Complex fractures, do we operate on enough to gain and maintain experience?

Complex fractures are generally assumed by our profession to require adequate training and continuing practice to treat optimally. The quantity of complex fractures treated in individual hospitals and by or under the care of individual orthopaedic consultants may have implications regarding the quality of care for particular patients and also for the training of specialist registrars.A complex fracture was defined as a comminuted peri- or intra-articular fracture or segmental shaft fracture: fractures acknowledged at specialist fracture courses and by special trauma surgeons to require particular training and experience to treat optimally. The AO classification was used: most fractures were in AO groups B and C [M.E. Muller, S. Narazian, P. Koch, J. Schatzker, The Comprehensive Classification of Longbones, Springer, Berlin, 1990]. Theatre records were used to identify all operated orthopaedic trauma cases over a period of 1 year in one District General Hospital (DGH) and one University Hospital, each serving populations of over 300000 and for 6 months in one DGH (population approximately 300000). Radiographs and hospital records were reviewed by two orthopaedic surgeons and the number and type of complex fractures documented as defined above. In hospital A, 69 complex fracture operations were carried out under the care of six consultants in 12 months. In hospital B, 24 complex fractures were treated by five consultants over a 6-month period and in hospital C, 127 complex fractures were treated by 10 consultants over a 12-month period. Some consultants (different consultants for different fracture regions) did not operate on any complex fracture of the proximal, mid, or distal humerus; proximal, mid, or distal radius or ulna; proximal, mid, or distal femur; proximal, mid, or distal tibia; calcaneum; peri-prosthetic; Lisfranc; or talus fracture during the specific time period. Some consultants only treated one or two such fractures. Where two surgeons had developed an area of special interest and cross-referral were encouraged individual surgeons were operating on up to 25 complex cases in their area of interest.This audit has shown that individual complex fractures present infrequently to particular hospitals and surgeons. This finding raises questions about the optimal management of such fractures: are we maintaining a sufficient level of expertise, or should there be more cross-referrals to surgeons with a specific interest either in trauma or in a particular anatomical region?

An assessment of the POSSUM system in orthopaedic surgery.

We describe the development and validation of a scoring system for auditing orthopaedic surgery. It is a minor modification of the POSSUM scoring system widely used in general surgery. The orthopaedic POSSUM system which we have developed gives predictions for mortality and morbidity which correlate well with the observed rates in a sample of 2326 orthopaedic operations over a period of 12 months.

Variations in GP nursing home patient workload: results of a multivariate analysis.

The number of old people living in UK nursing homes has increased substantially over the past 15 y. There is evidence that such patients generate larger workloads for primary carers than do those of similar age and sex living in their own homes. Clearly, any extra workload involved in providing primary care services to nursing home patients, needs to be reflected in the resources afforded general practitioners (GPs) who are tasked with its provision. By the same token variations in workloads between patients need to be examined and explained for any insights these might provide on funding issues. To examine and explain variations in GP workload associated with nursing home patients and determine the implications of these for GP funding, a 12 month case control study of all nursing home residents over 65 y old registered with nine general practices was undertaken. A multivariate regression analysis was used to examine variations in GP workload associated with 270 nursing home patients. Multivariate regression models explaining the variation in workload cost per month in terms of the GP practice delivering care and patients age and sex had little explanatory power (R(2)=0.07). A fuller method including the patient's Barthel score and initial diagnosis as additional explanatory variables added little to the explanatory power of the model (R(2)=0.12). The ability of the multivariate models used here to explain the variation in GP workload was poor. GPs may require an allowance to compensate for differences in workload associated with nursing home patients but adjusting these payments for differences in age, sex, initial diagnosis or the other variables included in this analysis would not appear to be supported.

The impact of nursing home patients on general practitioners' workload.

