Clinical Standards Advisory Group Research Articles

Implementation of standardized medical photography for cleft lip and palate audit

Much has been published relating to the treatment and surgical outcome of cleft lip and palate disorders. Clinical audit is one of the most important tools for assessing the quality of care provided, with medical photography an invaluable component of this process. The Clinical Standards Advisory Group Report 1998 recommended that cleft lip and palate patients should be audited when 0 (under 1 year of age), and then at the ages of 5, 10, 15 and 20 years. For both audit and research purposes, medical photographs need to be accurate and of a consistently high standard. This paper describes the development of a standardized photographic protocol for cleft patients of audit age, to the benefit of both the multidisciplinary team and the patients.

An integrated care pathway for the management of low back pain

Low back pain is a disabling condition that is responsible for a considerable amount of health service expenditure [HMSO, London, 1994, p. 1; The Back Pain Revolution. Churchill Livingstone, London, 1999]. Following national recommendations from the Clinical Standards Advisory Group [HMSO, London, 1994, p. 1] and the Royal College of General Practitioner Guidelines [Royal College of General Practice, London, 1996, 1999], local initiatives have attempted to integrate this advice into care pathways for low back pain. This paper will detail the background development, construction and audit of an integrated care pathway for the management of patients with acute low back pain in North Staffordshire.

Musculoskeletal Medicine in Practice

Objectives To provide a rapid access treatment facility in the primary care setting for patients with acute low back pain. To implement the recommendations of the Clinical Standards Advisory Group for back pain (CSAG).Design A pilot scheme was initially run with a treatment centre in each of Plymouth’s three locality care groups (LCGs). 12 months funding was obtained from each locality’s development funds. All GPs in the area were invited to refer patients according to an agreed protocol and targets for waiting times were set. Each centre was run by a practitioner with special skills and experience in the management of back pain.Setting Consulting rooms in three general practice surgeries with facilities for carrying out examinations, spinal manipulations, acupuncture and caudal epidurals.Participants The protocol for referral included patients between 18 and 60 with symptoms of six weeks duration or less who were not making progress and who would otherwise have been referred to secondary care.Results In the pilot year, 651 patients were referred and 92% were seen within two weeks of the request. 50% were off work at the time of referral. At discharge, 72% were more than 70% improved and only four percent required further referral, in the majority of cases for a neurosurgical opinion. The average cost per patient treated was £91, considerably less than hospital outpatient treatment.Conclusion A rapid response service for patients with acute back pain has been adopted by Plymouth’s PCT. This service has shown itself to be both effective and economical. A multidisciplinary sub-acute service was added after 12 months. The acute and the sub acute clinics together with the existing hospital pain clinic, provide a seamless service for patients with back pain that satisfies the principal recommendations in the CSAG (HMSO 1994) report.

Development of the Coping Strategies Questionnaire 24, a Clinically Utilitarian Version of the Coping Strategies Questionnaire.

Objective: To use principal-components analysis to obtain a shorter and therefore more clinically useful version of the Coping Strategies Questionnaire (CSQ). Subjects: A British sample of 214 chronic back pain patients attending outpatient spinal assessment. Results: A 4-factor solution was discovered that incorporates Catastrophizing, Diversion, Cognitive Coping, and Reinterpreting factors. Apart from the absence of a Praying and Hoping factor, this solution is similar to those previously found by researchers in this field. Conclusions: The new questionnaire (the CSQ24) is a valid utilitarian version of the CSQ that is easy to score and is appropriate for clinical use. In recent years, the effective management of chronic musculoskeletal pain, especially chronic low back pain (CLBP), has become a topical area of research. This is primarily because of a significant increase in the number of people seeking treatment for this condition (Clinical Standards Advisory Group, 1994) and a realization that the majority of common treatment options are unsuccessful (Barton, 2000; Clinical Standards Advisory Group, 1994; Evans & Richards, 1996). Specifically, the observation that physically and pathologically similar patients may react very differently to their condition has led to great interest in the cognitive and behavioral coping mechanisms such patients demonstrate. It was through the work of authors such as Lazarus and Folkman

Information recalled by women taking anti-epileptic drugs for epilepsy: a questionnaire study

Women with epilepsy have different needs from men, particularly associated with childbearing. Despite clinical guidelines, the care of women with epilepsy remains suboptimal. The aim of this study was to establish whether women with epilepsy recall being given information on topics relating to childbearing. Design of study and methods included a postal questionnaire study of 795 women with epilepsy and of childbearing age. The respondents were identified through both general practices and hospital clinics as part of the Clinical Standards Advisory Group study into Epilepsy Services. Of those women who considered the questions personally relevant, 38–48% recalled receiving information about contraception, pre-pregnancy planning, folic acid and teratogenicity, with lower overall proportions among adolescent women. The proportions that recalled receiving information about vitamin K, safety in child-care and breast-feeding were lower at 12, 24 and 24%, respectively. While it is recognised that information provided may not be recalled, our results suggest that further measures are required to improve the effectiveness of information provision in the UK in relation to women of childbearing age with epilepsy.

