- Email: [email protected]
Treatment guidelines and medical audit
877
coordinating centre should be set up in the UK to disseminate policies and guidelines (including guidelines for investigations). Suggestions about who might take on this project included the Royal Colleges, the King’s Fund Centre, and a regional health authority.
Conference Treatment guidelines and medical audit "Closing the loop" in medical audit is a difficult issue both understand and to put into practice. It is, however, fundamental to the audit process that any change implemented as a result of audit is itself evaluated (the re-audit part of the cycle). At a symposium held at St George’s Hospital Medical School in London last week, Charles Shaw (King’s Fund) argued that treatment guidelines (or care protocols) should be an integral part of the audit cycle. An example of how treatment guidelines can close the loop is seen in the management of gastrointestinal bleeds at St George’s: the application of criteria for action led to better use of endoscopy facilities and a large reduction in mortality among high-risk patients. Guidelines can be developed locally or adapted from national guidelines (the British Thoracic Society guidelines for the care of asthma patients being a good example of the latter). Alternatively, clinicians in one hospital might decide to adapt guidelines from another hospital or district. Why
to
re-invent the wheel? The purpose of the symposium was to determine whether there is a need for a guideline coordinating centre. Dr Joe Collier (St George’s) presented the results of a national survey that gave a picture of the position on April 1, 1991, the date when the new NHS managements were introduced in UK hospitals and when the setting of standards for treatment and the introduction of audit became official NHS policy. The study showed that fewer than 50% of NHS hospitals had treatment guidelines in place and fewer than 10% had guidelines that could be considered
comprehensive. The introduction of treatment guidelines in the USA has been driven largely by litigation and risk assessment. The motivation in the UK comes mainly from a professional desire to monitor the quality of treatment and to provide clear guidelines for junior staff. Thus guidelines focus
predominantly
on
particular diagnostic categories
or
drug
The UK can, however, learn from the risk assessment approach in the US. An example of this would be an audit of all hospital inpatient falls, which would then lead to the introduction of a protocol for the prevention of falls in hospital. The result would be a reduction in the risk of falls (and litigation) for the hospital. In the new NHS the implementation of a risk strategy such as this could influence a purchaser’s choice of where to place a contract for medical
use.
care.
Non-adherence to treatment guidelines is not illegal, as Mr John Finch (Centre for Health Care Law) explained. In a court of law a complainant would still be required to prove negligence. Some delegates were concerned about the use of national, rigid guidelines that may leave no room for justifiable variations. Mr Finch suggested that if audit resulted in a reductionist approach, which excluded potentially beneficial treatments as a means of controlling resources, health authorities (or trusts) might be found legally responsible for promoting dangerous practice. Guidelines cannot be deemed to be effective if they do not reach the people for whom they are intended. One survey showed that a set of local guidelines, which had been available for 12 years, still reached only 57% of the medical staff, despite impressive attempts at distribution. The meeting ended with agreement that a guideline
Clinical Audit Unit, Lewisham Hospital, London SE13
Janet Richardson
Hereditary non-polyposis colorectal Hereditary non-polyposis colorectal
cancer
cancer
(HNPCC)
for 5-10% of all the cases of colorectal cancer (CRC). At its second meeting last year in Amsterdam (Dis Colon Rectum 1991: 34: 224-25), the International Collaborative Group on HNPCC agreed on a set of minimum criteria for recruitment of patients to the collaborative studies. (1) At least three relatives should have histologically verified colorectal cancer, and one of them should be a first-degree relative of the other two; familial adenomatous polyposis should be excluded. (2) At least two successive generations should be affected. (3) In one of the relatives colorectal cancer should be diagnosed before age 50. The group met again, in Turin, on Sept 22. Some of the members felt that, if they applied the "Amsterdam criteria", several families, especially those with the combination of colon cancer and endometrial cancer, frequently encountered in HNPCC, could not be classified as HNPCC. In discussion, it was clarified that the Amsterdam criteria are not meant to formulate a new definition of HNPCC but rather to provide a basis for uniformity in multicentre studies. Three investigations were proposed in Amsterdam, of which two are still in progress. The completed study, designed to ascertain the number of families in the various centres, the recommended screening procedures, the age at diagnosis of CRC, and the occurrence of interval cancers, includes data on 165 families from Denmark, Finland, Italy, Japan, The Netherlands, Switzerland, and the USA. Regarding screening, most centres advise colonoscopy as the only procedure. The interval between examinations varies from 1 to 3 years. In most centres screening begins at 20-25 years. Lifelong screening is recommended by three centres; the others advise discontinuation at age 60-75 years. The family material included 840 patients with CRC. The mean age at diagnosis was 45 years, and about 15% were diagnosed at age 60 or later. A total of 682 high-risk relatives are being followed, and after follow-up ranging from 1 to 10 years the incidence of interval cancers seems low (6 in all). The following studies were proposed: a randomised controlled trial to evaluate the appropriate interval between screening examinations (P. Lynch); development of strategies for cooperative linkage studies (T. Bishop); investigations to determine whether young patients with CRC diagnosed below age 40 represent new mutations (J.-P. Mecklin); and inquiry into the epidemiology of endometrial cancer in HNPCC (H. Vasen).
accounts
Contact: Secretariat ICG-HNPCC, Foundation for the Detection of Hereditary Tumours, c/o University Hospital, Rijnsburgerweg 10, bldg 50, 2333 AA Leiden, Netherlands. H. F. A. Vasen
J.-P. Mecklin P. Meera Khan H. T. Lynch
coordinating centre should be set up in the UK to disseminate policies and guidelines (including guidelines for investigations). Suggestions about who might take on this project included the Royal Colleges, the King’s Fund Centre, and a regional health authority.
