Systematic review of antimicrobial drug prescribing in hospitals.

Prudent prescribing of antimicrobial drugs to hospital inpatients may reduce incidences of antimicrobial drug resistance and healthcare-associated infection. We reviewed the literature from January 1980 to November 2003 to identify rigorous evaluations of interventions to improve hospital prescribing of antimicrobial drugs. We identified 66 studies with interpretable data, of which 16 reported 20 microbiologic outcomes: gram-negative resistant bacteria, 10 studies; Clostridium difficile-associated diarrhea, 5 studies; vancomycin-resistant enterococci, 3 studies; and methicillin-resistant Staphylococcus aureus, 2 studies.

Statistical evaluation of learning curve effects in surgical trials.

Randomized controlled trials (RCTs) in surgery have been impeded by concerns that improvements in the technical performance of a new technique over time (a "learning curve") may distort comparisons. The statistical assessment of learning curves in trials has received little attention. In this paper, we discuss what a learning curve effect is, the factors which effect it, how to display it, and how to incorporate the learning effect into the trial analysis.

Interventions to improve antibiotic prescribing practices for hospital inpatients.

Background: Up to 50% of antibiotic usage in hospitals is inappropriate. In hospitals infections caused by antibiotic-resistant bacteria are associated with higher mortality, morbidity and prolonged hospital stay compared with infections caused by antibiotic-susceptible bacteria. Clostridium difficile associated diarrhoea (CDAD) is a hospital acquired infection that is caused by antibiotic prescribing.

Effect of multivitamin and multimineral supplements on morbidity from infections in older people (MAVIS trial): pragmatic, randomised, double blind, placebo controlled trial.

Objective: To examine whether supplementation with multivitamins and multiminerals influences self reported days of infection, use of health services, and quality of life in people aged 65 or over.

Design: Randomised, placebo controlled trial, with blinding of participants, outcome assessors, and investigators.

Setting: Communities associated with six general practices in Grampian, Scotland.

The reported incidence of work-related ill-health in Scotland (2002-2003).

Background: Although incidence data for work-related ill-health in the UK are available, more detailed information for smaller geographical areas has hitherto been unpublished.

Aims: To estimate the incidence of work-related ill-health reported by clinical specialists in Scotland, 2002-2003.

Methods: THOR (The Health and Occupation Reporting network) is a UK wide reporting scheme for work-related ill-health.

Initial oxygen management in patients with an exacerbation of chronic obstructive pulmonary disease.

Background: The Norfolk and Norwich University Hospital (NNUH) is situated in rural Norfolk, and ambulance journey times are often >30 min. Longer ambulance journeys could lead to a greater risk of hypercapnia, if inappropriately high concentrations of oxygen are given during an exacerbation of COPD.

Aim: To investigate the effect of high concentration oxygen (HCO, FiO(2) > 0.

Theory-based identification of barriers to quality improvement: induced abortion care.

Background: The UK Royal College of Obstetricians and Gynaecologists published the clinical guideline, The Care of Women Requesting Induced Abortion, to address recognized variations in care. There is little empirical evidence on factors that influence compliance with the guideline. A better understanding of such factors is needed for quality improvement initiatives.

Effectiveness of strategies to disseminate and implement clinical guidelines for the management of impacted and unerupted third molars in primary dental care, a cluster randomised controlled trial.

Objective: To investigate the effectiveness and cost-effectiveness of different guideline implementation strategies, using the Scottish Intercollegiate Guidelines Network (SIGN) Guideline 42 "Management of unerupted and impacted third molar teeth" (published 2000) as a model.

Design: A pragmatic, cluster RCT (2x2 factorial design).

Subjects: Sixty-three dental practices across Scotland.

Performance characteristics of eight estradiol immunoassays.

Measurement of estradiol is useful in assisted reproduction, evaluation of infertility, menopause, and male feminization. The analytic performance of 8 estradiol immunoassays was evaluated. The imprecision and accuracy of the Access, ADVIA Centaur, ARCHITECT i2000, AutoDELFIA, Elecsys 2010, IMMULITE 2000, and Vitros ECi estradiol assays (see text for proprietary information) were evaluated by using an isotope dilution-gas chromatography-mass spectrometry (ID-GC-MS) reference method.

Safety of research bronchoscopy, biopsy and bronchoalveolar lavage in asthma.

Bronchoscopy with endobronchial biopsy (EBB) and/or bronchoalveolar lavage (BAL) has become an important research tool in asthma. A recent report has suggested audit and reporting of the safety of these procedures. A total of 159 asthmatic patients (84 males, 75 females), aged 18-52 (median 27) yrs, forced expiratory volume in one second 53-120 (median 88) % predicted, underwent 273 bronchoscopies in six clinical research studies.

The impact of guidelines on mild hypertension in pregnancy: time series analysis.

Objective: To determine the impact of a national strategy to promote implementation of a guideline on the management of mild, non-proteinuric hypertension in pregnancy.

Design: Simple, interrupted time series analysis.

Setting: Four maternity units in Scotland.

A randomised controlled trial of a tailored multifaceted strategy to promote implementation of a clinical guideline on induced abortion care.

