Audit Advisory Group Research Articles

Young-onset type 2 diabetes: A neglected group requiring urgent attention.

Dr Soon H Song is a member of the NICE Diabetes Update Guideline Committee and National Diabetes Audit Advisory Group for Young Type 2 Diabetes. Professor Brian M Frier has no conflict of interest to declare.

A multi-centre audit of epistaxis management in England: is there a case for a national review of practice?

The ENT-UK Clinical Audit and Practice Advisory Group initiated a pilot audit to investigate variance in epistaxis management between six units nationwide. All patients with a diagnosis of epistaxis who were admitted for in-patient care at six ENT departments between November 2011 and February 2012 were prospectively enrolled. A total of 166 patients were included in the study. Variance was demonstrated between the six units in a number of the key outcome areas. Twenty-eight per cent of patients were identified as eligible for operative intervention for epistaxis in one unit, compared with only 12.5 per cent in another. There are measurable, patient-relevant outcomes to assess epistaxis management and these can highlight areas of potential improvement. This pilot audit gives a snapshot of modern practice, which shows variance between the six units assessed. A national audit may allow us to improve patient experience and maximise efficiency in delivering emergency care in our most common patient encounter.

Family Physicians Are Essential for Mental Health Care Delivery

As the largest and most widely distributed of primary care physicians, family physicians have an important role in providing mental health care, especially in rural and underserved areas. However, the proportion of family physicians who report providing mental health care is low. Policy barriers such as payment for mental health services should be explored to ensure access to mental health care for patients across the urban to rural continuum.

Abstracts from the Clinical Audit and Practice Advisory Group Annual Audit and Evidence-Based Medicine Meeting, at the ENT UK Meeting, 9 September 2010, University Hospital Coventry, UK

Abstracts from the Clinical Audit and Practice Advisory Group Annual Audit and Evidence-Based Medicine Meeting, at the ENT UK Meeting, 9 September 2010, University Hospital Coventry, UK

Evidence review and ENT‐UK consensus report for the use of aminoglycoside‐containing ear drops in the presence of an open middle ear

BACKGROUND AND OBJECTIVES OF REVIEW: The use of aminoglycoside drops in the presence of a perforation/grommet is still a common practice amongst the UK ENT community, in spite of theoretical risk of ototoxicity. Mindful of the need to produce clinical guidelines based on the best available evidence, it was the intention of the Clinical Audit and Practice Advisory Group of the British Association of Otolaryngologists - Head and Neck Surgeons (ENT-UK) to produce evidence-based guidelines. In the absence of good evidence, intentions were shifted towards producing consensus guidelines using validated methodology. Literature review, review of international guidelines and consensus guidelines. A MEDLINE literature search (1966 to August 2006) was conducted, using the following strategies: 'ototoxicity and drops', 'ototoxic and drops', 'vestibulotoxicity and drops', 'vestibulotoxic and drops', 'cochleotoxicity and drops', 'cochleotoxic and drops'. Foreign language articles were not excluded. RESULTS OF THE LITERATURE REVIEW: The inclusion of foreign language articles and manually searching the reference sections of identified articles revealed further evidence not considered in previous reviews on this subject. However, the available 'evidence' that does exist remains to be of poor quality, consisting of data from a number of case reports and small case series. Prospective studies into the ototoxic effects of aminoglycoside ear drops either support their use but lack power to statistically confirm this, or are performed in conditions that are not representative of normal clinical conditions. In the light of issues raised from the literature review, a questionnaire was produced. The questionnaire was initially completed by council members of the British Society of Otology, then revised and presented at a meeting of the British Society of Otology, where a consensus panel was formed. ENT-UK recommends that when treating a patient with a discharging ear, in whom there is a perforation or patent grommet: if a topical aminoglycoside is used, this should only be in the presence of obvious infection. Topical aminoglycosides should be used for no longer than 2 weeks. The justification for using topical aminoglycosides should be explained to the patient. Baseline audiometry should be performed, if possible or practical, before treatment with topical aminoglycosides.