BACKGROUND: Although the number of people in nursing homes has risen substantially in recent years, the shift of responsibility into general practice has rarely been accompanied by extra resources. These patients may be associated with a higher general practitioner (GP) workload than others of similar age and sex. AIM: To assess the GP workload associated with nursing home residents and its associated costs. METHOD: All nursing home residents aged over 65 years and registered with nine Nottinghamshire practices during one year were matched with patients living in the community for general practice, age, and sex. Data were collected retrospectively for both groups on key workload measures. Costs for the workload measures were calculated using published estimates. RESULTS: Data were collected for 270 pairs of patients. Nursing home patients had more face-to-face contacts in normal surgery hours, telephone calls, and out-of-hours visits. The mean workload cost per month of a nursing home patient (assuming that one patient was seen per visit) was estimated to be 18.21 Pounds (10.49 Pounds higher than the cost of controls). A sensitivity analysis demonstrated that potential savings in visiting costs associated with increasing the numbers of patients seen per visit were 27% for one extra patient seen per visit and 44% for four extra patients. CONCLUSION: Nursing home residents were associated with higher workload for GPs than other patients of the same age and sex living in the community. Our costings provide a basis for negotiating suitable reimbursement of GPs for their additional work.

Head injury in the severely injured: long-term follow-up in 157 patients.

Ninety-two patients with head injury in the context of multiple injury were followed up 5 years after injury. Severe disability in this group of patients was nearly always due to brain/spinal cord injury, rather than musculoskeletal injury. A substantial number of patients with mild or moderate head injuries had significant persisting disability 5 years after injury.

Age and proximity to death as predictors of GP care costs: results from a study of nursing home patients.

This paper reports the results of a study of GP costs associated with a group of nursing home patients who died at various stages during a 12-month period. The relationship between costs per month of care, patient age and proximity to death, where sex and diagnosis are controlled for are reported. A comparison of care costs for patients in their last year of life and those who survived the course of the study is also made. The study found that those in their last year of life were significantly more expensive to care for than those who survived the duration of the study, but that there was no statistically significant difference in age. In multivariate regression analyses, it was also found that among those who died during the study care costs were unrelated to age, but significantly related to proximity to death. The study supports the contention of others (Zweifel P, Felder S, Meiers M. Ageing of population and health care expenditure: a red herring? Health Econ 1999; 8: 485-496) that health care costs are more directly related to proximity to death than age.

The impact of nursing home patients on prescribing costs in general practice.

OBJECTIVES: To compare the costs of prescribing for older people in nursing homes with older people living at home and to compare patterns of prescribing between these two groups. DESIGN: Retrospective case-control study. SETTING: Nine general practices in Nottinghamshire. SUBJECTS: Two hundred and seventy patients aged 65 years and over living in nursing homes matched for age, sex and general practice, with 270 patients living in their own homes. MAIN OUTCOME MEASURES: A comparison of the costs of prescriptions, the number of items on prescription and the types of drugs prescribed between the cases and controls. RESULTS: The mean cost of prescriptions per patient month was almost three times higher for nursing home patients than controls (45.27 pounds compared to 16.46 pounds). The mean number of items prescribed per patient month was also higher in nursing home patients (5.60 compared to 2.55). Total costs of prescriptions for nursing home patients were higher than for controls (P < 0.0001), as were total numbers of prescription items (P < 0.001). There were differences in the types of medication prescribed between the two groups, including considerably higher costs for central nervous system drugs, ulcer healing drugs, laxatives and enteral nutrition in nursing home residents. CONCLUSIONS: When calculating general practice prescribing budgets, nursing home patients should have a greater weighting than other patients of similar age and sex.

Anxiety and depression disorders 5 years after severe injuries: a prospective follow-up study.

Individuals with severe injuries were investigated 5 years after the traumatic events, and predictors of anxiety and depression disorders were identified. Trauma victims were selected who had an Injury Severity Score of > or = 16 and were brought to all hospitals in the Mersey region and North Wales over 1 year. The 212 patients aged > or = 15 years who left the hospital alive and lived within an accessible distance of the study hospital in Warrington were contacted 5 years later and 158 (74.5%) received follow-up assessment. Thirty-eight subjects (36.9%) reported "definite" anxiety and/or depression disorders and, of these, only 21.1% reported taking psychotropic medications. Factors associated with anxiety and/or depression disorders at follow-up were: sequelae of head injury (i.e., cognitive problems, posttraumatic seizures, facial pain): writing impairment: disability due to thorax problems; and a new trauma during follow-up. Initial severity or types of injuries and overall residual disability rated by the investigator were not strong predictors of anxiety and/or depression disorders at follow-up.

