Working IT Out in Medical Practice: IT Systems Design and Development as Co-Realisation

Objectives: The paper explores possibilities for situating IT design and development work within the context of use so as to support the co-realisation of technology and ‘design in use’. The aim is to build a new understanding between IT professionals and users which is grounded upon what happens as the latter grapple with the problems of applying IT, appropriating its functionalities and affordances into their work practices and relations.

Methods: Following a discussion of participatory design and ethnomethodology, a novel method called co-realisation, which aims to provide a synthesis of the preceding methods, is suggested as an alternative. Through a discussion of findings from a case study of IT systems design and development in healthcare we show how the co-realisation approach might provide work-affording systems and how user-designer relations might be reformulated. We suggest that work-affording systems can be developed through the deployment of an engaged facilitator who works with the users to unpack the work site-specific potentialities of technology.

Results: The case study shows how risk of non-adoption might be minimised through the development of partnerships, and how the presence of the facilitator in the workplace capitalises on the mundane work undertaken therein and how the facilitator might work with the users to develop artefacts that support this work as opposed to reconfiguring it.

Conclusions: The case study illustrates co-realisation in action and how it might be seen to reconfigure relations between users and designers in a way that appears productive. Co-realisation can help address the widely observed problem of IT systems failures in healthcare.

Trusting the Record

Objectives: This paper aims to contribute to a longstanding interest in documents and paperwork in healthcare work through an examination of everyday work with patient records in a clinic.

Methods: An ethnographic study of record keeping practices in a deliberate self harm clinic was conducted to consider the role that document work plays in the development of trust in the routine social interactions of a working division of labor.

Results and conclusions: Issues of trust are seen to play central roles within the complexities of organizational working and some consequent implications for the deployment and use of electronic medical record systems are considered.

Improving ‘knife to skin time’: process modelling and new technology in medical work

As healthcare becomes information intensive technology increasingly plays an important role in managing patient care; information gathering and dissemination; and co-ordinating work. One approach to ensuring resources, staff and systems are allocated and used efficiently is process modelling. This paper presents some findings from the Dependability Interdisciplinary Research Collaboration (DIRC) project, on ‘process modelling’ as an aspect of managerial activity and the work involved in both creating and implementing process maps or models. Our ethnographic investigations document some of the problems in developing process maps of medical activity as part of a desire to ‘improve knife to skin time’. We suggest that process maps are not systematic, rational, scientific deductions of the most efficient process. Process maps are locally sensible versions of best practice, and problems may arise where such locally sensible versions are exported throughout an organization to other settings where other relevances may apply.

A novel method for classifying cortical state to identify the accompanying changes in cerebral hemodynamics

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We classified brain state using a vector-based categorisation of neural frequencies.

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Changes in cerebral blood volume (CBV) were observed when brain state altered.

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During these state alterations, changes in blood oxygenation were also found.

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State dependent haemodynamic changes could affect blood based brain imaging.

Background

Many brain imaging techniques interpret the haemodynamic response as an indirect indicator of underlying neural activity. However, a challenge when interpreting this blood based signal is how changes in brain state may affect both baseline and stimulus evoked haemodynamics.

New method

We developed an Automatic Brain State Classifier (ABSC), validated on data from anaesthetised rodents. It uses vectorised information obtained from the windowed spectral frequency power of the Local Field Potential. Current state is then classified by comparing this vectorised information against that calculated from state specific training datasets.

Results

The ABSC identified two user defined brain states (synchronised and desynchronised), with high accuracy (∼90%). Baseline haemodynamics were found to be significantly different in the two identified states. During state defined periods of elevated baseline haemodynamics we found significant decreases in evoked haemodynamic responses to somatosensory stimuli.

Comparison to existing methods

State classification – The ABSC (∼90%) demonstrated greater accuracy than clustering (∼66%) or ‘power threshold’ (∼64%) methods of comparison.

Haemodynamic averaging – Our novel approach of selectively averaging stimulus evoked haemodynamic trials by brain state yields higher quality data than creating a single average from all trials.

Conclusions

The ABSC can account for some of the commonly observed trial-to-trial variability in haemodynamic responses which arises from changes in cortical state. This variability might otherwise be incorrectly attributed to alternative interpretations. A greater understanding of the effects of cortical state on haemodynamic changes could be used to inform techniques such as general linear modelling (GLM), commonly used in fMRI.

Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis

OBJECTIVE

To compare the effectiveness of acupuncture with other relevant physical treatments for alleviating pain due to knee osteoarthritis.