Appropriateness of intravenous cannulation by paramedics: A london study

Introduction. The number of patients undergoing intravenous (IV) cannulation by paramedics has increased dramatically over recent years in the UK. Treatment protocols for cannulation in the field are loosely defined. Variation in practice may lead to patients' receiving differential treatment according to customary practice, rather than according to their clinical conditions. Objectives. To explore variations in practice and assess level of appropriatenesss of IV cannulation by London Ambulance Service (LAS) paramedics; to revise treatment protocols and work toward clinical guidelines, if indicated by study findings. Methods. Skill usage data were analyzed for all LAS paramedics for 1995-96. All patients who were IV-cannulated and transported to three hospitals by LAS during March 1996 were identified. A panel of accident and emergency (A&E) and prehospital specialists judged each case for appropriateness. Results. Variation during the year was wide, with a range of 1 to 221 (mean 47) patients cannulated per paramedic, although the majority showed some consistency in frequency of skill usage. A sample of 183 cases was reviewed. The majority judged 149 (81.4%) to be appropriate, although there was considerable disagreement between reviewers (κ = 0.43, p < 0.001). Data suggested that those paramedics who cannulate more frequently cannulated less appropriately during the study period (lowest 30%: 73.9% appropriate; highest 30%: 45.8% appropriate, p = 0.05). Conclusion. Despite wide variation between paramedics, the panel judged overall appropriateness of cannulation to be high. The audit advisory group judged that new clinical guidelines might not achieve an improvement in practice and were not supported by study findings. It was recommended that variations be addressed through individual practice review. PREHOSPITAL EMERGENCY CARE 2000;4:156-163

A PPROPRIATENESS OF I NTRAVENOUS C ANNULATION BY P ARAMEDICS : A L ONDON S TUDY

Introduction. The number of patients undergoing intravenous (IV) cannulation by paramedics has increased dramatically over recent years in the UK. Treatment protocols for cannulation in the field are loosely defined. Variation in practice may lead to patients' receiving differential treatment according to customary practice, rather than according to their clinical conditions. Objectives. To explore variations in practice and assess level of appropriatenesss of IV cannulation by London Ambulance Service (LAS) paramedics; to revise treatment protocols and work toward clinical guidelines, if indicated by study findings. Methods. Skill usage data were analyzed for all LAS paramedics for 1995–96. All patients who were IV-cannulated and transported to three hospitals by LAS during March 1996 were identified. A panel of accident and emergency (A&E) and prehospital specialists judged each case for appropriateness. Results. Variation during the year was wide, with a range of 1 to 221 (mean 47) patients cannulated per paramedic, although the majority showed some consistency in frequency of skill usage. A sample of 183 cases was reviewed. The majority judged 149 (81.4%) to be appropriate, although there was considerable disagreement between reviewers (κ = 0.43, p < 0.001). Data suggested that those paramedics who cannulate more frequently cannulated less appropriately during the study period (lowest 30%: 73.9% appropriate; highest 30%: 45.8% appropriate, p = 0.05). Conclusion. Despite wide variation between paramedics, the panel judged overall appropriateness of cannulation to be high. The audit advisory group judged that new clinical guidelines might not achieve an improvement in practice and were not supported by study findings. It was recommended that variations be addressed through individual practice review.

Collecting, maintaining and using evidence of clinical effectiveness: experience at a district health authority.

Collecting, maintaining and using evidence of clinical effectiveness: experience at a district health authority.

Quality of care of patients with diabetes: collation of data from multi-practice audits of diabetes in primary care.

GPs are now playing a greater role in the care of patients with diabetes. The challenges described in the Saint Vincent Joint Task Force Report include achievement of a reduction in long-term complications by collecting key clinical information and systematically organizing care of patients with diabetes. The number of practices conducting audit and the number of primary care audit groups conducting multi-practice audits of diabetes have increased since the introduction of audit in 1991. We aimed to determine the feasibility of collating data from multi-practice audits of diabetes in primary care and to describe the pattern of care for diabetes patients in primary care. A confidential postal questionnaire was sent to all medical audit advisory groups that had completed a multi-practice audit of diabetic care. The main outcome measures studied were prevalence and treatment of known diabetes and annual compliance with key process measures. Data could be collated for 17 of the 25 audit groups that supplied data representing information from 495 practices with 38 288 diabetic patients. Seven audit groups supplied data from a population denominator comprising 1475512 patients giving a prevalence of 1.46% (range 1.1-1.7%), 50.7% (range 32.5-69.0%) were managed by general practice only, 19.1% (7.6-39.7%) by hospital care only and 30.2% (11.0-49.5%) by shared care. Annual mean compliance for process measures showed wide variations: glycated haemoglobin or fructosamine checked for 72.5% (range 25.3-89.3%), fundi checked for 67.5% (57.8-86.6%), urine checked for 65.8% (27.5-80.0%), blood pressure checked for 87.6% (76.9-96.5%), smoking checked for 71.45 (21.9-86.0%), feet checked for 67.7% (40.0-90.8%) and BMI checked for 52.5% (26.4-68.2%). This study shows the feasibility of collating audit data and the potential of this approach for describing patterns of care and highlighting general and local deficiencies. Information about levels of performance in large numbers of patients can be used to set standards or norms against which individual practitioners can compare their own activity. Comparison of the health needs of local populations with national data could be used to inform commissioning services. However, audits should employ uniform evidence-based criteria so as to facilitate collation and allow comparison.