Back pain--whose responsibility?

Back pain--whose responsibility?

Obstacles to effective treatment of depression: a general practice perspective.

The Clinical Standards Advisory Group (CSAG) was asked by UK health ministers to advise on the standards of clinical care attainable for people with depression. The GP survey reported here is one part of a multicomponent UK-wide study of services for depression that also included visits to a sample of services and structured patient telephone interviews. The aim of this study was to survey GPs' perceptions of the availability and quality of primary and community-based services for people with depression, and to seek their views on barriers to the provision of good clinical services. A structured postal questionnaire was sent to all GPs (3530) in the 11 geographical areas visited during the CSAG study. A total of 1703 (48%) GPs returned the questionnaire. The main obstacles to providing a good service for people with depression included not having enough time, a lack of services to refer to and difficulty in accessing services. More than half of the respondents (58%) were aware of guidelines for the management of depression, and 62% had attended a teaching session on depression within the last 3 years. Factors that influenced GPs to refer people with depression to other services were risk to the patient, a clear need for specialist treatment and the need for assessment. Overall, GPs appeared to be satisfied with the quality of specialist services. GPs appeared to view obstacles to providing effective treatment of depression as being more allied to external issues, in particular service provision, rather than internal factors such as their own knowledge and skills. The study revealed continuing concerns over excessive workload, and longstanding difficulties with the interface between primary and secondary mental health services.

Use of a Psychological Screening Tool to Predict Poor Outcome in Back Pain

M A McMenemy, M Barrow Roodlands Hospital, Edinburgh Introduction Research has shown that psychological factors can affect the natural history of simple low back pain. In 1994, the Clinical Standards Advisory Group (CSAG) on back pain recommended that a biopsychosocial assessment be done at six weeks after injury and that this could be performed by a therapist. The purpose of this study was to measure anxiety and depression, using the HAD scale, and to evaluate if ‘depressed’ or ‘anxious’ patients had a poor outcome from physiotherapy management.

How effective are guidelines for the management of low back pain

The National Institute for Clinical Effectiveness (NICE) recently published its first referral practice guide for general practitioners containing inter alia referral advice for acute low back pain.1 The NICE guidelines are to be evaluated in pilot schemes before being disseminated nationally. Six years have passed since the publication of the Clinical Standards Advisory Group (CSAG) report on back pain2 and it is four years since the Royal College of General Practitioners (RCGP) issued its own guidelines for the management of acute low back pain.3 Changes in practice introduced in response to these documents might give an indication of the likely success of the NICE guidelines in altering referral patterns and the …

It takes more than clinical effectiveness to change nursing practice: an unsuccessful project in the nurse promotion of urinary continence

Evidence base: primary care nurses have previously been shown to be effective at improving urinary incontinence in women under 60 years, by teaching pelvic floor exercises. We tried to apply this finding to practice.R&D project: this development project involved devising and delivering an evidence-based training package, ideally to one nurse member of every practice-based primary care team (about 70). Patient outcomes were to be assessed at 6 months, and the process of changing practice recorded. Despite extending the project, only 16 nurses received training, and only a handful of patients were recruited.Impediments to progress: the large number of factors which presented difficulties are discussed using the Clinical Standards Advisory Group’s framework for describing evidence-based service changes in primary care. These included lack of GP support, insufficient ‘grass roots’ enthusiasm, time constraints and the heavy workloads of primary care nurses, work not fitting into existing roles, no product champion, no supporting changes in secondary care.Conclusion: neither evidence nor education alone are sufficient to change practice. Current changes in primary care organisation may influence future attempts to change nurse practice in the promotion of continence.

Cleft Lip and Palate Care in the United Kingdom—The Clinical Standards Advisory Group (CSAG) Study. Part 3: Speech Outcomes

Abstract Objective: To summarize speech outcomes in children born with unilateral cleft lip and palate (UCLP) throughout the United Kingdom. Design: Prospective descriptive study on a cross-sectional sample of children. Patients/Participants: Data were collected for 238 5-year-olds (born between April 1, 1989, and March 31, 1991) and 218 12-year-olds (born between April 1, 1982, and March 31, 1984) with complete UCLP. Main Outcomes: Ratings of intelligibility, nasality, “speech cleft type characteristics” and speech therapy intervention. Conclusions: Nineteen percent of 5-year-olds and 4% of 12-year-olds were judged to be impossible to understand or just intelligible to strangers. Thirty-four percent of 5-year-olds and 17% of 12-year-olds had at least one serious error of consonant production. Eighteen percent of 5-year-olds and 12-year-olds had consistent hypernasality of mild, moderate, or severe degree. Approximately two-thirds of both age groups had undergone speech therapy.

Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 1: background and methodology.

To review the history of cleft care in the United Kingdom and the rationale and methodology of a national study. Descriptive overview to introduce this series of papers. Fifty National Health Service cleft teams. Two age cohorts, 5-year-olds and 12-year-olds, with nonsyndromic complete unilateral cleft lip and palate and their parents. Facial development and appearance, quality of bone grafts, speech, oral health and patient/parent satisfaction. The case for a national assessment of cleft care is made. The methodology of the cross-sectional outcome study is described, together with a survey of training for recently appointed clinicians.

Cleft Lip and Palate Care in the United Kingdom—The Clinical Standards Advisory Group (CSAG) Study. Part 2: Dentofacial Outcomes and Patient Satisfaction

Abstract Objective: To describe facial development and appearance, quality of bone grafts, oral health, and patient/parent satisfaction, with clinical outcome, for children in two age cohorts born with unilateral cleft lip and palate (UCLP) throughout the United Kingdom. Design: Cross-sectional outcome study. Setting: Fifty National Health Service cleft centers. Participants: Children born with complete UCLP between April 1, 1982, and March 31, 1984, (12-year-olds) and April 1, 1989, and March 31, 1991 (5-year-olds). Data were collected for 239 5-year-olds and 218 12-year-olds. The parents of these children were also interviewed to determine levels of satisfaction with care received. Main Outcome Measures: Skeletal pattern, dental arch relationship, success of alveolar bone grafting, facial appearance, oral health status, and patient/parent satisfaction. Results: Nearly 40% of 5- and 12-year-olds had poor dental arch relations, and 70% of 12-year-olds had midface retrusion. Fifteen percent of 12-year-olds...

Cleft Lip and Palate Care in the United Kingdom—The Clinical Standards Advisory Group (CSAG) Study. Part 1: Background and Methodology

Abstract Objective: To review the history of cleft care in the United Kingdom and the rationale and methodology of a national study. Design: Descriptive overview to introduce this series of papers. Setting: Fifty National Health Service cleft teams. Patients/Participants: Two age cohorts, 5-year-olds and 12-year-olds, with nonsyndromic complete unilateral cleft lip and palate and their parents. Main Outcome Measures: Facial development and appearance, quality of bone grafts, speech, oral health and patient/parent satisfaction. Conclusions: The case for a national assessment of cleft care is made. The methodology of the cross-sectional outcome study is described, together with a survey of training for recently appointed clinicians.

Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 3: speech outcomes.

To summarize speech outcomes in children born with unilateral cleft lip and palate (UCLP) throughout the United Kingdom. Prospective descriptive study on a cross-sectional sample of children. Data were collected for 238 5-year-olds (born between April 1, 1989, and March 31, 1991) and 218 12-year-olds (born between April 1, 1982, and March 31, 1984) with complete UCLP. Ratings of intelligibility, nasality, "speech cleft type characteristics" and speech therapy intervention. Nineteen percent of 5-year-olds and 4% of 12-year-olds were judged to be impossible to understand or just intelligible to strangers. Thirty-four percent of 5-year-olds and 17% of 12-year-olds had at least one serious error of consonant production. Eighteen percent of 5-year-olds and 12-year-olds had consistent hypernasality of mild, moderate, or severe degree. Approximately two-thirds of both age groups had undergone speech therapy.

Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 2: dentofacial outcomes and patient satisfaction.

To describe facial development and appearance, quality of bone grafts, oral health, and patient/parent satisfaction, with clinical outcome, for children in two age cohorts born with unilateral cleft lip and palate (UCLP) throughout the United Kingdom. Cross-sectional outcome study. Fifty National Health Service cleft centers. Children born with complete UCLP between April 1, 1982, and March 31, 1984, (12-year-olds) and April 1, 1989, and March 31, 1991 (5-year-olds). Data were collected for 239 5-year-olds and 218 12-year-olds. The parents of these children were also interviewed to determine levels of satisfaction with care received. Skeletal pattern, dental arch relationship, success of alveolar bone grafting, facial appearance, oral health status, and patient/parent satisfaction. Nearly 40% of 5- and 12-year-olds had poor dental arch relations, and 70% of 12-year-olds had midface retrusion. Fifteen percent of 12-year-olds had not received an alveolar bone graft, and only 58% of bone grafts that had been undertaken were successful. Twenty percent of 12-year-olds and 40% of 5-year-olds had untreated dental caries. Less than one-third of subjects had a good facial appearance as judged by a panel of experts. Levels of patient and parent satisfaction were generally high. A rigorous evaluation of cleft care in the United Kingdom reveals disappointing outcomes.