DESIGN

Systematic review with network meta-analysis, to allow comparison of treatments within a coherent framework. Comprehensive searches were undertaken up to January 2013 to identify randomised controlled trials in patients with osteoarthritis of the knee, which reported pain.

RESULTS

Of 156 eligible studies, 114 trials (covering 22 treatments and 9,709 patients) provided data suitable for analysis. Most trials studied short-term effects and many were classed as being of poor quality with high risk of bias, commonly associated with lack of blinding (which was sometimes impossible to achieve). End of treatment results showed that eight interventions: interferential therapy, acupuncture, TENS, pulsed electrical stimulation, balneotherapy, aerobic exercise, sham acupuncture, and muscle-strengthening exercise produced a statistically significant reduction in pain when compared with standard care. In a sensitivity analysis of satisfactory and good quality studies, most studies were of acupuncture (11 trials) or muscle-strengthening exercise (9 trials); both interventions were statistically significantly better than standard care, with acupuncture being statistically significantly better than muscle-strengthening exercise (standardised mean difference: 0.49, 95% credible interval 0.00-0.98).

CONCLUSIONS

As a summary of the current available research, the network meta-analysis results indicate that acupuncture can be considered as one of the more effective physical treatments for alleviating osteoarthritis knee pain in the short-term. However, much of the evidence in this area of research is of poor quality, meaning there is uncertainty about the efficacy of many physical treatments.

Alitretinoin for the treatment of severe chronic hand eczema

This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of alitretinoin for the treatment of adults with severe chronic hand eczema refractory to topical steroid treatment in accordance with the licensed indication, based upon the evidence submission from Basilea Pharmaceuticals Ltd to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal process. The clinical evidence came from a single placebo-controlled randomised controlled trial of daily treatment with alitretinoin for 12-24 weeks, with follow-up for a further 24 weeks, in patients with severe chronic hand eczema (CHE) unresponsive to topical steroids. A statistically significantly greater proportion of patients using alitretinoin achieved the primary end point of clear or almost clear hands by week 24 than did those with placebo. Dose-dependent headache was the most commonly reported adverse event in patients treated with alitretinoin. Serious adverse events were rare, but alitretinoin was associated with increases in both total cholesterol and triglycerides, which has implications for risks of future cardiovascular events. The manufacturer submitted a de novo decision analytic model to estimate, over a time horizon of 3 years, the cost-effectiveness of alitretinoin versus the other relevant comparators identified by NICE. In response to the points of clarification put to it by the ERG regarding the initial submission, the manufacturer provided additional evidence and a revised decision analytic model with a 'placebo' arm. In the manufacturer's original submission to NICE, the base-case incremental cost-effectiveness ratios (ICERs) reported for alitretinoin were 8614 pounds per quality-adjusted life-year (QALY) versus ciclosporin, -469 pounds per QALY versus psoralen + UVA (with alitretinoin dominant) and 10,612 pounds per QALY versus azathioprine. These ICERs decreased as the time horizon was extended in sensitivity analyses. In patients with hyperkeratotic CHE and in women of child-bearing potential, the ICER remained below 20,000. pounds When the health-related quality of life (HRQoL) values used in the model were replaced with those derived from an alternative study, these ICERs increased significantly (to 22,312 pounds per QALY for alitretinoin versus azathioprine). In the revised model, alitretinoin was reported to have an ICER of 12,931 pounds per QALY gained versus supportive care (placebo). However, the model underestimates the costs of treatment associated with alitretinoin. The manufacturer assumed that patients receiving alitretinoin visited the dermatologist every 4 weeks and ceased treatment as soon as they responded to it. If, in practice, patients would receive treatment for longer than this, then the manufacturer's model will have significantly underestimated the costs to the NHS. Additional analyses undertaken by the ERG produced ICERs close to 30,000 pounds per QALY gained for alitretinoin versus supportive care. This was largely due to uncertainty surrounding the impact of alitretinoin on HRQoL. The placebo-controlled trials conducted to date have established that alitretinoin can be efficacious for the treatment of severe CHE refractory to topical steroids, but longer term follow-up of trials or the implementation of registries is required to better establish the longer term efficacy or safety of alitretinoin. NICE recommended the use of alitretinoin for patients with severe CHE and a Dermatology Life Quality Index (DLQI) score of at least 15. Treatment was recommended to be stopped as soon as an adequate response was observed, or if CHE remained severe at 12 weeks, or if response was inadequate at 24 weeks.