What problems do patients present with outside normal general practice surgery hours? A prospective study of the use of general practice and accident and emergency services.

BACKGROUND: This study was designed to address some current issues concerning the use of general practice and accident and emergency (A & E) services outside normal surgery hours. METHOD: Six general practices in Nottingham (with a combined population of 46,698 patients) were recruited to take part in the study. Over a six month period, data were collected on patient contacts with general practice services and the local A & E department outside normal surgery hours. RESULTS: General practice services dealt with 63 per cent of first contacts over the course of the study. There were 3181 (136 per 1000 patients per year) contacts with general practitioners and deputizing service doctors (of which 1009 (31.7 per cent) were dealt with by telephone alone) and 1876 (80 per 1000 patients per year) attendances at the A & E department. There were marked differences in the distribution of problems that patients presented to the two types of service. The proportion of presentations dealt with by telephone alone by general practice services varied with the type of presentation. However, the use of the telephone was not particularly high, even for problems such as a sore throat. CONCLUSIONS: Given the differences in presentations to both general practice and A & E services there may be limited scope for altering patients' consulting patterns without making significant changes to service provision. However, there may be scope for increasing the proportion of general practice contacts dealt with by telephone alone.

Explaining variations in prescribing costs: results from a comparison of nursing home patients with matched pairs living in the community.

OBJECTIVES: To examine and explain variations in prescribing costs associated with nursing home patients and patients matched by age and sex living in the community. DESIGN: A 12-month case control study. SUBJECTS: All nursing home residents over 65-years-old registered with nine general practices and patients matched with them for age and sex living in the community. METHOD: Multivariate regression analysis of variations in monthly GP prescribing costs. RESULTS: Multivariate regression models explaining cost variations in terms of the GP practice delivering care and patients' age and sex had little explanatory power (R(2)=0.07 for nursing home patients, R(2)=0.03 for matched pairs). A fuller model for nursing home patients only, incorporating the patient's Barthel score and initial diagnosis as additional explanatory variables, added little to the explanatory power of the model (R(2)=0.16). CONCLUSION: The ability of the multivariate models used here to explain variations in prescribing costs among a group of elderly patients is poor. Adjusting weighted capitation formulae with respect to older patients to take account of such information or referring to it in negotiations on prescribing budgets would not appear to be warranted.

Disability after severe injury: five year follow up of a large cohort.

The early outcome for severely injured patients has improved in the last 20 years, but the level of continuing long term disability in such patients is not known. A large cohort of severely injured patients (ISS > 15) were interviewed and examined approximately 5 years following their injury. We present the preliminary results which show that only 30 per cent had made a full recovery, and that an alarming 47 per cent remain with moderate, severe or very severe disabilities. A large proportion (45%) of the persisting disability is due to pelvic and limb injury (74 per cent if brain and spinal cord injuries are excluded). This study reflects initial treatment in 13 District General Hospitals and one Teaching Hospital in a single geographical region in 1989 and 1990, and is the first such study in the UK. We conjecture whether more aggressive and specialized treatment and rehabilitation, especially of orthopaedic injuries, would improve these disappointing results.

Relation of out of hours activity by general practice and accident and emergency services with deprivation in Nottingham: longitudinal survey.

OBJECTIVES: To investigate the relation between out of hours activity of general practice and accident and emergency services with deprivation and distance from accident and emergency department. DESIGN: Six month longitudinal study. SETTING: Six general practices and the sole accident and emergency department in Nottingham. SUBJECTS: 4745 out of hours contacts generated by 45,182 patients from 23 electoral wards registered with six practices. MAIN OUTCOME MEASURES: Rates of out of hours contacts for general practice and accident and emergency services calculated by electoral ward; Jarman and Townsend deprivation scores and distance from accident and emergency department of electoral wards. RESULTS: Distances of wards from accident and emergency department ranged from 0.8 to 9 km, and Jarman deprivation scores ranged from -23.4 to 51.8. Out of hours contacts varied by ward from 110 to 350 events/1000 patients/year, and 58% of this variation was explained by the Jarman score. General practice and accident and emergency rates were positively correlated (Pearson coefficient 0.50, P = 0.015). Proximity to accident and emergency department was not significantly associated with increased activity when deprivation was included in regression analysis. One practice had substantially higher out of hours activity (B coefficient 124 (95% confidence interval 67 to 181)) even when deprivation was included in regression analysis. CONCLUSIONS: A disproportionate amount of out of hours workload fell on deprived inner city practices. High general practice and high accident and emergency activity occurred in the same areas rather than one service substituting for the other.