Resourcing innovative teaching of audit--models, methods and MAAGs.

Audit is an important part of clinical practice, and has been promoted as a core aspect of undergraduate and postgraduate medical education. Few examples of how audit is taught in the undergraduate curriculum exist. This article presents a model for student teaching using innovative methods, which include an extended role for teaching and learning support from Medical Audit Advisory Group staff. This may be a unique arrangement in the UK. We recommend this approach as using skilled resources effectively and encouraging a positive learning experience for students, which should contribute to their motivation and ability to carry out audit at postgraduate level.

Preventing ischaemic heart disease in one general practice: from one patient, through clinical audit, needs assessment, and commissioning into quality improvement

Editorial by Fahey and pp 112511301134 Since the introduction of clinical audit 1 2 and the creation of medical audit advisory groups,3 general practice has begun to look beyond reactive...

From audit to effectiveness: an historical evaluation of the changing role of Medical Audit Advisory Groups.

MAAGs were introduced as a result of the 1989 White Paper 'Working for Patients', with the remit to direct, coordinate and monitor medical audit activities in general practice. They were funded through the new FHSA management budget and each MAAG was responsible to its own FHSA. They were accepted as a completely new institution as a part of the introduction of an innovative management structure in a reformed NHS. When viewed in an historical context, MAAGs can actually be seen as a part of an expanding culture of greater objectivity and critical analysis which has burgeoned in medical practice over the last two decades. Although MAAGs began with an educational role with uniprofessional medical audit, they have embraced multiprofessional clinical audit in primary care in the context of the wider aspects of quality in practice. The last 20 years have seen the development of clinical guidelines, evidence-based medicine and application of business management theory to clinical quality. All these have reflected the increasing demand for explicit standards of care which has also formed the basis of clinical audit and MAAG activity. MAAGs should be seen as an inevitable concomitant of this historical trend to improve the application of scientific rigour in medical practice. With the adoption of clinical effectiveness, incorporating all these themes, as one of the NHS Executive's six medium-term priority areas, MAAGs are uniquely placed to act as agents of change to enhance the quality of primary health care.

Is ownership more important than the scientific credibility of audit protocols? A survey of medical audit advisory groups.

It is commonly accepted that ownership is an important factor in determining the acceptability and use of protocols or guidelines. We aimed to determine whether Medical Audit Advisory Groups (MAAGs) are prepared to accept and use audit protocols developed systematically by an external agency. A postal questionnaire was sent to all 105 MAAG chairmen in England and Wales to seek their views on the external development of protocols, the inclusion of evidence-based prioritized criteria, the general design of the protocols issued by the Lilly Audit Centre and the numbers of practices reported by MAAGs as making use of at least one of the first four protocols issued. Ninety-five MAAGs (90%) responded. Of these, 86% were in favour of the external development of protocols, and 98% and 94%, respectively, found evidence-based and prioritized criteria valuable; 98% felt the overall design and content of the Audit Centre protocols were excellent or good. A total of 1018 practices was known to have made use of one of these protocols, 261 taking part in multi-practice audits organized by their MAAGs. Ownership is not necessarily more important than scientific credibility and/or perceived utility. Externally developed audit protocols containing evidence-based, prioritized review criteria are acceptable to MAAGs, which are prepared to recommend their use in practice. Accordingly, such systematically developed protocols offer a promising and practical method for improving clinical effectiveness. Further research is needed, however, to determine the comparative impact on standards of care of protocols and other methods such as clinical guidelines.

Investigation into the attitudes of general practitioners in Staffordshire to medical audit.