Alitretinoin for the treatment of severe chronic hand eczema

This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of alitretinoin for the treatment of adults with severe chronic hand eczema refractory to topical steroid treatment in accordance with the licensed indication, based upon the evidence submission from Basilea Pharmaceuticals Ltd to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal process. The clinical evidence came from a single placebo-controlled randomised controlled trial of daily treatment with alitretinoin for 12–24 weeks, with follow-up for a further 24 weeks, in patients with severe chronic hand eczema (CHE) unresponsive to topical steroids. A statistically significantly greater proportion of patients using alitretinoin achieved the primary end point of clear or almost clear hands by week 24 than did those with placebo. Dose-dependent headache was the most commonly reported adverse event in patients treated with alitretinoin. Serious adverse events were rare, but alitretinoin was associated with increases in both total cholesterol and triglycerides, which has implications for risks of future cardiovascular events. The manufacturer submitted a de novo decision analytic model to estimate, over a time horizon of 3 years, the cost-effectiveness of alitretinoin versus the other relevant comparators identified by NICE. In response to the points of clarification put to it by the ERG regarding the initial submission, the manufacturer provided additional evidence and a revised decision analytic model with a ‘placebo’ arm. In the manufacturer’s original submission to NICE, the base-case incremental cost-effectiveness ratios (ICERs) reported for alitretinoin were £8614 per quality-adjusted life-year (QALY) versus ciclosporin, –£469 per QALY versus psoralen + UVA (with alitretinoin dominant) and £10,612 per QALY versus azathioprine. These ICERs decreased as the time horizon was extended in sensitivity analyses. In patients with hyperkeratotic CHE and in women of child-bearing potential, the ICER remained below £20,000. When the health-related quality of life (HRQoL) values used in the model were replaced with those derived from an alternative study, these ICERs increased significantly (to £22,312 per QALY for alitretinoin versus azathioprine). In the revised model, alitretinoin was reported to have an ICER of £12,931 per QALY gained versus supportive care (placebo). However, the model underestimates the costs of treatment associated with alitretinoin. The manufacturer assumed that patients receiving alitretinoin visited the dermatologist every 4 weeks and ceased treatment as soon as they responded to it. If, in practice, patients would receive treatment for longer than this, then the manufacturer’s model will have significantly underestimated the costs to the NHS. Additional analyses undertaken by the ERG produced ICERs close to £30,000 per QALY gained for alitretinoin versus supportive care. This was largely due to uncertainty surrounding the impact of alitretinoin on HRQoL. The placebo-controlled trials conducted to date have established that alitretinoin can be efficacious for the treatment of severe CHE refractory to topical steroids, but longer term follow-up of trials or the implementation of registries is required to better establish the longer term efficacy or safety of alitretinoin. NICE recommended the use of alitretinoin for patients with severe CHE and a Dermatology Life Quality Index (DLQI) score of at least 15. Treatment was recommended to be stopped as soon as an adequate response was observed, or if CHE remained severe at 12 weeks, or if response was inadequate at 24 weeks.

Influenza vaccine uptake among staff in care homes in Nottinghamshire: a random cluster sample survey

OBJECTIVES

To establish uptake of influenza vaccine amongst care home clinical staff in Greater Nottingham, and to investigate what could be done to improve vaccine uptake in this group.

STUDY DESIGN

Postal questionnaire surveys were used. In the first instance, a total sample survey was used. In the second instance, a sample of care home staff was surveyed, randomized at the care home level.

METHODS

A postal questionnaire completed by care home matrons was used to obtain a preliminary estimate of staff vaccine uptake. Individual staff questionnaires were then used to validate this finding, and measure attitudes, beliefs and behaviours associated with vaccination.

RESULTS

Vaccine uptake among those working in care homes with nursing was found to be low. Vaccine uptake was higher in homes with a policy recommending vaccination of staff. Most respondents who had received vaccination reported that they had done so because of an existing medical condition, rather than because of being a healthcare worker. A statistically significant relationship (P=0.02) was found between individuals' reported beliefs on how well they could resist influenza and their vaccination status.

CONCLUSIONS

All care homes for the elderly should have a vaccination policy which recommends staff vaccination. Educational campaigns, vaccination in the workplace and free provision of the influenza vaccine may help to improve vaccine uptake in this group.

Understanding the potential role of mobile phone-based monitoring on asthma self-management: qualitative study

BACKGROUND

National and international healthcare policy increasingly seeks technological solutions to the challenge of providing care for people with long-term conditions. Novel technologies, however, have the potential to change the dynamics of disease monitoring and self-management. We aimed to explore the opinions and concerns of people with asthma and primary care clinicians on the potential role of mobile phone monitoring technology (transmitting symptoms and peak flows, with immediate feedback of control and reminder of appropriate actions) in supporting asthma self-management.

