The incidence of device related bacteraemia in teaching
hospitals is more than twice that in other hospitals in England, and central
lines are the most commmon source, a new study has found. The incidence of
methicillin resistance Istaphylococcus Aureus (MRSA) was also found to be
higher in teaching hospitals.
Surveillance targeted at devices is the most efficient
strategy for dealing with the problem, say the authors, from the Public Health
Laboratory Service (Journal of Hospital Infection 2003;53;46-57).
In the study, the authors analysed data from the nosocomial
infection national surveillance scheme. They found that from 1997 to 2001, 7380
episodes of hospital acquired bacteraemia were reported from 73 NHS acute
hospitals – 17 teaching and 56 non-teaching hospitals. Of the episodes
examined, 2091 were from 388 083 patients in teaching hospitals and 4865 were
from 1 718 126 patients in non-teaching hospitals.
Device related sources were responsible for 52.4% and 43.2% of all hospital
acquired bacteraemia in teaching and non-teaching hospitals respectively.
Sources not related to devices accounted for about a quarter of all cases of
hospital acquired bacteraemia
Ref:
web
Back to top
Changes in the delivery of primary care have led to an
increase in workload. Much of this workload is accounted for by requests for
same day appointments (urgent appointments), home visits, and out of hours
calls. Studies of the effect of triage on workload have been small and had a
restricted focus (for example, calls in the morning only, out of hours, and home
visit requests received before 10.30 am).
Triage has been reported to reduce general practitioners same
day activity by between 25% and 49%, but only one small study examined use of
services after triage. This study found an increased rate of return to the
practice within the first week after triage.
The authors investigated the effect on general practitioner
and nurse workloads and cost of patient care of nurse telephone triage and
standard appointment management systems – both operating routinely in primary
care. A multiple interrupted time series analysis was used with
sequential introduction of the experimental triage system in different sites.
Repeated measures were taken one week in every month for 12 months.
The study was set in three primary care sites in York.
There were 4685 patients: 1233 in standard management, 3452 in the triage
system. All patients requesting same day appointments during study weeks were
included in the trial. The type of consultation (telephone, appointment, or visit),
time taken for consultation, presenting complaints, use of services during the
month after same day contact, and costs of drugs and same day, follow-up, and
emergency care were measured.
The triage system reduced appointments with general
practitioner by 29-44%. Compared with standard management, the triage system had
a relative risk of 0.85 for home visits, 2.41 for telephone care, and 3.79 for
nurse care.
The mean overall time in the triage system was 1.70 minutes
longer, but mean general practitioner time was reduced by 2.45 minutes. Routine
appointments and nursing time increased, as did out of hours and accident and
emergency attendance. Costs did not differ significantly between standard
management and triage: mean difference £1.48 more per patient for triage
Overall triage reduced the number of same day appointments
with general practitioners but resulted in busier routine surgeries, increased
nursing time, and a small but significant increase in out of hours and accident
and emergency attendance. Consequently, triage does not reduce overall costs per
patient for managing same day appointments.
Ref:
web
Back to top
At this time of the year as the sap starts to rise we begin
to think about … jogging again. This naturally leads to the treatment of
fungal infections of the foot. Bandolier has recently produced an article on
this.
Fungal infections of the foot are remarkably common,
affecting about 15% of people in the UK. Topical fungicides, some available
without prescription from chemists, are the first treatment option. When they
fail, oral fungicides can be tried. There are two systematic reviews to tell us
how effective these are.
An immediate reflection on these trials is, that for a common
complaint, how small was the total number of patients treated, and how small
were many of the trials.
Both the reviews have a brief discussion about cost
effectiveness, based on acquisition costs of medicines and effectiveness from
trials. For a number of possible treatments any estimate of the size of the
treatment effect is little more than a guess because the numbers are so small.
The best evidence was for topical azoles and allylamines,
with 480 and 706 patients. For all others there was information on fewer than
200 patients, and for oral griseofulvin only 33. It is impossible to do useful
cost effectiveness work when the limits on knowledge of effectiveness are so
profound.
Some of these treatments cost more than others, and some work
better than others. Maybe we should ask whether we should use treatments for
which there is little information, especially when the evidence we have says
they are less effective. Treatments that are more effective will probably cost
less in the end, especially when it means patients do not have to come back so
often.
In a health service where lack of capacity is the big issue,
interventions that relieve the strain on capacity should have a premium to
balance against acquisition costs.
The second review begins to address this argument for the
economic comparison of oral griseofulvin versus oral terbinafine. Even though
griseofulvin has a lower aquisition cost, the implication from the trial results
is that terbinafine is actually cheaper when a consultation costs more than
£25.
Given that in some areas of the UK general practitioners are
thin on the ground, the traditional cost of a GP visit of about £16 may need
revision.
Ref:
Bandolier
Back to top
