Use of antimicrobial dressings in England and the association with published clinical guidance: interrupted time series analysis.

OBJECTIVES: In healthcare systems, practices and products of unproven value and cost-effectiveness can decrease value and increase waste. Using the management of complex wounds, this study investigates temporal trends in the use of antimicrobials dressings, places this in the context of available evidence and discusses the potential impacts on the UK National Health Service (NHS). DESIGN: Secondary descriptive and interrupted time series (ITS) analysis of NHS prescription data. SETTING: Prescribing Cost Analysis (PCA) details all NHS prescriptions dispensed in the community in England. INTERVENTIONS: An ITS design was used to compare annual changes in the expenditure and use of antimicrobial and non-antimicrobial dressings before and after the publication of the 'intervention' of key evidence-based Scottish Intercollegiate Guidelines Network (SIGN) guidance in 2010. PRIMARY AND SECONDARY OUTCOME MEASURES: Trends in use and expenditure of antimicrobial dressings in relation to published clinical guidance. RESULTS: There was a large increase in the prescribing of, and expenditure on, antimicrobial wound dressings between 1997 and 2016. In 1997, the total number of dressings prescribed was 5 792 700; increasing to 11 447 102 in 2009 with expenditure increasing from £1 960 386 to £32 841 263. During the year of the SIGN intervention (2010), there was a significant drop in the use of silver but there was no consistent ongoing reduction from 2011 to 2015. CONCLUSIONS: Prescribing data can be used to identify products of unproven benefit, which also impose a significant financial burden. This study quantifies the huge increase in the use of antimicrobial wound dressings over a 20-year period despite the lack of compelling evidence to support their routine use. There is some suggestion, however that the use and expenditure decreased after the publication of key guidance. Routine data can be used to as part of more systematic efforts to increase value and reduce waste in health systems.

Never Events in UK General Practice: A Survey of the Views of General Practitioners on Their Frequency and Acceptability as a Safety Improvement Approach.

BACKGROUND: Never events (NEs) are serious preventable patient safety incidents and are a component of formal quality and safety improvement (Q&SI) policies in the United Kingdom and elsewhere. A preliminary list of NEs for UK general practice has been developed, but the frequency of these events, or their acceptability to general practitioner (GPs) as a Q&SI approach, is currently unknown. The study aims to estimate (1) the frequency of 10 NEs occurring within GPs' own practices and (2) the extent to which the NE approach is perceived as acceptable for use. METHODS: General practitioners were surveyed, and mixed-effects logistic regression models examined the relationship between GP opinions of NE, estimates of NE frequency, and the characteristics of the GPs and their practices. RESULTS: Responses from 556 GPs in 412 practices were analyzed. Most participants (70%-88%, depending on the NE) agreed that the described incident should be designated as a NE. Three NEs were estimated to have occurred in less than 4% of practices in the last year; however, two NEs were estimated to have occurred in 45% to 61% of the practices. General practitioners reporting that a NE had occurred in their practice in the last year were significantly less likely to agree with the designation as a NE compared with GPs not reporting a NE (odds ratio, 0.42; 95% CI = 0.36-0.49). CONCLUSIONS: The NE approach may have Q&SI potential for general practice, but further work to adapt the concept and content is required.

A review of non-glove personal protective equipment-related occupational dermatoses reported to EPIDERM between 1993 and 2013.