METHODS

This qualitative study recruited 48 participants (34 adults and teenagers with asthma, 14 asthma nurses and doctors) from primary care in Lothian (Central Scotland) and Kent (South East England). Thirty-nine participated in six focus groups, which included a demonstration of the technology; nine gave in-depth interviews before and after a 4-week trial of the technology.

RESULTS

Participants considered that mobile phone-based monitoring systems can facilitate guided self-management although, paradoxically, may engender dependence on professional/technological support. In the early phases, as patients are learning to accept, understand and control their asthma, this support was seen as providing much-needed confidence. During the maintenance phase, when self-management predominates, patient and professionals were concerned that increased dependence may be unhelpful, although they appreciated that maintaining an on-going record could facilitate consultations.

CONCLUSION

Mobile phone-based monitoring systems have the potential to support guided self-management by aiding transition from clinician-supported early phases to effective self-management during the maintenance phase. Continuing development, adoption and formal evaluation of these systems should take account of the insights provided by our data.

The national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis

OBJECTIVES

This study summarises the results of a National Audit of sino-nasal surgery carried out in England and Wales. It describes patient and operative characteristics as well as patient outcomes up to 36 months after surgery.

DESIGN

Prospective cohort study.

SETTING

NHS hospitals in England and Wales.

PARTICIPANTS

Consecutive patients undergoing surgery for nasal polyposis and/or chronic rhinosinusitis.

MAIN OUTCOME MEASURE

The total score derived from a 22-item version of the Sino-Nasal Outcome Test (SNOT-22). Lower scores represent better health-related quality of life.

RESULTS

A total of 3128 consecutive patients at 87 NHS hospitals were enrolled. There is a large improvement in SNOT-22 scores from the pre-operative period (mean = 42.0) to 3 months after surgery (mean = 25.5). The scores for patients undergoing nasal polypectomy improved from 41.0 before surgery to 23.1 at 3 months after surgery, while the scores for patients undergoing surgery for chronic rhinosinusitis alone improved from 44.2 to 31.2. The SNOT-22 scores reported at 12 and 36 months after surgery were similar to those reported at 3 months. Excessive bleeding occurred in 5% of patients during the operation and in 1% of patients after the operation. Intra-orbital complications were reported in 0.2%. Of those patients undergoing primary surgery for bilateral grade I or II polyposis, 18% had not received a pre-operative course of steroid treatment. At the 36-month follow-up, 11.4% of patients had undergone revision surgery.

CONCLUSIONS

The audit confirms that sino-nasal surgery is generally safe and effective. There is some evidence that patient selection for surgery could be improved.

Searching for HLA-DRB1*1206 in volunteer marrow donors in four US population groups

The frequencies of DRB1*12 alleles were determined in four US population groups by DNA sequencing. Only DRB1*120101 (or DRB1*1206 or *1210) and DRB1*120201 alleles were identified, the latter primarily in the Asian American population. Additional testing of a subset of samples to detect the presence of DRB1*1206 found all of the alleles to be DRB1*120101 (or DRB1*1210). Retesting of six samples previously typed as DRB1*1206 found only DRB1*120101 (or DRB1*1210).

Variation in day-case nasal surgery - why cannot we improve our day-case rates?

OBJECTIVES

The NHS plan states that 75% of all elective operations should be performed as day-cases. We set out to evaluate day surgery rates in sinonasal surgery and to identify factors limiting current practice.

STUDY DESIGN AND SETTING

Prospective multicentre cohort study.

PARTICIPANTS

3128 patients undergoing sinonasal surgery during 2000 and 2001.

OUTCOME MEASURES

Same day discharge, complication and readmission rates.

RESULTS

There is potential selection bias due to the non-random selection of NHS Trusts and patients in this study. However, as results are similar to Hospital Episode Statistics data such bias is probably small. Only 15.5% of all procedures are performed as day surgery. We are achieving day-case rates of 18, 20 and 6% for nasal polypectomy, intranasal antrostomy and extensive FESS respectively, compared with recently published targets of 90%, 80% and 50%. Factors significantly associated with overnight admission were use of packs, extensive surgery, excess post-operative bleeding and high ASA grade. There was considerable unexplained variation in day-case rates and the use of packs between different surgeons. A third of consultants pack all patients post-operatively. More than 51% of consultants admit all patients, while 5% discharge all patients on the day of surgery. There were no excess adverse events or readmissions amongst the day surgery patients. However, only 17% of in-patients would have liked to be discharged on the day of surgery. Both patient and surgeon must overcome resistance to day case surgery before targets can be reached.

