[Show abstract][Hide abstract] ABSTRACT: Carotid endarterectomy (CEA) reduces the risk of stroke in patients with internal carotid stenosis of 50-99 per cent. This study assessed national surgical practice through audit of CEA procedures and outcomes.
This was a prospective cohort study of UK surgeons performing CEA, using clinical audit data collected continuously and reported in two rounds, covering operations from December 2005 to December 2007, and January 2008 to September 2009.
Some 352 (92·6 per cent) of 380 eligible surgeons contributed data. Of 19,935 CEAs recorded by Hospital Episode Statistics, 12,496 (62·7 per cent) were submitted to the audit. A total of 10,452 operations (83·6 per cent) were performed for symptomatic carotid stenosis; among these patients, the presenting symptoms were transient ischaemic attack in 4507 (43·1 per cent), stroke in 3572 (34·2 per cent) and amaurosis fugax in 1965 (18·8 per cent). The 30-day mortality rate was 1·0 per cent (48 of 4944) in round 1 and 0·8 per cent (50 of 6151) in round 2; the most common cause of death was stroke, followed by myocardial infarction. The rate of death or stroke within 30 days of surgery was 2·5 per cent (124 of 4918) in round 1 and 1·8 per cent (112 of 6135) in round 2.
CEA is performed less commonly in the UK than in other European countries and probably remains underutilized in the prevention of stroke. Increasing the number of CEAs done in the UK, together with reducing surgical waiting times, could prevent more strokes.
British Journal of Surgery 02/2012; 99(2):209-16. DOI:10.1002/bjs.7810 · 5.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Data are limited on the proportion of stroke patients nationally appropriate for thrombolysis either within the 3 h time window or the recently tested 4.5 h. This information is important for the redesign of services.
Data on case mix, eligibility for thrombolysis, treatment and outcomes were extracted from the National Sentinel Stroke 2008 Audit dataset. This contains retrospective data on up to 60 consecutive stroke admissions from each acute hospital in England, Wales and Northern Ireland between 1 April and 30 June 2008.
All relevant hospitals participated, submitting data on 11,262 acute stroke patients. 2118 patients arrived within 2 h and 2596 within 3 h of the onset of symptoms and 587 people were already in hospital. Therefore, 28% (3183) were potentially eligible for thrombolysis based on a 3 h time criterion. Of these, 1914 were under 80 years and 2632 had infarction with 14% (1605) meeting all three National Institute of Neurological Disorders and Stroke study criteria and so being potentially eligible for thrombolysis. If the time window is increased to 4.5 h then only another 2% became eligible. If the age limit was removed for treatment, the percentage potentially appropriate for tissue plasminogen activator increased to 23% within 3 h and 26% within 4.5 h. Overall, 1.4% (160) of patients were thrombolysed.
Thrombolysis rates are currently low in the UK. 14% of patients in this sample were potentially suitable for thrombolysis using the 3 h time window. This would only increase marginally if thrombolysis was extended to include those up to 4.5 h. The greatest impact on increasing the proportion of patients suitable for thrombolysis would be to increase the number of patients presenting early and by demonstrating that the treatment is safe and effective in patients over 80 years of age.
Journal of neurology, neurosurgery, and psychiatry 01/2011; 82(1):14-9. DOI:10.1136/jnnp.2009.203174 · 6.81 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To establish current physiotherapy practice in the secondary management of falls and fragility fractures compared with national guidance.
Web-based national clinical audit.
Acute trusts (n=157) and primary care trusts (n=146) in England, Wales and Northern Ireland.
Data were collected on 5642 patients with non-hip fragility fractures and 3184 patients with a hip fracture. Those patients who were bedbound or who declined assessment or rehabilitation were excluded from the analysis. Results indicate that of those with non-hip fractures, 28% received a gait and balance assessment, 22% participated in an exercise programme, and 3% were shown how to get up from the floor. For those with a hip fracture, the results were 68%, 44% and 7%, respectively.
Physiotherapists have a significant role to play in the secondary prevention of falls and fractures. However, along with managers and professional bodies, more must be done to ensure that clinical practice reflects the evidence base and professional standards.
[Show abstract][Hide abstract] ABSTRACT: The standards of care for older people who present with a fractured neck of femur (#NOF) have been defined by previously published national guidelines. To assess compliance with these standards the Healthcare Commission commissioned the Clinical Effectiveness and Evaluation Unit (CEEU) for the Royal College of Physicians to deliver 'The National Clinical Audit of Falls and Bone Health for Older People'.