Cleft Lip and Palate Care in the United Kingdom—The Clinical Standards Advisory Group (CSAG) Study. Part 4: Outcome Comparisons, Training, and Conclusions

Abstract Objective: A critical appraisal of cleft care in the United Kingdom. Design: Retrospective comparative study. Setting: All National Health Service cleft centers in the United Kingdom. Patients/Participants: Children born with unilateral complete clefts of the lip and palate between April 1, 1982, and March 31, 1984 (12-year-olds), and April 1, 1989, and March 31, 1991 (5-year-olds). Newly appointed and senior cleft clinicians. Main Outcome Measures: Skeletal pattern, dental arch relationship, success of alveolar bone grafting, dental health, facial appearance, oral health status, patient/parent satisfaction. Conclusions: This paper highlights the poor outcomes for the fragmented cleft care in the United Kingdom, compared with European centers. There is an urgent need for a review of structure, organization, and training.

Cleft lip and palate management by U.K. consultant oral and maxillofacial surgeons: a national survey.

Following the report of the Clinical Standards Advisory Group (CSAG), a national survey of U.K. consultant oral and maxillofacial surgeons was performed to determine the current cleft lip and palate practice of this group prior to the implementation of proposed radical changes in the delivery of cleft services. The views of these surgeons regarding the proposed changes was also sought. An anonymous postal questionnaire sent to all 266 consultants in the U.K., which requested information on the practice of cleft surgery during a defined 1-year period (March 1997 through February 1998). It included the numbers and types of procedures performed, the involvement of multidisciplinary care, research and audit activity, and questions regarding the implementation of CSAG. One hundred ninety-one replies (72% response rate). Seventy-three surgeons were actively involved with mainly secondary cleft surgery. A varied number and range of procedures were undertaken, with most surgeons performing less than five of each procedure per year. Audit and research activity was 26%. The majority of both noncleft and cleft surgeons agreed with proposals made by CSAG (except for cleft osteotomy procedures). In the U.K. at present, there are many oral and maxillofacial surgeons performing mainly secondary cleft surgery; overall, the number of procedures performed by these surgeons per year is small. Intraspecialty referral is suggested to further improve patient outcome.

Cleft Lip and Palate Management by U.K. Consultant Oral and Maxillofacial Surgeons: A National Survey

Abstract Objective: Following the report of the Clinical Standards Advisory Group (CSAG), a national survey of U.K. consultant oral and maxillofacial surgeons was performed to determine the current cleft lip and palate practice of this group prior to the implementation of proposed radical changes in the delivery of cleft services. The views of these surgeons regarding the proposed changes was also sought. Design: An anonymous postal questionnaire sent to all 266 consultants in the U.K., which requested information on the practice of cleft surgery during a defined 1-year period (March 1997 through February 1998). It included the numbers and types of procedures performed, the involvement of multidisciplinary care, research and audit activity, and questions regarding the implementation of CSAG. Results: One hundred ninety-one replies (72% response rate). Seventy-three surgeons were actively involved with mainly secondary cleft surgery. A varied number and range of procedures were undertaken, with most surgeo...

Patients’ perspectives on services for epilepsy: a survey of patient satisfaction, preferences and information provision in 2394 people with epilepsy

The objectives of this study were to provide a comprehensive survey of satisfaction with care, care preferences and information provision for patients with epilepsy, and to formulate recommendations for the development of epilepsy services based on the findings. A questionnaire was distributed to 4620 patients who were currently receiving antiepileptic drugs for epilepsy, regardless of aetiology, duration or severity. Two different samples of patients with epilepsy were questioned: the first an unselected sample drawn from primary care, and the second consisting of consecutive patients drawn from hospital clinics. There were 2394 responses to the questionnaire. Satisfaction with primary and hospital care was high, both overall and for specific aspects. However, two major shortcomings were identified. First, few respondents felt that their care was shared between hospital and GP. Secondly, provision of information about epilepsy was perceived to be poor, particularly by the elderly. Younger patients and patients with severe epilepsy had a higher satisfaction with and preference for hospital care, whereas older age groups were more satisfied with and preferred primary care. Patients’ main reasons for preferring primary care were that it was more personal and the GP was more familiar with them, and secondary care was preferred because the hospital doctor knew more about epilepsy. In conclusion, we have conducted the largest representative UK survey of patients’ perceptions and views of the care available for epilepsy. Although patient satisfaction was high, information provision is poor and the shared care model is not operating effectively. We recommend that an emphasis be placed on methods for improving the interface between primary and secondary care. The setting up of hospital epilepsy centres, as recommended by the recently published Clinical Standards Advisory Group report on epilepsy , would provide a focus for these efforts and for information provision.