CONCLUSIONS

Strategies for improving day-case rates in sinonasal surgery. All ASA grade 1 and 2 patients could be considered for day-case surgery, but particularly those with less extensive disease on radiography, and those planned to undergo less extensive procedures. Excess peri-operative bleeding was reported in 6% of patients. There must therefore be provision for overnight admission if required. Greater utilisation of day-case units, selective use of packs, and earlier removal may increase the proportion of patients managed as day-cases. There remains considerable variation in practice at both consultant and trust levels. Units should continue to audit their own figures and compare them against national rates in order to reduce nationwide variation in practice.

15-year follow-up results of the hydroxyapatite ceramic-coated femoral stem

PURPOSE

To evaluate the clinical and radiological outcomes following implantation of the Furlong hydroxyapatite ceramic-coated femoral stem in total hip arthroplasty.

METHODS

A longitudinal cohort of 116 consecutive patients (134 hips) was followed up prospectively. The follow-up period was at least 13 years (range, 13- 15 years). Clinical and radiological assessments were made using the Merle d'Aubigne and Postel score and Engh score for fixation and stability, respectively. Osteointegration was assessed radiographically by examining the bone implant interface using the method described by Gruen.

RESULTS

22 patients died during the study period and 6 were lost to follow-up. The respective mean Merle d'Aubigne and Postel scores for pain, range of movement, and ability to walk were 2.2, 2.8, and 2.4 preoperatively and 5.8, 4.8, and 5.4 postoperatively. Engh described satisfactory bony ongrowth as 10 points or more; the mean Engh score for fixation and stability was 24.7 (fixation=10, stability=14.7). One femoral stem was revised for a periprosthetic fracture caused by a fall, but none was revised for loosening. This gave a 99% survival at 13 years (95% confidence interval 94-100).

CONCLUSION

The long-term results of this hydroxyapatite ceramic-coated femoral prosthesis are very satisfactory.

Hospital volume of throughput and periprocedural and medium-term adverse events after percutaneous coronary intervention: retrospective cohort study of all 17,417 procedures undertaken in Scotland, 1997-2003

OBJECTIVE

To determine whether percutaneous coronary intervention (PCI) hospital volume of throughput is associated with periprocedural and medium-term events, and whether any associations are independent of differences in case mix.

DESIGN

Retrospective cohort study of all PCIs undertaken in Scottish National Health Service hospitals over a six-year period.

METHODS

All PCIs in Scotland during 1997-2003 were examined. Linkage to administrative databases identified events over two years' follow up. The risk of events by hospital volume at 30 days and two years was compared by using logistic regression and Cox proportional hazards models.

RESULTS

Of the 17,417 PCIs, 4900 (28%) were in low-volume hospitals and 3242 (19%) in high-volume hospitals. After adjustment for case mix, there were no significant differences in risk of death or myocardial infarction. Patients treated in high-volume hospitals were less likely to require emergency surgery (adjusted odds ratio 0.18, 95% confidence interval (CI) 0.07 to 0.54, p = 0.002). Over two years, patients in high-volume hospitals were less likely to undergo surgery (adjusted hazard ratio 0.52, 95% CI 0.35 to 0.75, p = 0.001), but this was offset by an increased likelihood of further PCI. There was no net difference in coronary revascularisation or in overall events.

CONCLUSION

Death and myocardial infarction were infrequent complications of PCI and did not differ significantly by volume. Emergency surgery was less common in high-volume hospitals. Over two years, patients treated in high-volume centres were as likely to undergo some form of revascularisation but less likely to undergo surgery.

Cross-transmission of nosocomial pathogens in an adult intensive care unit: incidence and risk factors

The incidence and determinants of cross-transmission in an adult intensive care unit (ICU) were examined under normal conditions. Four hundred and thirty patients were followed for 3947 patient-days. Cross-transmitted pathogens were identified by genetic typing. A cross-transmission episode was defined as when two or more patients had indistinguishable isolates and had been treated in the ICU during intervals up to seven days apart. The direction of cross-transmission was confirmed if the incriminated pathogen was isolated from the donor before admission of the recipient; otherwise, both patients could potentially be a donor or a recipient. These patients were excluded from the risk factor analysis. Recipients of pathogens were compared with those who were not involved in cross-transmission. Out of 22 056 examined specimens, 275 isolates were typed and 40 episodes of cross-transmission were detected. The overall incidence of cross-transmission was 10.7 [95% confidence intervals (CI) 7.6-14.5] per 1000 patient-days. In multivariate analysis, those who were nursed in an understaffed environment [odds ratio (OR) = 3.3, 95% CI 1.4-7.8], had a nasogastric tube (OR = 2.9, 95% CI 1.1-7.8) and were ventilated (OR = 2.5, 95% CI 1.1-6.0) for all of their stay, compared with none or part of their stay, showed an increase in the risk of cross-transmission. Repeated bronchoscopy (OR = 5.1, 95% CI 1.04-25) compared with no bronchoscopy and immunosuppresion (OR = 3.9, 95% CI 1.2-12.5) also increased the risk. This study showed that cross-transmission of nosocomial pathogens in the ICU is associated with understaffing, immunosuppression and factors that result in multiple staff/patient contacts, thus emphasizing the importance of hand hygiene.