The audit was developed by a multi-disciplinary team using available best evidence to set audit standards. All acute hospital trusts admitting orthopaedic trauma cases and all primary care trusts (PCTs) in England were recruited. Patients >65 years old presenting with a proven #NOF were included in the audit with a target of 20 cases per participating site.
Data was entered for 3184 #NOF patients. 80% (2555/3184) were female with a median age of 83 years admitted from their own home (68% 2152/3184). Over 97% (3172/3184) presented to the A&E department on the same day as the fall (88% 2813/3184). The time in the A&E department was less than 2h in only 20% (640/3133) of cases with 23% (716/3133) having a stay of >240min. 35% (1080/3088) of #NOF patients were operated on within 24h of admission. Causes of delay to theatre included awaiting medical review (59% 566/956) or organisational reasons (29% 278/956). 48% (1480/2998) of patients were sat out of bed within 24h. Only 35% (1115/3184) of patients were cared for in an orthogeriatric setting. The median length of stay for the #NOF patients was 16 days with an interquartile range of 10-27 days.
There are currently unacceptable wide variations in the delivery of clinical care to older people presenting with a #NOF. Of concern were the long lengths of time in A&E for many patients and the low level of routine access to pre-operative medical assessment. It is hoped that the launch of joint initiatives between the British Orthopaedic Association and the British Geriatric Society aimed at delivering service improvements in this area should lead to improved outcomes.
[Show abstract][Hide abstract] ABSTRACT: To assess timeliness of carotid endarterectomy services in the United Kingdom.
Observational study with follow-up to March 2008.
UK hospitals performing carotid endarterectomy.
UK surgeons undertaking carotid endarterectomy from December 2005 to December 2007.
Provision and speed of delivery of appropriate assessments of patients; carotid endarterectomy and operative mortality; 30 day postoperative mortality.
240 (61% of those eligible) consultant surgeons took part from 102 (76%) hospitals and trusts. Of 9913 carotid endarterectomies recorded on hospital episode statistics, 5513 (56%) were included. Of the patients who underwent endarterectomy, 83% had a history of transient ischaemic attack or stroke. Of these recently symptomatic patients, 20% had their operation within two weeks of onset of symptoms and 30% waited more than 12 weeks. Operative mortality was 0.5% during the inpatient stay and 1.0% (95% confidence interval 0.7% to 1.3%) by 30 days.
Only 20% of symptomatic patients had surgery within the two week target time set by the National Institute for Health and Clinical Excellence (NICE). Although operative mortality rates are comparable with those in other countries, some patients might experience disabling or fatal stroke while waiting for surgery and hence not be included in operative statistics. Major improvements in services are necessary to enable early surgery in appropriate patients in order to prevent strokes.
[Show abstract][Hide abstract] ABSTRACT: This paper presents the methods and findings of a survey of current service configuration in tuberculosis screening, treatment and prevention in England and Wales, which was conducted as part of the development of the National Institute for Health and Clinical Excellence guidelines on tuberculosis for the country.
A random sample of health protection units (HPUs) was surveyed (stratified geographically) in England. For Wales, National Health Service boundaries were used. There was a 100% sample of HPUs (33 clinics) in London and a 50% sample (81 clinics) outside London. The survey was completed by nurses in tuberculosis clinics. The questionnaire asked for details of caseload in terms of active disease (notified cases) and latent infection (screening and chemoprophylaxis), and the different types of specialist tuberculosis services offered.
Completed surveys were obtained from 67 of 81 clinics outside London and all 33 clinics in London. An association was found between the number of notifications and personnel, in line with previous British Thoracic Society guidelines. Higher notification areas, especially in London, provide additional specialist services such as human immunodeficiency virus/tuberculosis clinics and specialist paediatric clinics. Clinics in London also reported higher usage of incentives, directly observed therapy (DOT) and free prescriptions. Low notification areas outside London tend to see more patients at home for contact tracing and treatment review. However, there is considerable variation in the use of DOT and chemoprophylaxis that is not entirely explained by differences in caseload.
The survey showed that service configuration was organized in different ways in both high and low incidence areas. There is a need to share good practice and explore ways to configure services effectively in line with local needs.
Public Health 07/2008; 122(6):602-12. DOI:10.1016/j.puhe.2007.09.015 · 1.43 Impact Factor