BACKGROUND: Personal protective equipment (PPE) is defined as equipment that protects the wearer's body against health/safety risks at work. Gloves cause many dermatoses. Non-glove PPE constitutes a wide array of garments. Dermatoses resulting from these have hitherto not been documented. OBJECTIVES: To determine the incidence and types of non-glove PPE-related dermatoses. PATIENTS/METHODS: We analysed incident case reports from dermatologists of non-glove PPE-related dermatoses to a UK-wide surveillance scheme (EPIDERM) between 1993 and 2013. RESULTS: The dermatoses associated with non-glove PPE accounted for 0.84% of all occupational skin disease. Of all PPE-related cases, 194 (9.2%) were attributable to non-glove PPE. Of these, 132 (68.0%) occurred in men, and the median age (both male and female) was 42 years (range 18-82 years). The non-glove PPE-related dermatoses were diagnosed as: allergic contact dermatitis (47.4%), irritant contact dermatitis (16.0%), friction (11.3%), occlusion (11.3%), unspecified dermatitis (8.8%), acne (3.1%), infections (1.5), and contact urticaria (0.52%). The industries most associated with non-glove PPE-related dermatoses were manufacturing (18.6%), public administration and defence (17.0%), health and social work (15.5%), and transport, storage, and communication (9.8%). CONCLUSIONS: Clothing, footwear, facemasks and headgear need to be recognized as causes of dermatoses occurring at body sites less commonly associated with occupational skin disease.

Development and piloting of a survey to estimate the frequency and nature of potentially harmful preventable problems in primary care from a UK patient's perspective.

OBJECTIVES: To design and pilot a survey to be used at the population level to estimate the frequency of patient-perceived potentially harmful preventable problems occurring in UK primary care. To explore the nature of the problems, patient-suggested strategies for prevention and opinions of clinicians and the public regarding the potential for harm. DESIGN: A survey was codesigned by three members of the public and one researcher and piloted through public and patient involvement and engagement networks. SETTING: Self-selected sample of the UK population. PARTICIPANTS: 977 members of the public accessed the online survey during October and November 2015. PRIMARY OUTCOME MEASURES: Respondent feedback about the ease of completion of the survey, quality of responses in terms of review by clinicians and members of the public, preliminary estimates of the frequency and nature of patient-perceived potentially harmful problems occurring in the last 12 months. RESULTS: 638 (65%) members of the public completed the survey and few respondents reported any difficulty in understanding or completing the survey. 132 (21%) respondents reported experiencing a potentially harmful preventable problem during the past 12 months and 108 (82%) of these respondents provided a description that was adequate for at least one clinician to form an opinion about the potentially harmful problem. Respondents were older than the UK generally, more likely to work or volunteer in the healthcare sector and tended to use primary care more frequently but their confidence and trust in their own general practitioner (GP) was similar to that of the UK population as measured by the annual English GP patient survey. CONCLUSIONS: The survey was acceptable to patients and mostly provided data of sufficient quality for review by clinicians and members of the public. It is now ready to use at a population level to estimate the frequency and nature of potentially harmful preventable problems in primary care from a patient's perspective.

Exploring Study Designs for Evaluation of Interventions Aimed to Reduce Occupational Diseases and Injuries.

Effective interventions to reduce work-related exposures are available for many types of work-related diseases or injuries. However, knowledge of the impact of these interventions on injury or disease outcomes is scarce due to practical and methodological reasons. Study designs are considered for the evaluation of occupational health interventions on occupational disease or injury. Latency and frequency of occurrence of the health outcomes are two important features when designing an evaluation study with occupational disease or occupational injury as an outcome measure. Controlled evaluation studies-giving strong indications for an intervention effect-seem more suitable for more frequently occurring injuries or diseases. Uncontrolled evaluation time or case series studies are an option for evaluating less frequently occurring injuries or diseases. Interrupted time series offer alternatives to experimental randomized controlled trials to give an insight into the effectiveness of preventive actions in the work setting to decision and policy makers.

Worldwide trends in incidence in occupational allergy and asthma.

PURPOSE OF REVIEW: Recent improvements in the methods for analyzing trends in occupational health surveillance and the prospect of future improvements in the collecting and sharing of electronic data alongside increasing availability of linked datasets make this a good time to review the existing literature on trends in occupational allergy and asthma (OAA). RECENT FINDINGS: There is a notable lack of reports of recent trends in OAA in the academic literature and much of the published work comes from European countries. The incidence of OAA appears to be declining based on physician-reporting or recognized compensation claims for the countries with published data. However, we need to be cautious in interpreting this as a decline in the 'true' incidence of OAA. Few of the studies adjusted appropriately for changes in the population at risk and one of the most robust study designs showed no change in the incidence of allergic contact dermatitis in contrast to the other studies. SUMMARY: Many existing datasets have the potential to be used to examine trends, and studies from Canada show the potential of using linked databases for surveillance. We hope that this review will encourage improvements in the analysis, and more dissemination, of trends.

