A recent paper in Medical Care from the USA has suggested that analysis of hospital outcome measures, a very relevant question since the Bristol enquiry and the Shipman case, is too complex, often inaccurate and may be incomplete. They suggest a means of standardising outcomes. They suggest that analyses should be restricted to comparisons of subgroups of patients in which a close fit exists between the quality of care for the disease state and the expected outcome. This approach is unproven but seemed an interesting research attempt to look at outcomes.

Since their inception, quality-assessment studies based on administrative data have been criticised for their imprecision. Various risk-adjustment methods have been devised to make the screens more precise, but unexplained differences in inpatient populations may persist. The model described by the authors is to select specific disease-outcome pairs, rather than risk adjustment across all disease categories. The outcome looked at by the authors included unplanned readmissions, but the model could be used to monitor other outcomes of hospital care, such as complications and mortality.

They chose eight criteria that have been outlined for the selection of disease-outcome pairs to be studied in large administrative data base analysis:

• The disease should be well defined and easily diagnosed

• If disease groups are used, they should be clinically homogeneous

• The disease must be prevalent

• The disease should not be affected by the limitations of the ICD-9 coding scheme

• There must be a medically plausible link between the outcome and the inpatient process of care

• The limitations of the administrative database, especially completeness must be considered

• Care that leads to the outcome, but conforms to practice standards must be excluded

• The outcome must be prevalent

A panel of experts identified suitable subjects according to the above criteria. Some similar work was required of the experts to decide if the outcome chosen was relevant to the disease in question.

A recent BMJ leading article looked at the effectiveness of specialist liaison nurses. It made the point that the number and roles of clinical nurse specialists continue to increase in many areas of health care, despite limited evidence about their use. Nevertheless, nurses now lead services, admit and discharge patients, make autonomous clinical decisions, and organise programmes of care. What do we know about the use of such nurses and about their effectiveness?

A database maintained at the University of Sheffield identifies 603 specialist posts in 40 acute trusts, but most of these emerging new initiatives have not been reliably evaluated. The UK nursing registration body (the United Kingdom Central Council) does not define standards or set specific training for clinical nurse specialists or nurse practitioners, and, since the title is not protected, it can be used by any registered nurse. The council has, however, issued proposals for a professional standards framework for these developing roles.

In terms of what these specialist nurses do best there is less consensus. Few randomised-controlled trials have looked at the value of clinical nurse specialists in terms of clinical and cost effectiveness, although evaluative surveys have revealed high levels of satisfaction with the care received. One randomised trail investigated the role of the specialist nurse for patients with stroke in the community and showed that specialist nurse intervention (advice, information, and support to patients and their families) resulted in, at best, a small improvement in social activities, and only for mildly disabled patients.

A number of randomised trials of the effects of a specialist nurse co-ordinator for terminally ill patients and those after myocardial infarction showed little difference in patient or family outcomes.

Evidence of nurse led interventions in heart failure is more positive. Nurses’ involvement in pre-discharge patient education and home visiting, concentrating on adherence to treatment and recognising early signs of deterioration, has shown significant reductions in readmission rates and quality of life. Another nurse specialism with positive outcomes is anticoagulation management: nurse specialists are no more expensive than the consultant service, are at least as effective in terms of control, and offer some clear advantages.

Some of the early work on practice variation in hospital was done on urinary tract infection. Interesting to see the exercise being repeated some 30 years later in general practice. Take heart UK GPs, this was done in the USA.

200 family practitioners were asked how to treat the following patient:

A 30 year old woman with a one day history of urinary urgency, dysuria, and blood in the urine. She was an established patient to the practice with two prior episodes of UTI.