 2.09 and 1.99 respectively in 1993. FCEs were between 5% and 8% higher than admissions over the five years. The number of ordinary (that is, overnight) inpatient admissions per patient rose from 1.23 to 1.41 over the five year period and day case inpatient admissions from 1.25 to 3.45. Chemotherapy accounted for 50% of the rise in day case admissions; colonoscopy and sigmoidoscopy were associated with a further 18%. Fourteen per cent of the increase in ordinary admissions was also because of chemotherapy.

CONCLUSION

The monitoring of site specific trends in admission, treatments, and procedures on a population basis should be a core requirement of health authorities to inform needs assessment, resource allocation, and service planning. The rise in admissions and chemotherapy treatments have implications for drug costs, laboratory and inpatient services, monitoring, and clinical audit.

Breast, lung and colorectal cancer incidence and survival in South Thames Region, 1987-1992: the effect of social deprivation

BACKGROUND

This paper describes the relationship between social deprivation and incidence of, and survival from, breast, lung, and colorectal cancers among residents of the South Thames regions. We analysed 23,505 cases of breast cancer, 29,903 cases of lung cancer and 21,905 cases of colorectal cancer, aged 40-99 inclusive at diagnosis and diagnosed between 1 January 1987 and 31 December 1992.

METHODS

Using the 1991 Census in conjunction with the Townsend index on social deprivation, we derived proxy indicators of deprivation based on patients' home postal codes. Cumulative relative five-year survival rates (per cent) were calculated for each cancer. We then compared our results with the relevant standardized incidence and mortality ratios by deprivation status.

RESULTS

A clear trend was observed in standardized mortality rates across deprivation tenths for the three tumour sites: mortality increased with deprivation. A strong positive correlation was found between deprivation and the incidence of lung cancers (p < 0.0001), but no association was found between deprivation and incidence of breast and colorectal cancers. Significantly lower five-year relative survival rates were found for breast and colorectal cancer patients in the most deprived Townsend tenths. Breast cancer patients resident in the most affluent tenth of enumeration districts had a 70 per cent relative survival ratio compared with 57 per cent in the most deprived tenth. The corresponding figures for colorectal cancer patients were 40 per cent and 32 per cent, respectively.

CONCLUSIONS

Survival differences by deprivation status exist in South Thames among patients suffering from breast or colorectal cancers and are not explained by differences in the incidences of these diseases. For lung cancer, incidence and mortality were positively correlated with deprivation, but no socio-economic gradient was found for survival.

Management of colorectal cancer in three South Thames District Health Authorities

This study describes the management of colorectal cancer, diagnosed in 1988, of residents in three South Thames Districts. Of the 328 cases identified as having being diagnosed in 1988, case notes were retrieved on 263 (80%) including 62 registered by death certificate only. There were 159 cases (61%) of colon cancer and 104 cases (39%) of rectal cancer. Of these, 172 cases (68%) were admitted electively and 90 (32%) as emergencies. Patients subsequently diagnosed with colon cancer had a relative risk of being admitted through emergency (relative to rectal cancer patients) of 1.39 (95% C.I.: 1.16, 1.67). Elective admissions varied significantly by district of residence (P < 0.0001) ranging from 36-65% for colon cancers and from 63-92% for rectal cancers across the three districts. Dukes' stage was recorded in only 143 (54%) sets of case notes, with significant variation by district of residence in the proportion of elective patients for whom a Dukes' stage was indicated (P < 0.01). Two-hundred and thirty-six (90%) cases received treatment. Of the treated cases, 233 patients received surgery with 29 cases of colon cancer (18%) and 32 cases of rectal cancer (31%) receiving adjuvant therapy. The proportions of anterior resection, AP resection and colostomies given, varied by district. Patients presenting for elective surgery were more likely to be treated by a consultant than patients presenting on emergency: the relative risks were 2.58 (95% C.I.: 1.74, 3.82) for colon cancer patients and 4.93 (95% C.I.: 2.20, 11.06) for rectal cancer patients. In 44 (26%) colon cancer cases and 21 (22%) rectal cancer cases it was explicitly stated that the tumour had not been fully resected. For colon tumours the five year relative survival rates were 35% (95% C.I.: 21%, 50%), 52% (95% C.I.: 34%, 70%), and 14% (95% C.I.: -2%, 30%) in districts A, B and C respectively. The corresponding figures for rectal tumours were 45% (95% C.I.: 27%, 64%), 62% (95% C.I.: 41%, 83%) and 24% (95% C.I.: -1%, 50%). There were wide variations in the representation, management of and survival from colorectal cancers across the three districts. Differences were significant at the level of district of residence, mode of presentation and surgical grade. More assiduous recording of Dukes' stage is imperative if consensus is to be achieved on effective management. Further work is also warranted on district differences in diagnostic and referral protocols.