Differential alteration of stem and other cell populations in ducts and lobules of TGFα and c-Myc transgenic mouse mammary epithelium

Genes associated with proliferation are active in stem and progenitor cells, and their over-expression can promote cancer. Two such genes, c-Myc and TGFalpha, promote morphologically dissimilar mammary tumors in transgenic mice. We investigated whether their over-expression affects population size and cell cycle activity in stem and other cell populations in non-neoplastic mammary epithelia. Results indicated that both cell population and cell cycle regulation are cell type- and microenvironment-specific. To create a tool for identifying and categorizing the five cellular phenotypes by light microscopy, we adapted previously established ultrastructural criteria. Using nulliparous MMTV-c-myc or MT-tgfalpha mice, we determined and compared the relative sizes the putative stem, progenitor and differentiated cell populations. PCNA staining was used to compare the portion of each cell population in the cell cycle. Cell population sizes were analyzed relative to: (1) their location in ducts versus lobules (microenvironment), (2) genotype, and (3) cell type. Population sizes differed significantly by genotype, depending on microenvironment (p=0.0008), by genotype, depending on cell type (p<0.0001), and by microenvironment, depending on cell type (p=0.03). The number of cycling cells was also affected by all three factors, confirming that the interplay of cell type, gene expression and three-dimensional organization are very important in tissue morphogenesis and function. We describe a structure in mammary epithelium consistent with that of a stem cell niche, and show that it is altered in MMTV-c-myc and likely altered in MT TGFalpha transgenic epithelia.

Results of a hydroxyapatite-coated (Furlong) total hip replacement

We describe the survival of 134 consecutive JRI Furlong hydroxyapatite-coated uncemented total hip replacements. The mean follow-up was for 14.2 years (13 to 15).

Patients were assessed clinically, using the Merle d’Aubigné and Postel score. Radiographs were evaluated using Gruen zones for the stem and DeLee and Charnley zones for the cup. Signs of subsidence, radiolucent lines, endosteal bone formation (spot welds) and pedestal formation were used to assess fixation and stability of the stem according to Engh’s criteria. Cup angle, migration and radiolucency were used to assess loosening of the cup. The criteria for failure were revision, or impending revision because of pain or loosening. Survival analysis was performed using a life table and the Kaplan-Meier curve.

The mean total Merle d’Aubigné and Postel score was 7.4 pre-operatively and 15.9 at follow-up. During the study period 22 patients died and six were lost to follow-up. None of the cups was revised. One stem was revised for a periprosthetic fracture following a fall but none was revised for loosening, giving a 99% survival at 13 years. Our findings suggest that the long-term results of these hydroxyapatite-coated prostheses are more than satisfactory.

Use of computer-aided detection (CAD) tools in screening mammography: a multidisciplinary investigation

We summarise a set of analyses and studies conducted to assess the effects of the use of a computer-aided detection (CAD) tool in breast screening. We have used an interdisciplinary approach that combines: (a) statistical analyses inspired by reliability modelling in engineering; (b) experimental studies of decisions of mammography experts using the tool, interpreted in the light of human factors psychology; and (c) ethnographic observations of the use of the tool both in trial conditions and in everyday screening practice. Our investigations have shown patterns of human behaviour and effects of computer-based advice that would not have been revealed by a standard clinical trial approach. For example, we found that the negligible measured effect of CAD could be explained by a range of effects on experts' decisions, beneficial in some cases and detrimental in others. There is some evidence of the latter effects being due to the experts using the computer tool differently from the intentions of the developers. We integrate insights from the different pieces of evidence and highlight their implications for the design, evaluation and deployment of this sort of computer tool.

