Follow-up to D&Cs

Anna Howard and Nigel Moss have followed up the data on D&Cs, which we produced in December 1997. The following is a shortened version of their report. The review of 1995/6 hospital data suggested that there was inappropriate use of D&C for dysfunctional uterine bleeding in women aged under 40 years. The scientific evidence suggests that D&C for dysfunctional uterine bleeding should be restricted to women aged over 40 on the grounds that serious pathology is very uncommon in younger women and not likely to be detected by a D&C.

There were more than 36,000 Gynaecology discharges in 1996/97 in Bro Taf. A D&C procedure was recorded for 666 episodes, a 20% decrease on the number recorded for the previous year. 79 episodes occurred in cases with a primary diagnosis of dysfunctional bleeding (menorrhagia) compared with 107 for 1995/96.

The latest data show that D&C is still the largest single operative procedure performed on women under 40 with a primary diagnosis of menorrhagia. Figure 1 shows the hospitals recording D&C between 1995/96 and 1996/97. The number in Porth hospital fell by over 50%. This reduction is believed to have arisen largely from changes in coding procedures.

The proportion of women of all ages given a D&C as day cases varied considerably: Porth (88%) and Caerphilly (60%) were much greater, whilst East Glamorgan (10%) had a proportion significantly less than the 42% average.

The proportion of D&Cs under the age of 40 years compared with all ages was highest in Porth and Llandough at 36% of all cases.

In view of the small numbers of cases where D&C may have been inappropriately used, it may be more worthwhile looking at how care for dysfunctional bleeding is organised within primary care and the appropriateness of referral to secondary care.

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Waiting times are here again

Waiting times by consultant are back on the Internet. This will be of help to many people, especially general practitioners who wish to choose a consultant with a short waiting list. To remind readers the Internet address is:

http://www.open.gov.uk/hmis/specproc.htm

Sadly the data are old - from December 1997. They badly need to be updated. This valuable resource really needs to be sorted out. It seems to us that the Welsh office need to concentrate a bit more on useful data

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The Quince online!

We are pleased to say that The Quince is now on the Internet, as you will know if you are reading this! The Internet address - just to repeat it - is:

http://www.normanvetter.com/Quince/

You will find all of the past issues here, though in a slightly different format from the Newsletter itself. We have yet to learn how to do double columns in .html! The figures aren't too great either, but we're still learning.

Do let us know what you think!

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Follow-up to antibiotic resistance

Bryn Davies the General Practice Adviser for Bro Taf has written to us following the piece on antibiotic resistance

I note your Bulletin on this topic in the Issue 5 April ‘98 of the Quince. As far as antibiotic usage in the Bro Taf area is concerned it has declined by approximately 2% in the last year ending December 1997. This may of course be a reflection of the low incidence of influenza last winter but it is pleasing to note that we do not have a deepening problem.

I would also like to draw attention to the fact that detailed guidance on the use of anti-infectives has been issued to all general practitioners and consultants recently in the District Medical Committee Professional Guidance Document. These guidelines were drawn up by a group of microbiologists and general practitioners working together to produce guidance based on evidence.

Anyone who wishes to obtain a copy can get one from Bryn at Bro Taf HQ, Churchill House.

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How much of what we do is effective - 20%?

The phrase "20-25% of medical decisions are evidence-based" comes from a series of conjectures, many of them humorous, starting back in the 70's. For example, in an exchange between two giants of epidemiology, Kerr White (who related the incident to Iain Chalmers) and Archie Cochrane, Kerr suggested that "only about 15-20% of physicians' interventions were supported by objective evidence that they did more good than harm". Archie interrupted him with: "Kerr, you're a damned liar! you know it isn't more than 10%".

Shortly thereafter, the US Congress's Office of Technology Assessment reported that "only 10% to 20% of all procedures currently used in medical practice have been shown to be efficacious by controlled trial" and repeated the charge in 1983. Richard Smith in the BMJ more recently repeated these gloomy figures on this side of the Atlantic

David Sackett reported that he decided to determine the proportion of patients whose most important intervention for their most important diagnosis were based on systematic reviews or RCTs, or convincing non-experimental evidence (don't need an RCT to tell you that it's good to shock a VF-arrest), or without convincing evidence.

The study was followed by a series of others of about the same design. They found that their service treated 53% of its patients on the basis of systematic reviews and RCTs, another 29% on the basis of convincing non-experimental evidence, and just 19% on the basis of guessing and hope [Lancet 1995;346:407-10].

Psychiatric services, both in-patient (67% of admissions treated on the basis of systematic reviews and RCTs) [Quality in Health Care 1996;5:215-7] and out-patient psychiatry documented results as good or better as those in medicine.

A consecutive series of consultations in general practice in Leeds found 31% based on RCTs and 51% based on convincing non-experimental evidence [BMJ 1996;312:819-21].

So it ain't perfect, but by concentrating on evidence you can improve it.

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Contact Dr N J Vetter, the editor of this newsletter (01222 – 744196) for an up-to date list, or to add to the list, or if you want more or less copies of The Quince

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