Problems found in the over-75s by the annual health check.

BACKGROUND: Research into the health of elderly people has found problems unknown to their general practitioners. It was anticipated that annual checks, as required by the 1990 general practitioner contract, would help to detect these problems, yet the value of these checks has been questioned. AIM: To investigate the problems found by general practice contractual annual checks of the over-75s and the consequent actions taken; to identify patient, demographic or practice characteristics associated with the discovery of problems. METHOD: In 40 practices, information was collected on patients over 75 years of age receiving a health check during a 3-month period. Practices used their normal methods of recruitment and assessment. Practice staff were interviewed to find how assessments were organized. RESULTS: Practices saw a mean of 12% of their over-75s during the study; 44% were found to have at least one problem. Action was taken to help resolve problems in 82% of patients with a problem. The most prevalent problems related to physical condition, and fewer functional problems than expected were found. There were large differences between practices in the proportions of elderly patients seen for a check and the proportion found to have problems; these were not attributable to practice size or demography. Multivariate analysis showed that practice or patient characteristics were poor predictors of finding problems. CONCLUSION: The argument in favour of conducting annual checks is supported by the finding that nearly half the patients assessed were found to have problems for which some action was taken. Some practices could increase their rate of uptake by modifying the organization of invitations for checks. More problems may be found by adopting a more functionally based assessment.

Preventable deaths among major trauma patients in Mersey Region, North Wales and the Isle of Man.

Preventable and unexpected deaths following injury were identified from among 1088 victims of major injuries arising in a defined population and area during a 12-month period. In hospital, 44 (16 per cent) deaths from blunt injury, one death from penetrating injury and one death from drowning were preventable. In patients sustaining blunt injuries, 22 per cent of non-head-injury deaths and 13 per cent of head-injury deaths were preventable. In all preventable head-injury deaths either a delay in operation (35 per cent) or no operation for mass lesions (65 per cent) occurred, often because of misdiagnosis as alcohol intoxication (22 per cent) or CVA (22 per cent). Multiple preventable factors were more likely in non-head-injury deaths and included missed injuries (67 per cent), poor airway care (57 per cent), delayed or no operation (52 per cent), undertransfusion (38 per cent) and inadequate surgery (19 per cent). By TRISS methodology the outcome was unexpected, in 53 per cent blunt injury deaths in hospital and 2.8 per cent of survivors. Three preventable blunt injury deaths (6.8 per cent) had probabilities of survival < 50 per cent and were not, therefore, identified as unexpected by TRISS. A preventable death rate of 16 per cent for blunt injuries equates to 638 preventable blunt injury deaths each year in England and Wales.

The epidemiology of pelvic fractures in the Mersey Region.

The Mersey Region Trauma Survey was performed over 12 months in 1989 and 1990 to study the epidemiology of trauma in a population of 3,200,000. All deaths from injuries, and all survivors with an injury severity score of 15 or over were included, giving a total of 1088 cases. This paper, primarily epidemiological, considers those victims with a pelvic fracture (153 patients), and especially those who reached hospital alive (111 patients). The epidemiology, hospital care and mortality are considered, but the specific management of individual fractures is not.

Maxillofacial and associated injuries in severely traumatized patients: implications of a regional survey.