Primary Care Medication Safety Surveillance with Integrated Primary and Secondary Care Electronic Health Records: A Cross-Sectional Study.

INTRODUCTION: The extent of preventable medication-related hospital admissions and medication-related issues in primary care is significant enough to justify developing decision support systems for medication safety surveillance. The prerequisite for such systems is defining a relevant set of medication safety-related indicators and understanding the influence of both patient and general practice characteristics on medication prescribing and monitoring. OBJECTIVE: The aim of the study was to investigate the feasibility of linked primary and secondary care electronic health record data for surveillance of medication safety, examining not only prescribing but also monitoring, and associations with patient- and general practice-level characteristics. METHODS: A cross-sectional study was conducted using linked records of patients served by one hospital and over 50 general practices in Salford, UK. Statistical analysis consisted of mixed-effects logistic models, relating prescribing safety indicators to potential determinants. RESULTS: The overall prevalence (proportion of patients with at least one medication safety hazard) was 5.45 % for prescribing indicators and 7.65 % for monitoring indicators. Older patients and those on multiple medications were at higher risk of prescribing hazards, but at lower risk of missed monitoring. The odds of missed monitoring among all patients were 25 % less for males, 50 % less for patients in practices that provide general practitioner training, and threefold higher in practices serving the most deprived compared with the least deprived areas. Practices with more prescribing hazards did not tend to show more monitoring issues. CONCLUSIONS: Systematic collection, collation, and analysis of linked primary and secondary care records produce plausible and useful information about medication safety for a health system. Medication safety surveillance systems should pay close attention to patient age and polypharmacy with respect to both prescribing and monitoring failures; treat prescribing and monitoring as different statistical processes, rather than a combined measure of prescribing safety; and audit the socio-economic equity of missed monitoring.

Evaluating interventions aimed at reducing occupational exposure to latex and rubber glove allergens.

OBJECTIVE: Concerns over occupational exposures to blood-borne viruses resulted in increased protective glove use; consequentially latex allergy became a hazard for some occupational groups. Interventions aimed at managing this problem included substitution measures (eg, non-powdered/non-latex gloves), but such changes may not occur simultaneously across occupational sectors. This study evaluated whether the incidence of occupational dermatoses fell after interventions aiming to reduce exposure to 'latex and rubber glove allergens' ('latex') were introduced, and whether these interventions were more effective for healthcare workers (HCWs), compared with non-HCWs. METHODS: Incidence rate ratios (IRRs) comparing cases reported to EPIDERM (a UK-wide surveillance scheme) during post versus pre-intervention periods were calculated, both where 'latex' was cited and for cases associated with other exposures ('controls'). RESULTS: Among HCWs, cases of contact urticaria and allergic contact dermatitis (ACD) where 'latex' was cited showed significant downward trends post-intervention, with IRRs of 0.72, 95% CI; 0.52 to 1.00 and 0.47, 95% CI; 0.35 to 0.64 respectively. For HCWs, this fall in 'latex' associated ACD was significantly greater (p=0.02) than for other exposures ('controls') IRR=0.85, 95% CI; 0.57 to 1.28, and greater than that among non-HCWs (IRR 0.75, 95% CI; 0.61 to 0.93). Increases over time were seen for irritant contact dermatitis (ICD) reporting for HCWs, both for cases associated with 'latex' (IRR 1.47, 95% CI: 1.02 to 2.13) and for other exposures ('controls') IRR 1.36, 95% CI 1.06 to 1.76, but not for non-HCWs. CONCLUSIONS: A reduction in overall ACD, particularly in HCWs, coincided with interventions aimed at managing workplace contact dermatoses associated with 'latex' exposure. A coincidental rise in ICD reporting is also important, both for hand care and for infection control strategies.