Why did treatment rates for colorectal cancer in south east England fall between 1982 and 1988? The effect of case ascertainment and registration bias

BACKGROUND

We had two aims in undertaking this study, as follows: (1) to describe regional and district trends in incidence and treatment for colorectal cancer in South East England from 1982 to 1988; (2) to examine the effect of registration practice and case ascertainment on district variations in incidence and treatment using data on death certificate only (DCO) registrations, mortality and stage.

METHODS

We included all cases registered by the Thames cancer registry diagnosed with colon or rectal cancer between 1982 and 1988 and resident in 28 districts in the two South Thames regions. Indirect standardized incidence ratios were calculated for the districts and a alpha 2 test for trend was carried out.

RESULTS

In the SE England regional analysis, between 1982 and 1988 there was a significant increase in the incidence of cases of colon and rectal cancer in the over-75s, but treatment rates remained unchanged. Treatment rates fell significantly in the under-65s although incidence rates remained unchanged. Age is a strong predictor of nontreatment. Between 1982 and 1988 the relative risk of not receiving treatment increased for all ages over 65 years. DCO registrations accounted for 22 percent and 15 percent of all colon and rectal cancer cases, respectively, between 1982 and 1988. The proportions rose (between 1982 and 1988) from 10 and 8 percent to 25 and 19 percent in colon and rectal cancer, respectively. DCO registration rates increased over time and in all age groups in South East England for both colon and rectal cancer between 1982 and 1988, but the largest increase was in the over-75s. Thirty-two per cent of colon and 25 per cent of rectal cases were unstaged. Although the proportion of unstaged cases remained constant over time, they were increasingly the result of DCO registrations. Errors in the registry staging data rendered those cases which were staged unusable. In the district analysis, there were significant variations in age-standardized incidence, treatment and DCO registration ratios across the 28 districts for men and women with colon and rectal cancer between 1982 and 1988. DCO registrations show a negative correlation with treatment for both colon and rectal cancer (p < 0.05) and with incidence for only rectal cancer.

CONCLUSIONS

We report significant differences in age-standardized incidence and treatment ratios across 28 districts in South East England, some of which, can be accounted for by differences in registration practice. There is a complex relationship between DCO registrations and incidence and treatment for both colon and rectal cancer. DCO registrations are a good proxy for under-ascertainment of incidence in rectal cancer but not colon cancer, and are a good proxy for under-ascertainment of treatment in both colon and rectal cancers. Information from the cancer registry can be used to examine registration and treatment rates across districts. However, if variations are to be adequately explained, meticulous data collection on stage and quality control are essential.

Reliability of data of the Thames cancer registry on 673 cases of colorectal cancer: effect of the registration process

OBJECTIVE

To measure the reliability of data collected by the Thames cancer registry and to identify factors in the registration process affecting reliability.

DESIGN

A retrospective study of data from the registry, including death certificate only registrations, and hospital case notes on cases of colorectal cancer diagnosed in 1983 or 1988.

SETTING

Four districts in South Thames region.

SUBJECTS

673 cases of colorectal cancer in resident patients.

MAIN MEASURES

Dates of birth, diagnosis of cancer, and death; sex; tumour site; whether treatment was given; type of treatment; and district of residence.

RESULTS

Among the 416 (62%) case notes retrieved, including 66 death certificate only registrations, full or high agreement between registry data and hospital notes was recorded for sex, district of residence, and dates of birth and death. Only 12% of cases had the same date of diagnosis, which may be due to failure of registry policy. Lower agreement rates occurred for tumour site (87%), whether treatment occurred (84%), and treatments administered (80%, 1983; 72%, 1988). 20% of surgical treatments and 37% of adjuvant therapy, radiotherapy, and chemotherapy were not recorded by the registry. Disagreements were common among death certificate only registrations. Such registrations accounted for 16(32%) disagreements over tumour site, 33(41%) major disagreements over date of diagnosis (difference > 30 days), and 47(44%) disagreements over treatment. In 65 cases the registry failed to capture all treatments carried out within the six month follow up period, 38(58%) of which were for death certificate only registrations. In 36% of death certificate only registrations the patients survived more than one year from diagnosis, indicating a failure of registry policy over retrospective follow up.

CONCLUSIONS

Registry data on district of residence; sex; dates of birth, diagnosis, and death are highly reliable, but treatment and tumour site data are less so. Lack of follow up in death certificate only registrations and failure to monitor treatments during follow up period seemed to be associated with disagreements.