Conference Treatment guidelines and medical audit "Closing the loop" in medical audit is a difficult issue both understand and to put into practice. It is, however, fundamental to the audit process that any change implemented as a result of audit is itself evaluated (the re-audit part of the cycle). At a symposium held at St George’s Hospital Medical School in London last week, Charles Shaw (King’s Fund) argued that treatment guidelines (or care protocols) should be an integral part of the audit cycle. An example of how treatment guidelines can close the loop is seen in the management of gastrointestinal bleeds at St George’s: the application of criteria for action led to better use of endoscopy facilities and a large reduction in mortality among high-risk patients. Guidelines can be developed locally or adapted from national guidelines (the British Thoracic Society guidelines for the care of asthma patients being a good example of the latter). Alternatively, clinicians in one hospital might decide to adapt guidelines from another hospital or district. Why
to
re-invent the wheel? The purpose of the symposium was to determine whether there is a need for a guideline coordinating centre. Dr Joe Collier (St George’s) presented the results of a national survey that gave a picture of the position on April 1, 1991, the date when the new NHS managements were introduced in UK hospitals and when the setting of standards for treatment and the introduction of audit became official NHS policy. The study showed that fewer than 50% of NHS hospitals had treatment guidelines in place and fewer than 10% had guidelines that could be considered
comprehensive. The introduction of treatment guidelines in the USA has been driven largely by litigation and risk assessment. The motivation in the UK comes mainly from a professional desire to monitor the quality of treatment and to provide clear guidelines for junior staff. Thus guidelines focus
predominantly
on
particular diagnostic categories
or
drug
The UK can, however, learn from the risk assessment approach in the US. An example of this would be an audit of all hospital inpatient falls, which would then lead to the introduction of a protocol for the prevention of falls in hospital. The result would be a reduction in the risk of falls (and litigation) for the hospital. In the new NHS the implementation of a risk strategy such as this could influence a purchaser’s choice of where to place a contract for medical
use.
care.
Non-adherence to treatment guidelines is not illegal, as Mr John Finch (Centre for Health Care Law) explained. In a court of law a complainant would still be required to prove negligence. Some delegates were concerned about the use of national, rigid guidelines that may leave no room for justifiable variations. Mr Finch suggested that if audit resulted in a reductionist approach, which excluded potentially beneficial treatments as a means of controlling resources, health authorities (or trusts) might be found legally responsible for promoting dangerous practice. Guidelines cannot be deemed to be effective if they do not reach the people for whom they are intended. One survey showed that a set of local guidelines, which had been available for 12 years, still reached only 57% of the medical staff, despite impressive attempts at distribution. The meeting ended with agreement that a guideline
Clinical Audit Unit, Lewisham Hospital, London SE13
Janet Richardson
Hereditary non-polyposis colorectal Hereditary non-polyposis colorectal
cancer
cancer
(HNPCC)
for 5-10% of all the cases of colorectal cancer (CRC). At its second meeting last year in Amsterdam (Dis Colon Rectum 1991: 34: 224-25), the International Collaborative Group on HNPCC agreed on a set of minimum criteria for recruitment of patients to the collaborative studies. (1) At least three relatives should have histologically verified colorectal cancer, and one of them should be a first-degree relative of the other two; familial adenomatous polyposis should be excluded. (2) At least two successive generations should be affected. (3) In one of the relatives colorectal cancer should be diagnosed before age 50. The group met again, in Turin, on Sept 22. Some of the members felt that, if they applied the "Amsterdam criteria", several families, especially those with the combination of colon cancer and endometrial cancer, frequently encountered in HNPCC, could not be classified as HNPCC. In discussion, it was clarified that the Amsterdam criteria are not meant to formulate a new definition of HNPCC but rather to provide a basis for uniformity in multicentre studies. Three investigations were proposed in Amsterdam, of which two are still in progress. The completed study, designed to ascertain the number of families in the various centres, the recommended screening procedures, the age at diagnosis of CRC, and the occurrence of interval cancers, includes data on 165 families from Denmark, Finland, Italy, Japan, The Netherlands, Switzerland, and the USA. Regarding screening, most centres advise colonoscopy as the only procedure. The interval between examinations varies from 1 to 3 years. In most centres screening begins at 20-25 years. Lifelong screening is recommended by three centres; the others advise discontinuation at age 60-75 years. The family material included 840 patients with CRC. The mean age at diagnosis was 45 years, and about 15% were diagnosed at age 60 or later. A total of 682 high-risk relatives are being followed, and after follow-up ranging from 1 to 10 years the incidence of interval cancers seems low (6 in all). The following studies were proposed: a randomised controlled trial to evaluate the appropriate interval between screening examinations (P. Lynch); development of strategies for cooperative linkage studies (T. Bishop); investigations to determine whether young patients with CRC diagnosed below age 40 represent new mutations (J.-P. Mecklin); and inquiry into the epidemiology of endometrial cancer in HNPCC (H. Vasen).
accounts
Contact: Secretariat ICG-HNPCC, Foundation for the Detection of Hereditary Tumours, c/o University Hospital, Rijnsburgerweg 10, bldg 50, 2333 AA Leiden, Netherlands. H. F. A. Vasen
J.-P. Mecklin P. Meera Khan H. T. Lynch