Objective: To evaluate the effectiveness and efficiency of a tailored multifaceted strategy, delivered by a national clinical effectiveness programme, to implement a guideline on induced abortion.

Design: Cluster randomised controlled trial.

Setting And Participants: All 26 hospital gynaecology units in Scotland providing induced abortion care.

Interrupted time series designs in health technology assessment: lessons from two systematic reviews of behavior change strategies.

Objectives: In an interrupted time series (ITS) design, data are collected at multiple instances over time before and after an intervention to detect whether the intervention has an effect significantly greater than the underlying secular trend. We critically reviewed the methodological quality of ITS designs using studies included in two systematic reviews (a review of mass media interventions and a review of guideline dissemination and implementation strategies).

Methods: Quality criteria were developed, and data were abstracted from each study.

Sample size calculator for cluster randomized trials.

Cluster randomized trials, where individuals are randomized in groups are increasingly being used in healthcare evaluation. The adoption of a clustered design has implications for design, conduct and analysis of studies. In particular, standard sample sizes have to be inflated for cluster designs, as outcomes for individuals within clusters may be correlated; inflation can be achieved either by increasing the cluster size or by increasing the number of clusters in the study.

Effectiveness and efficiency of guideline dissemination and implementation strategies.

Objectives: To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework for deciding when it is efficient to develop and introduce clinical guidelines.

Room for improvement: a systematic review of the quality of evaluations of interventions to improve hospital antibiotic prescribing.

Introduction: In 1999, the British Society for Antimicrobial Chemotherapy (BSAC) and Hospital Infection Society (HIS) convened a working party on optimization of antibiotic prescribing in hospitals. This study was undertaken in order to evaluate the current evidence base on the effectiveness of interventions to change antibiotic prescribing to hospital inpatients.

Methods: We have systematically reviewed the literature from 1980 to identify interventions that alone, or in combination, are effective in improving antibiotic prescribing to hospital inpatients.

Outcomes of an intervention to improve hospital antibiotic prescribing: interrupted time series with segmented regression analysis.

Objectives: To evaluate an intervention to reduce inappropriate use of key antibiotics with interrupted time series analysis.

Methods: The intervention is a policy for appropriate use of Alert Antibiotics (carbapenems, glycopeptides, amphotericin, ciprofloxacin, linezolid, piperacillin-tazobactam and third-generation cephalosporins) implemented through concurrent, patient-specific feedback by clinical pharmacists. Statistical significance and effect size were calculated by segmented regression analysis of interrupted time series of drug use and cost for 2 years before and after the intervention started.

Can psychological models bridge the gap between clinical guidelines and clinicians' behaviour? A randomised controlled trial of an intervention to influence dentists' intention to implement evidence-based practice.

Objective: The lag between publication of evidence for clinical practice and implementation by clinicians may be decades. Research using psychological models demonstrates that changing intention is very important in changing behaviour. This study examined an intervention (rehearsing alternative actions) to change dentists' intention to implement evidence-based practice (EBP) for third molar (TM) management.

Systematic reviews of the effectiveness of quality improvement strategies and programmes.

Systematic reviews provide the best evidence on the effectiveness of healthcare interventions including quality improvement strategies. The methods of systematic review of individual patient randomised trials of healthcare interventions are well developed. We discuss methodological and practice issues that need to be considered when undertaking systematic reviews of quality improvement strategies including developing a review protocol, identifying and screening evidence sources, quality assessment and data abstraction, analytical methods, reporting systematic reviews, and appraising systematic reviews.

Linking Community Health Index and Scottish Morbidity Records for neonates: the Grampian experience.

Objective: To describe linking Community Health Index (CHI) records with Scottish Morbidity Records for neonates (SMR11) for the purpose of follow-up in a large clinical trial.

Design: A two-stage probabilistic computer match based on date of birth, surname and postcode, supplemented with hand matching.

Setting: Aberdeen Maternity Hospital, Grampian.

Assessing the long-term effect of educational reminder messages on primary care radiology referrals.

Aim: To investigate whether the effect of educational reminder messages for knee and lumbar spine radiographs varied over a 12 month period.

Materials And Methods: In a previous randomized, controlled trial, educational reminder messages attached to x-ray reports were shown to be effective in reducing the number of radiograph requests by general practitioners for knee and lumbar spine radiographs. In this study, all radiology departments from the previous trial were asked for monthly referral records for the 12 month intervention period for knee and lumbar spine radiographs for each general practice.

Research designs for studies evaluating the effectiveness of change and improvement strategies.

The methods of evaluating change and improvement strategies are not well described. The design and conduct of a range of experimental and non-experimental quantitative designs are considered. Such study designs should usually be used in a context where they build on appropriate theoretical, qualitative and modelling work, particularly in the development of appropriate interventions.

The method of minimization for allocation to clinical trials. a review.

Minimization is a largely nonrandom method of treatment allocation for clinical trials. We conducted a systematic literature search to determine its advantages and disadvantages compared with other allocation methods. Minimization was originally proposed by Taves and by Pocock and Simon.