Why are a quarter of all cancer deaths in south-east England registered by death certificate only? Factors related to death certificate only registrations in the Thames Cancer Registry between 1987 and 1989

This paper describes the results of a study set up to investigate factors associated with the high proportions of 'death certificate only' registrations (DCOs) for all cancers registered in south-east England between 1987 and 1989 and to identify those which might be subject to registry intervention. DCOs as a proportion of all registrations (n = 162,131) were analysed by age, sex, district of residence, place of death and survival. DCO registration ratios (standardised for age and sex) were then derived for each of the 56 districts in the Thames Regions. A multiple logistic regression model was generated to estimate the effect of age at diagnosis, tumour survival and patient sex on final source of registration. To minimise the number of dummy variables needed, each of the 56 districts was ranked into quartiles: quartile 1 contained the 14 districts with the lowest age- and sex-standardised ratios for DCO registrations and quartile 4 comprised the 14 districts with the highest DCO ratios. Final source of registration was treated as a binomial trial (case notes or death certificates). The significance of associations was measured using the deviance difference as an approximate chi-square statistic. The effect of each variable on source of registration was estimated as an odds ratio. Interaction terms were also fitted. To estimate the effect of place of death on DCO registrations, a second model was generated for deceased patients only (n = 98,455, adding 'place of death' to the list of explanatory variables already used. A further interaction term was fitted to account for interaction between place of death and district quartile of residence. Around 24% of all patient deaths were registered as DCOs by the Thames Cancer Registry between 1987 and 1989. Of these, 40.9% died in an acute NHS hospital setting, 37.1% died at home, 10.4% died in hospices and 3.4% died in non-NHS hospitals. Increasing age, decreasing survival, district of residence and place of death were positively associated with death certificate registrations. The district effect was sustained in the regression model with significant positive associations shown for DHA quartile of residence. In the deceased group of patients, both district of residence and place of death were independent predictors of DCOs. Death occurring outside the acute NHS hospital setting increased the odds of being a DCO within and across district quartiles. DCOs could be reduced by better case ascertainment in some districts.(ABSTRACT TRUNCATED AT 400 WORDS)

The impact on colorectal cancer survival of cases registered by 'death certificate only': implications for national survival rates

This paper describes the effect of including death certificate only (DCO) registrations on 5 year relative survival rates for colorectal cancer in four district health authorities (DHAs) in south-east England. A retrospective case note study was set up to examine all cases of colorectal cancer listed in the Thames Cancer Registry (TCR) as having been diagnosed in 1983 and 1988 and resident in one of four districts, A, B, C and D. A total of 673 sets of cases notes were requested from all hospitals within the four districts, including 150 sets on DCO cases. Of 465 (69%) sets of case notes retrieved, 378 (72.3%) were non-DCO cases. Of these, 14 were excluded from survival analysis because of missing dates of diagnosis or death in the notes. Eighty-seven (58.0%) sets of case notes were retrieved on DCO registrations, of which seven were excluded because no date of diagnosis was available in the notes. Retrieval rates on case note registrations varied by DHA of residence: 73.3% in DHA A, 96.6% in DHA B, 34.5% in DHA C and 79.2% in DHA D. The corresponding figures for DCO registrations were 63.5%, 69.0%, 7.4% and 76.2%. Cumulative relative 5 year survival rates by DHA of residence were calculated first for cases registered from case notes and then for all cases including those registered solely from a death certificate. The total number of cases used in the survival analysis was 444 (18% DCOs). In all four DHAs, 5 year survival decreased with the inclusion of DCO registrations: by 9.1% in district A (from 52.8 to 43.7), by 4.5% in district B (from 59.6 to 55.1), by 4.8% in district C (from 80.0 to 75.2) and by 7.6% in district D (from 31.4 to 23.8). The overall reduction in survival was 8.6%. The exclusion of death certificate only registrations from survival data is an important source of bias. Using TCR data, we compared DCO proportions for colorectal cancer with other sites. DCO proportions were shown to vary by tumour site and survival time. The DCO registration is an important quality measure of ascertainment and follow-up. OPCS should publish DCO proportions by registry area and cancer site. Registries should implement DCO monitoring as part of quality improvement programmes.

Incompleteness and retrieval of case notes in a case note audit of colorectal cancer

Hospital case notes are a crucial source of data but are subject to two major biases: incompleteness of data and non-retrieval. To assess these biases in relation to colorectal cancer a study was performed of all cases of colorectal cancer listed in the Thames cancer registry in patients resident in one of four districts in South Thames regions with a diagnosis in 1988. Five medical record sites were involved. Retrieval rate for all case notes for districts combined was 80%. In two districts the rates were too high for further investigation; in the other two respectively patient survival and whether treatment was given were positively associated with retrieval. Among the four districts incompleteness of notes ranged from 38% to 62% for staging, 8% to 40% for treatment, and 70% to 25% for diagnostic tests. Information about treatment was missing in 3% to 20%; survival data were omitted in less than 5%. In all districts completeness of case notes was inadequate and in some non-retrieval compounded the problem. Missing data reduce the quality of cancer registry data and potentially undermine interpretation of epidemiological studies and evaluation of care. Further research is warranted into the standards and resourcing of medical records departments and their effects on retrieval and data quality. Structured proformas could be applied across specialties to identify missing items in case notes, to identify areas where standards are required, or to audit notes where standards have already been agreed. A staging protocol to set standards for colorectal cancer has been adopted in one district, and a prospective audit is being established.