Improvements in carotid endarterectomy in Scotland: results of a national prospective survey

BACKGROUND AND AIMS

The effectiveness of carotid endarterectomy (CEA) depends upon selection of patients with a high absolute risk of stroke, avoidance of delays from intial presentation to surgery and provsion of surgery with a low perioperative risk of stroke. We evaluated these aspects of practice in Scottish hospitals and, by encouraging adherence to national (SIGN) guidelines, attempted to improve the effectiveness of CEA.

METHODS

Prospective independent survey of patient selection, pre-operative delays and surgical performance for all CEAs performed in Scottish National Health Service hospitals over two 13 month periods from September 1997 and February 1999 respectively.

RESULTS

Thirteen hospitals performed 485 CEAs in the first period and 392 in the second, equating to an overall annual rate of 79 per million population. During both periods at least 95% of patients reported symptoms of carotid terittory ischaemia, but the proportion with stenoses greater than >70% rose from 89% to 97% (p<0.0001). The delays between referral, surgical consultation and subsequent surgery fell significantly but remained unacceptably long. The proportion seen by the surgeon within two weeks of referral rose from 36% to 43% (p=0.05) and the proportion operated on within one month thereafter rose from 35% to 49% (p<.0001). The perioperative combined major stroke and death rate was 3% in both periods.

CONCLUSION

We demonstrated significant changes in practice, in line with national guidelines, which would be expected to improve the effectiveness of our national programme of CEA. There is further scope for improving performance, particularly in relation to pre-operative delays.

Community-acquired Legionnaires' disease in Nottingham--too many cases?

The aim of this study was to compare the incidence of community-acquired Legionnaires' Disease in Nottingham with England and Wales and to explore reasons for any difference observed. Based on data from the National Surveillance Scheme for Legionnaires' Disease (1980-1999), the rate of infection in England and Wales was 1.3 per million/year compared with 6.6 per million/ year in Nottingham. Domestic water samples were obtained from 41 (95%) of 43 Nottingham cases between 1997 and 2000. In 16 (39%) cases, Legionella sp. were cultured in significant quantities. Proximity to a cooling tower was examined using a 1:4 case-controlled analysis. No significant difference in the mean distance between place of residence to the nearest cooling tower was noted (cases 2.7 km vs. controls 2.3 km; P = 0.5). These data suggest that Nottingham does have a higher rate of legionella infection compared to national figures and that home water systems are a source.

Who is being tested for genital chlamydia in primary care?

OBJECTIVES

To explore current patterns of testing for genital chlamydial infection in primary care, and to identify practice characteristics influencing testing rates.

METHOD

Aggregate numbers of chlamydia tests and results for each practice in Nottingham Health District were matched to practice characteristics. Age specific testing rates and diagnosed prevalence were calculated, and characteristics of the practice tested for association with chlamydia testing rates.

RESULTS

Most tests (63.1%) were performed on women over the age of 25, but the proportion of positive tests was highest in 15-19 year olds (13.3%) followed by 20-24 year olds (8.2%). A higher ratio of GP principals to female practice population was associated with higher testing rates and more chlamydia isolations, but the ratio of female GP principals to patients was associated with higher testing rates only in 20-24 year olds. Diagnosed incidence was greatest in more socioeconomically deprived practice populations, and this was not explained by higher testing rates. Men were rarely tested.

CONCLUSION

Current testing practice in primary care does not reflect the known epidemiology of genital chlamydia infection. Practices with lower doctor-patient ratios do less testing, and measures to enable their active participation in the envisaged screening programme will be important in reaching all at-risk groups.

Limited diversity of HLA-DRB1*02 alleles and DRB1-DRB5 haplotype associations in four United States population groups

At least 60 DRB1*02 positive individuals from each of four US population groups found within a hematopoietic stem cell volunteer donor registry - Caucasoids, African Americans, Asians/Pacific Islanders, and Hispanics - were randomly selected from a database of 82,979 individuals. DRB1*02 alleles were identified by DNA sequencing. A total of five of 23 known DRB1*02 alleles were detected. DRB1*15011 was the predominant DRB1*02 allele in Caucasoids and Hispanics. The most common DRB1*02 allele observed in African Americans was DRB1*1503, and DRB1*15021 in Asians/Pacific Islanders. Caucasoids were found to be the least diversified; only DRB1*15011 and DRB1*16011 were observed. A subset of individuals was also typed for DRB5 alleles by DNA sequencing. DRB5*01011, DRB5*0102, DRB5*0103, DRB5*0108N and DRB5*0202 were detected and nine DRB1-DRB5 haplotypes defined.

