Joint Audit Research Articles

Complications of diagnostic cardiac catheterisation: results from 34,041 patients in the United Kingdom confidential enquiry into cardiac catheter complications. The Joint Audit Committee of the British Cardiac Society and Royal College of Physicians of London.

To evaluate the frequency and nature of complications in patients undergoing diagnostic cardiac catheterisation and to assess the feasibility of a voluntary cooperative audit system. 27 centres enrolled patients over a two year period. Each centre voluntarily reported numbers of patients catheterised every month. Complications were reported as they occurred. Feedback was provided in the form of newsletters and reports. 39,795 procedures were registered, of which 33,776 were diagnostic catheterisations in adults or adolescents, 1265 were paediatric catheter studies in patients under the age of 12 years, and 4754 were coronary angioplasties or balloon dilatation of valves. 83.3% of diagnostic catheter studies in adults were left heart studies with coronary arteriography. The overall complication rate for diagnostic studies was 0.80%, mortality rate 0.12%, emergency surgical intervention rate 0.08%. Complication rates varied between centres, but there was no correlation with case load. Different patterns of complication were associated with different technical approaches. Complication rates of diagnostic catheterisation are low but neither negligible nor irreducible. Voluntary audit of this kind has limitations, but it is useful and inexpensive.

Government Proposals for New Legislation on Education and Special Educational Needs

Summary Three important documents on education have identified issues which are currently being debated in parliament with specific reference to special educational needs ‐‐ The Joint Audit Commission HMI Report ‘Getting in on the Act’, the DFE White Paper ‘Choice and Diversity’ and the DFE Green Paper ‘Special Educational Needs’. This article examines these papers which lay out proposals for future legislation with particular reference to the statementing procedure established by the 1981 Education Act.

General practitioners, skin lesions and the new contract

We reviewed all skin lesions received in our laboratory from general practitioners (GPs) during a three-month period before the introduction of the new contract for GPs and during the same period a year later. For comparison we also reviewed skin lesions received from the general and plastic surgeons. Particular attention was paid to the completeness of excision. There was a significant increase in the number of skin lesions removed in general practice after the introduction of the new contract. Both benign and malignant lesions were more likely to be incompletely excised by GPs compared with surgeons. The GPs first noted to carry out minor surgery after the new contract came into force were less likely to have completely excised lesions than their more experienced colleagues. We suggest the future monitoring of lesions removed in general practice, possibly by the formation of a joint audit group.

Time delays in provision of thrombolytic treatment in six district hospitals. Joint Audit Committee of the British Cardiac Society and a Cardiology Committee of Royal College of Physicians of London.

To measure the delays between onset of symptoms and admission to hospital and provision of thrombolysis in patients with possible acute myocardial infarction. Observational study of patients admitted with suspected myocardial infarction during six months. Six district general hospitals in Britain. 1934 patients admitted with suspected myocardial infarction. Route of admission to hospital and time to admission and thrombolysis. Patients who made emergency calls did so sooner after onset of symptoms than those who called their doctor (median time 40 (95% confidence interval 30 to 52) minutes v 70 (60 to 90) minutes). General practitioners took a median of 20 (20 to 25) minutes to visit patients, rising to 30 (20 to 30) minutes during 0800-1200. The median time from call to arrival in hospital was 41 (38 to 47) minutes for patients who called an ambulance from home and 90 (90 to 94) minutes for those who contacted their doctor. The median time from arrival at hospital to thrombolysis was 80 (75 to 85) minutes for patients who were treated in the cardiac care unit and 31 (25 to 35) minutes for those treated in the accident and emergency department. The time from onset of symptoms to thrombolysis could be reduced substantially by more effective use of emergency services and faster provision of thrombolysis in accident and emergency departments.

Provision of services for the diagnosis and treatment of heart disease. Fourth report of a Joint Cardiology Committee of the Royal College of Physicians of London and the Royal College of Surgeons of England.