The aim of this paper was to study the incidence and causes of facial injuries occurring in conjunction with major trauma, and to examine the role of the maxillofacial surgeon in the management of severely injured patients. A prospective study was undertaken of 1088 patients seen in 16 hospitals over a 1-year period. A total of 161 (15%) patients sustained facial injuries. Of these, 33% died at the scene of the incident and 21% died in hospital. There was poor resuscitation in 32% of patients, and a total of 32 injuries were missed in 19 patients. The involvement of the maxillofacial surgeon in the management of severely injured patients is examined. Our findings emphasize the need for early referral to the maxillofacial surgeon. It is concluded that maxillofacial surgery should be an on-site speciality, closely associated with the neurosurgical centre.

Severe motorcycle injury in Mersey region and North Wales.

Ninety-three patients were involved in serious motorcycle accidents (death or Injury Severity Score more than 15) during a 1-year period among a total of 554 victims of serious road traffic accidents studied at 16 district general and teaching hospitals. There were 91 males and two females. The average age was 29 years (range 15-81 years). Of these, 32 per cent died at the scene of the accident or in transit; 68 per cent arrived alive at the above hospitals. Of the latter, 30 per cent died in hospital. The commonest cause of death was multiple injuries. The Injury Severity Score of patients admitted to hospital was a mean of 32.1. The Glasgow Coma Score was below 9 in 33.8 per cent. Of those admitted to hospital, the average length of stay was 38.7 days. 67 per cent were admitted to intensive therapy unit of whom 41.3 per cent had to be ventilated for an average of 3.55 days. There were four preventable deaths among the patients who died after being admitted to hospital. Many body areas are frequently injured in motorcycle accidents which occur usually in fit males. Careful assessment along with vigorous and aggressive treatment is particularly important for this group. Access to a specialized trauma centre would be beneficial.

The epidemiology of major injuries in Mersey Region and North Wales.

A prospective epidemiological study was undertaken to determine the workload and patient characteristics for a putative trauma centre in a large defined area. One thousand and eighty-eight patients were included: 430 brought in dead, 309 hospital deaths and 349 survivors. Types of injury were: blunt 76 per cent, penetrating 3.6 per cent, burns 5.8 per cent, other 14 per cent. The incidence of blunt injury was 19/100,000 for patients arriving alive at hospital and accounted for 0.08 per cent of new A & E attendances. Eight per cent of blunt injury patients were children, 68 per cent were adults and 24 per cent elderly. Major causes of injury were: road accidents 67 per cent and falls 26 per cent. In patients arriving alive after blunt injuries, those who subsequently died were significantly older, more severely injured and more physiologically impaired. Hospital mortality was 45 per cent for blunt, 43 per cent for penetrating injuries, and 67 per cent for burns. TRISS methodology indicated 53 per cent of hospital deaths from blunt injuries were unexpected. Practically, it is questionable whether the incidence of major injuries is sufficient to provide the volume of patients necessary to sustain a Level I Trauma Centre. Nevertheless, concentration of injury service is essential, since no hospital receives sufficient patients to develop and maintain expertise.

Evaluation of the short-term impact of counseling in general practice.

This paper describes the findings of a randomised controlled trial of the short-term impact of counseling in the general practice setting. Compared with patients who received usual advice from their general practitioner for acute problems such as relationship difficulties, anxiety and depression, those who received counseling from qualified counselors working within the primary health care context showed greater improvement in psychological health as measured by the General Health Questionnaire. Significantly fewer of those counselled were prescribed anti-depressant drugs by the general practitioners in the study, or were referred to psychiatrists or clinical psychologists for care. In addition those patients who attended sessions with the practice counselor were more likely to report that they were satisfied with their treatment and more expressed feelings of well-being.

Regional review of blunt trauma in children.

Seventy-five severely injured children (Injury Severity Score greater than 15 or death) were identified during a 1-year prospective audit of all severe trauma in a single region. Fourteen children were admitted primarily to the regional children's hospital, comprising 0.2 per cent of that accident and emergency department workload. Paediatric trauma admissions to the 15 district general hospitals averaged 3.1 children per hospital per year or 0.007 per cent of the accident and emergency department attendances. There were 38 deaths (51 per cent), of which 15 occurred before admission to hospital. Significant deficiencies in acute management were identified at both types of hospital. There is a need to improve trauma management of children at tertiary care level and district general hospitals by developing trauma management protocols. The low number of severely injured children presenting to the district general hospitals suggests the need for a regional trauma system.