Working IT out in medical practice: IT systems design and development as co-realisation

OBJECTIVES

The paper explores possibilities for situating IT design and development work within the context of use so as to support the co-realisation of technology and 'design in use'. The aim is to build a new understanding between IT professionals and users which is grounded upon what happens as the latter grapple with the problems of applying IT, appropriating its functionalities and affordances into their work practices and relations.

METHODS

Following a discussion of participatory design and ethnomethodology, a novel method called co-realisation, which aims to provide a synthesis of the preceding methods, is suggested as an alternative. Through a discussion of findings from a case study of IT systems design and development in healthcare we show how the co-realisation approach might provide work-affording systems and how user-designer relations might be reformulated. We suggest that work-affording systems can be developed through the deployment of an engaged facilitator who works with the users to unpack the work site-specific potentialities of technology.

RESULTS

The case study shows how risk of non-adoption might be minimised through the development of partnerships, and how the presence of the facilitator in the workplace capitalises on the mundane work undertaken therein and how the facilitator might work with the users to develop artefacts that support this work as opposed to reconfiguring it.

CONCLUSIONS

The case study illustrates co-realisation in action and how it might be seen to reconfigure relations between users and designers in a way that appears productive. Co-realisation can help address the widely observed problem of IT systems failures in healthcare.

Trusting the record

OBJECTIVES

This paper aims to contribute to a longstanding interest in documents and paperwork in healthcare work through an examination of everyday work with patient records in a clinic.

METHODS

An ethnographic study of record keeping practices in a deliberate self harm clinic was conducted to consider the role that document work plays in the development of trust in the routine social interactions of a working division of labor.

RESULTS AND CONCLUSIONS

Issues of trust are seen to play central roles within the complexities of organizational working and some consequent implications for the deployment and use of electronic medical record systems are considered.

Modelling the effects of the reorganization of vascular services

Background

Vascular services are currently in a state of evolution in many areas. A study has been carried out to model the economic and outcome implications of possible reconfiguration of vascular services.

Methods

Computer modelling was carried out based on an urban area with a teaching hospital (TH) and four surrounding district hospitals (DGHs) serving a population of 1·8 million. Data for the model were derived from a number of sources including local activity analysis, record linkage for cross-boundary flows, local audit, prospective surveys and systematic literature reviews.

Results

Analysis demonstrated a number of key differences in service provision between the TH and DGHs which were consistent with findings from literature reviews. These included differences in the use of endovascular treatments and femorodistal bypass, differences in case-mix and rates of particular procedures, and differences in outcome as measured by mortality and amputation rates. Computer modelling examined a number of options for the reconfiguration of services, including variations on fully centralized and hub and spoke arrangements. Cost estimates suggested that centralization and hub and spoke would result in an increased cost of £1 240 000–1 430 000 per year for the entire service, with over 80 per cent of these costs being related to expected increases in activity. Consideration of a number of key areas suggested that the resultant changes would save approximately 20 lives, 65 amputations and seven strokes per year for the population under consideration.

Conclusion

Reconfiguration of vascular services is likely to be highly cost effective. There is little difference in expected cost and outcomes between fully centralized and hub and spoke arrangements but the latter is preferred on the basis of decreased shift of resources and strong patient preference for local services.

Prospective audit of carotid endarterectomy in Scotland

Background

Carotid endarterectomy (CEA) is a proven means of stroke prevention provided it is performed in appropriate patients, soon after the index ischaemic event and with low perioperative morbidity and mortality rates. This study investigated how well these conditions are being met in Scotland.

Methods

This was a prospective study of all 485 CEAs performed in National Health Service hospitals between 1 September 1997 and 31 September 1998. Data collection was by four independent research nurses.

Results

The median patient age was 67 (interquartile range 61–73) years; 461 patients (95 per cent) were operated on for focal symptoms, 389 of whom had a stenosis of 70 per cent or more. Some 36 per cent of patients were seen by the operating surgeon within 2 weeks of referral and 35 per cent were operated on within 1 month thereafter. The perioperative combined major stroke and death rate was 3 per cent. Operations were performed by 30 surgeons in 13 hospitals. The number of CEAs per surgeon ranged from one to 49, with ten surgeons undertaking fewer than ten operations. The number of CEAs per hospital ranged from four to 99 with only three surgeons undertaking more than 50 operations. The number of CEAs per hospital ranged from four to 99 with three hospitals undertaking 50 or more operations in the study period.

Conclusion

Despite the ‘diffuse’ nature of vascular surgical services necessitated by the demography and geography of Scotland, CEA is currently being performed with a perioperative major stroke and death rate substantially lower than that reported from randomized controlled trials. However, the overall effectiveness of surgery might be improved by reducing the delays to surgery.