The principal conclusions of the fourth report of the Joint Cardiology Committee are: 1 Cardiovascular disease remains a major cause of death and morbidity in the population and of utilisation of medical services. 2 Reduction in the risk of cardiovascular disease is feasible, and better co-ordination is required of strategies most likely to be effective. 3 Pre-hospital care of cardiac emergencies, in particular the provision of facilities for defibrillation, should continue to be developed. 4 There remains a large shortfall in provision of cardiological services with almost one in five district hospitals in England and Wales having no physician with the appropriate training. Few of the larger districts have two cardiologists to meet the recommendation for populations of over 250,000. One hundred and fifty extra consultant posts (in both district and regional centres) together with adequate supporting staff and facilities are urgently needed to provide modest cover for existing requirements. 5 The provision of coronary bypass grafting has expanded since 1985, but few regions have fulfilled the unambitious objectives stated in the Third Joint Cardiology Report. 6 The development of coronary angioplasty has been slow and haphazard. All regional centres should have at least two cardiologists trained in coronary angioplasty and there should be a designated budget. Surgical cover is still required for most procedures and is best provided on site. 7 Advances in the management of arrhythmias, including the use of specialised pacemakers, implantable defibrillators, and percutaneous or surgical ablation of parts of the cardiac conducting system have resulted in great benefit to patients. Planned development of the emerging sub-specialty of arrhythmology is required. 8 Strategies must be developed to limit the increased exposure of cardiologists to ionising radiation which will result from the expansion and increasing complexity of interventional procedures. 9 Supra-regional funding for infant cardiac surgery and transplantation has been successful and should be continued. 10 Despite advances in non-invasive diagnosis of congenital heart disease the amount of cardiac catheterisation of children has risen due to the increase in number of interventional procedures. Vacant consultant posts in paediatric cardiology and the need for an increase in the number of such posts cannot be filled from existing senior registrar posts. All paediatric cardiac units should have a senior registrar and in the meantime it may be necessary to make proleptic appointments to consultant posts with arrangements for the appointees to complete their training. 11 Provision of care for the increasing number of adolescent and adult survivors of complex congenital heart disease is urgently required. The management of these patients is specialised, and the committee recommends that it should ultimately be undertaken by either adult or pediatric cardiologists with appropriate additional training working in supra-regionally funded centers alongside specially trained surgeons. 12 Cardiac rehabilitation should be available to all patients in the United Kingdom. 13 New recommendations for training in cardiology are for a total of at least five years in the specialty after general professional training, plus a year as senior registrar in general medicine. An additional year may be required for those wishing to work in interventional cardiology and adequate provision must be made for those with an academic interest. 14 It is essential that both basic and clinical research is carried out in cardiac centres but these activities are becoming increasingly limited by the lack of properly funded posts in the basic sciences and restriction in the number of honorary posts for clinical research workers. 15 A joint audit committee of the Royal College of Physicians and the British Cardiac Society has been established to coordinate audit in the specialty. All district and regional cardiac centres should cooperate with the work of the committee, in addition to their participation in local audit activities.

Innovations in State Tax Administration

By 1980 the states had adopted a number of structural reforms in their tax and revenue agencies that were intended to enhance economy and efficiency. A variety of structures still existed, but common patterns were emerging. This was particularly true with respect to the appointment rather than election of heads of tax agencies, consolidation of the administration of major taxes into a single agency, and the organization of tax departments along functional rather than tax-type lines (Mikesell, 1981). Despite the structural reforms, concerns arose at the beginning of the 1980s that the states still lagged behind in of their tax laws. Penniman observed that income tax administration had improved since the late fifties but had not kept pace with the growing volume of taxpayers or the increasing complexities of enforcement (1980, p. 266). She recommended a number of changes, including tightening of income tax statutes, higher appropriations for tax agencies, hiring personnel on the basis of merit principles, increasing use of Internal Revenue Service (IRS) tax tapes, and development of interstate joint audit programs. Following their survey of the states, Henszey and Roadarmel (1981) suggested that weak criminal tax evasion statutes and the small number of auditors employed by state tax agencies impaired enforcement. Much has changed in the of state tax laws since the early 1980s. The most newsworthy events in state taxation have been the tax amnesties offered by half the states. Of greater import, however, for fortifying taxpayer compliance were the legal and administrative reforms that were often enacted in conjunction with the tax amnesty. The amnesty states adopted various innovations including stiffening civil and criminal tax evasion penalties, employing more auditors, collectors, and other personnel, purchasing new computer technology, creating special investigations units, and increasing use of IRS computer tapes of individual and business tax returns (Parle and Hirlinger, 1986; Mikesell, 1986). Changes in compliance tools and strategies likely have not been confined to the amnesty states, but how widespread are they? This paper examines and compares tax compliance tools and strategies utilized by the revenue departments or departments chiefly responsible for the collection of income taxes in the states. Data are presented from a survey administered to the states that gathered information on auditing and collections procedures, service offerings, and appeals to modify taxpayer attitudes. This article first examines a compliance policy model, then provides a discussion of the method-

Determinants of participation in home energy audit/loan programs: Discrete choice model results

Discrete choice models are developed for decisions to participate in home energy audit and loan programs. A nested logit model of joint audit and loan decisions is also estimated. The results suggest that attitudinal variables concerning the information value and convenience of audits are the best predictors of the audit choice. A belief that conservation retrofits improve home value is the best predictor of the loan choice. The nested logit model results show that audit and loan choices are independent; this is probably due to a low level of awareness about loan availability.

Pneumococcal pneumonia. A misleading diagnosis for audit studies.

IN PREPARATION for a joint audit study, four community hospitals reviewed their statistics of patients discharged with a primary diagnosis of pneumonia during the past two calendar years. The total number of discharges was determined for each of the different International Classification of Diseases Adapted (ICDA) codes for pneumonia. In most persons, the cause of the pneumonia was not specified, but there were 48 cases of pneumococcal pneumonia from all hospitals during the two years. This seemed to be an unusually high number of reported cases for a group of small hospitals. Therefore, a special study of pneumococcal pneumonia was conducted along with a general study of pneumonia. Two screening criteria were used for the pneumococcal pneumonia study, which included (1) abnormal chest roentgenogram, ie, compatible with pneumonia anytime during admission, and (2) positive sputum culture for pneumococci. Of the 48 records coded as a primary discharge diagnosis of pneumococcal

What Can Regulators Regulate? The Case of Electricity

What Can Regulators Regulate? The Case of Electricity