To investigate the attitudes of general practitioners to medical audit, and any associations between their attitudes and their personal characteristics. Postal questionnaire survey. SETTING --Staffordshire, United Kingdom. 870 Staffordshire general practitioners. Agreement or disagreement and associations between the attitudes to 16 statements about audit and the doctors' personal or practice characteristics--namely, sex, number of years since qualification, practice list size, number of partners, and the practices' experience of audit. 601 Staffordshire general practitioners (69%) responded. There was most agreement with the statements that audit is time consuming (86%), that ongoing training and education is needed (71%), that there is a compulsion applied on doctors to audit (68%), and that extra resources for audit should be provided by the medical audit advisory group (65%). There was considerable disagreement (53% of general practitioners) with the statement that ¿government policy to expect general practitioners to do audit will enhance the population's health.¿ The median response by the 601 general practitioners was four positive responses out of 14 statements about audit (two of the 16 statements could not be graded positive or negative to audit). Women doctors generally had more positive attitudes towards audit, and so had those working with smaller mean list sizes, those in larger partnerships, and those in practices that had carried out audit for a longer time. There was a generally negative attitude to medical audit, but it was encouraging that those doctors with the most experience of audit obtained the most job satisfaction from it. More effort is needed to convince general practitioners of the value of audit. Without this, attempts to involve other members of the primary care team in multidisciplinary clinical audit are unlikely to be effective. Successful audits that are shown to be cost effective as well as leading to improvements in patient care should be publicised and replicated. A higher proportion of resources should be devoted to audit.

Promoting user involvement in clinical audit: surveys of audit committees in primary and secondary care

The Department of Health has suggested that organizations should develop mechanisms to ensure successful input from patients and carers into clinical audit processes, advocating the involvement of consumers at all stages of the audit cycle. Two national surveys, of Trust Clinical Audit Committees and Medical Audit Advisory Groups respectively, explored the extent to which audit committees involve users, either as committee members or in relation to other methods of involvement in the audit process. The results indicate limited but increasing involvement of users as audit committee members, but there are benefits, limitations and barriers to user membership. Other reported activities suggest that the most widespread method of involving users is in user satisfaction surveys with little systematic evidence of input to the decision‐making stage and negotiation of topics for audit. The research suggests that guidance is needed on how to involve users effectively at different stages in the audit cycle.

The costs and benefits of asking patients for their opinions about general practice.

Patient views are important in the evaluation of the quality of health care. The use of surveys needs to be evaluated to determine their cost-effectiveness and benefits. To determine the costs of conducting patient opinion surveys in general practice and to find out how effective patient surveys are in stimulating changes which are beneficial for patient care. Postal questionnaire to all 102 medical audit advisory groups (MAAGs) and 98 family health services authorities (FHSAs) in England and Wales, followed by postal questionnaire to 302 general practices reported to have conducted surveys, sampled by the type or questionnaire used. Numbers of MAAGs and FHSAs reporting surveys in general practice; types of questionnaire used; estimated costs; changes made; and benefits identified were measured. Eighty-five (83%) MAAGs and 75 (77%) FHSAs responded. One hundred and fifty-four (96%) of MAAGs or FHSAs reported survey activity. Types of questionnaire used were 1) designed by the practice, 2) designed by the MAAG or FHSA, possibly in collaboration with a practice, or 3) standard 'off-the-shelf'. One hundred and thirty-three (44%) practices responded. Total costs to a practice of conducting a survey ranged from nothing to over 2200 Pounds. Questionnaires designed by the practice are likely to be more costly than other designs. Some practices had surveys provided free of charge by MAAG or FHSA. Sixty-one per cent of practices said changes had been implemented and a further 22% of practices said changes were planned. The most common change was to appointment systems. Benefits were identified for patients, staff, the practice, the MAAG or FHSA and the NHS. Surveys also brought benefits in relationships and understanding. Only 8.2% of practices felt the costs of surveys outweighed the benefits. Many practices are surveying patients' opinions. Surveys can be costly but MAAGs and FHSAs can provide expertise and resources. Surveys using any of the types of questionnaire are likely to lead to changes and identifiable benefits. Benefits of surveys are perceived by the majority of practices to outweigh the costs.

Assessing the work of medical audit advisory groups in promoting audit in general practice.

Objectives--To determine the role of medical audit advisory groups in audit activities in general practice. Design--Postal questionnaire survey. Subjects--All 104 advisory groups in England and Wales in 1994. Main measures--Monitoring audit: the methods used to classify audits, the methods used by the advisory group to collect data on audits from general practices, the proportion of practices undertaking audit. Directing and coordinating audits: topics and number of practices participating in multipractice audits. Results--The response rate was 86-5%. In 1993-4, 54% of the advisory groups used the Oxfordshire or Kirklees methods for classifying audits, or modifications of them. 99% of the advisory groups collected data on audit activities at least once between 1991-2 and 1993-4. Visits, questionnaires, and other methods were used to collect information from all or samples of practices in each of the advisory group's areas. Some advisory groups used different methods in different years. In 1991-2, 57% of all practices participated in some audit, in 1992-3, 78%, and in 1993-4, 86%. 428 multipractice audits were identified. The most popular topic was diabetes. Conclusions--Advisory groups have been active in monitoring audit in general practice. However, the methods used to classify and collect information about audits in general practices varied widely. The number of practices undertaking audit increased between 1991-2 and 1993 1. The large number of multipractice audits supports the view that the advisory groups have directed and coordinated audit activities. This example of a national audit programme for general practice may be helpful in other countries in which the introduction of quality assurance is being considered.

Promoting audit in primary care: roles and relationships of medical audit advisory groups and their managers.

To investigate perceptions of family health service authorities and medical audit advisory groups of advisory groups' involvement in clinical audit and wider quality issues; communication with the authorities; and manager satisfaction. National postal questionnaire survey in 1994. All family health services authority districts in England and Wales. Chief executives or other responsible authority officers and advisory group chairpersons in each district. Priorities of advisory group and authority for audit; involvement of advisory group in wider quality issues; communication of information to, and contacts with, the authority and its involvement in planning the future work of the advisory group; and authorities' satisfaction. Both groups' views about audit were similar and broadly consistent with current policy. Advisory group involvement in wider quality issues was extensive, and the majority of both groups thought this appropriate. Much of the information about their activities collected by advisory groups was not passed on to the authority. The most frequent contact between the two groups was the advisory group's annual report, but formal personal contact was the most valued. Most authority respondents thought their views had been recognised in the advisory group's planning of future work; only a small minority were not satisfied with their advisory groups. Dissatisfied respondents received less information from their advisory groups, had less contact with them, and thought they had less input into their plans. There was some evidence that advisory groups in the "dissatisfied districts" were less involved in clinical audit and with their authorities in wider quality issues. Most advisory groups are developing their activities in clinical audit and have expanded their scope of work. The quality and availability of information about progress with audit is a cause for concern to both groups.

Audit activity and quality of completed audit projects in primary care in Staffordshire.

To survey audit activity in primary care and determine which practice factors are associated with completed audit; to survey the quality of completed audit projects. From April 1992 to June 1993 a team from the medical audit advisory group visited all general practices; a research assistant visited each practice to study the best audit project. Data were collected in structured interviews. Staffordshire, United Kingdom. All 189 general practices. Audit activity using Oxford classification system. Quality of best audit project by assessing choice of topic; participation of practice staff; setting of standards; methods of data collection and presentation of results; whether a plan to make changes resulted from the audit; and whether changes led to the set standards being achieved. Audit information was available from 169 practices (89%). 44(26%) practices had carried out at least one full audit; 40(24%) had not started audit. Mean scores with the Oxford classification system were significantly higher with the presence of a practice manager (2.7(95% confidence interval 2.4 to 2.9) v 1.2(0.7 to 1.8), p < 0.0001) and with computerisation (2.8(2.5 to 3.1) v 1.4 (0.9 to 2.0), p < 0.0001), organised notes (2.6(2.1 to 3.0) v 1.7(7.2 to 2.2), p = 0.03), being a training practice (3.5(3.2 to 3.8) v 2.1(1.8 to 2.4), p < 0.0001), and being a partnership (2.8(2.6 to 3.0) v 1.5(1.1 to 2.0), p < 0.0001). Standards had been set in 62 of the 71 projects reviewed. Data were collected prospectively in 36 projects and retrospectively in 35. 16 projects entailed taking samples from a study population and 55 from the whole population. 50 projects had a written summary. Performance was less than the standards set or expected in 56 projects. 62 practices made changes as a result of the audit. 35 of the 53 that had reviewed the changes found that the original standards had been reached. Evaluation of audit in primary care should include evaluation of the methods used, whether deficiencies were identified, and whether changes were implemented to resolve any problems found.

The Need for Stakeholder Councils in Social Audits

The emerging discipline of social reporting accounting and auditing is compared with its financial counterparts and the need for different institutional arrangements are identified. An element of social accounting is to report on the ethical integrity of operations and governance of the entity. These concerns make it unacceptable for social auditors to be subject to the influence of the directors who are responsible for preparing the accounts. This inherent conflict of interest with financial auditors creates what is described in the accounting literature as an audit expectation gap. An Audit Advisory Group representing key stakeholders was formed to assist in a pioneering 1994 social audit. This stakeholder council provided both information and verification for the social impact accounts. Because stakeholder councils are appointed and operate independently of management they also introduce a way to minimise the expectation gap of financial audits in either the private or public sector.