Systematic review of carotid artery procedures and the volume-outcome relationship in Europe.

BACKGROUND: Hospitals that conduct more procedures on the carotid arteries may achieve better outcomes. In the context of ongoing reconfiguration of UK vascular services, this systematic review was conducted to evaluate the relationship between the volume of carotid procedures and outcomes, including mortality and stroke. METHODS: Searches of electronic databases identified studies that reported the effect of hospital or clinician volume on outcomes. Reference and citation searches were also performed. Inclusion was restricted to European populations on the basis that the model of healthcare delivery is similar across Europe, but differs from that in the USA and elsewhere. Analyses of hospital and clinician volume, and carotid endarterectomy (CEA) and carotid artery stenting (CAS) were conducted separately. RESULTS: Eleven eligible studies were identified (233 411 participants), five from the UK, two from Sweden, one each from Germany, Finland and Italy, and a combined German, Austrian and Swiss population. All studies were observational. Two large studies (179 736 patients) suggested an inverse relationship between hospital volume and mortality (number needed to treat (NNT) as low as 165), and combined mortality and stroke (NNT as low as 93), following CEA. The evidence was less clear for CAS; multiple analyses in three studies did not identify convincing evidence of an association. Limited data are available on the relationship between clinician volume and outcome in CAS; in CEA, an inverse relationship was identified by two of three small studies. CONCLUSION: The evidence from the largest and highest-quality studies included in this review support the centralization of CEA.

Procedure Volume and the Association with Short-term Mortality Following Abdominal Aortic Aneurysm Repair in European Populations: A Systematic Review.

OBJECTIVE: To evaluate the relationship between the volume of abdominal aortic aneurysm (AAA) procedures undertaken and the primary outcome of mortality in Europe. Previous systematic reviews of this relationship are outdated and are overwhelmingly based on US data. DATA SOURCES: Comprehensive searching within MEDLINE and other bibliographic databases supplemented by citation searching and hand-searching of journals was undertaken to identify studies that reported the effect of hospital or clinician volume on any reported outcomes in adult, European populations, undergoing AAA repair and published in the last 10 years. METHODS: Two reviewers conducted study selection with independent, duplicate data extraction and quality assessment. A planned meta-analysis was not conducted because of the high risk of bias, the likelihood of individual study subjects being included in more than one study and diversity in the clinical populations studied and methods used. RESULTS: Sixteen studies (n = 237,074 participants) from the UK (n = 11 studies), Germany (n = 3 studies), Norway (n = 1 study), and one from the UK and Sweden were included. Data in the included studies came from administrative databases and clinical registries incorporating a variety of clinical and procedural groups; the study quality was limited by the use of observational study designs. Overall, the evidence favoured the existence of an inverse volume outcome relationship between hospital volume and mortality. Insufficient evidence was available to reach conclusions on the relationship between clinician volume and outcome and between hospital or clinician volume and secondary outcomes including complications and length of hospital stay. CONCLUSIONS: The evidence from this review suggests a relationship between the hospital volume of AAA procedures conducted and short-term mortality; however, as volume typically represents a complex amalgamation of factors further research will be useful to identify the core characteristics of volume that influence improved outcomes.

How effective are prevention strategies in reducing the prevalence of pressure ulcers?

The prevalence of pressure ulcers has remained constant at about 7% over the past 20 years, even though considerable time and money has been invested in various prevention strategies. This literature review explores whether pressure-prevention programmes can reduce the prevalence rate still lower or whether they are working but are limited by an increasingly aged population and rising patient acuity.

The study of hygiene behaviour in Botswana: a combination of qualitative and quantitative methods.

This paper describes a study from northern Botswana which explored the relationship between hygiene behaviour and diarrhoeal diseases in young children. Both qualitative and quantitative data collection methods were used. The qualitative methods included observations, key informant interviews, in-depth interviews and focus groups. The quantitative methods included spot check observations, anthropometric measurements, the monitoring of diarrhoea morbidity and the administration of a socioeconomic questionnaire. A profile of hygiene behaviours was developed for this community and traditional beliefs related to diarrhoea were identified. The methods described provided considerable information in a short period of time. They were also relatively inexpensive and easy to implement, thus providing a model for further studies dealing with hygiene behaviour in developing countries. The information gathered enabled the identification of areas needing further research, the development of health education programmes and provided the basis for larger epidemiological studies.

Understanding of hygiene behaviour and diarrhoea in two villages in Botswana.

This paper describes a study which took place in two villages in north-east district of Botswana from July 1990 through July 1991. Qualitative data collection methods were used including: observations, key-informant interviews, focus groups, and in-depth interviews. The data were used for understanding and interpreting the cultural belief systems regarding specific hygiene behaviours and diarrhoea, with emphasis on hand washing. Hand washing was said to occur for three main reasons: to remove contamination, for social reasons, and for comfort reasons. Sources of dirt on the hands included human blood and faeces. Many perceived causes of diarrhoea were identified, including pogwana (dehydration associated with sunken anterior fontanelle). Traditional concepts regarding the treatment and prevention of diarrhoea were also identified. It is suggested that beliefs surrounding hygiene behaviour and diarrhoea should be incorporated into health education programmes.

PIP: During July 1990 to July 1991, in northeastern Botswana, focus groups, observations, and interviews were conducted in two villages largely inhabited by people from the Tswana and Kalanga tribes. Researchers examined hygiene behaviors (especially hand washing) and attitudes towards infantile diarrhea in these villages. Villagers considered hand washing after defecation to be a modern idea. Hand washing was not always done, especially if one went into the bush to defecate. People considered it more important to wash hands before meals. Identified sources of contamination were one's own body (through scratching, touching oneself while urinating, blowing the nose, hands [especially the left hand], blood [especially menstrual blood], and adult feces), soil, weeds, chicken feces, laundry water, and sometimes dish-washing water, but not cow dung and mud. Hand washing after touching each source was not always done. The focus groups identified a list of words for diarrhea in Setswana and Kalanga so health workers could track diarrhea morbidity. Both languages had a word for diarrhea that characterized the condition as having more frequent stools than usual and being affected by general ill health. Pogwana referred to dehydration associated with sunken anterior fontanelle. Many mothers did not know the cause of diarrhea. Some perceived causes of diarrhea were worms in the brain or in the stomach, a bewitched child, malnutrition, teething, watermelons, contaminated water or food, or cold weather. Ways to prevent diarrhea identified by the traditional healer included not feeding the child dirty food, not storing cooked food overnight, not giving too many different foods each day, and keeping yards swept. Diarrhea treatment options were: take the child to the clinic right away; visit a faith or traditional healer; and treat the child at home with oral rehydration salts, a home-made sugar/salt solution, or a traditional herb tea. All mothers mentioned additional fluids. Traditional healers sometimes used enemas. These findings suggest that health education programs should incorporate the beliefs revolving around hygienic behavior and diarrhea.

The use of microbiology in the study of hygiene behaviour.

Faecal indicator bacteria have been used to measure levels of hygiene in a variety of settings. This paper describes a study in northern Botswana which used the isolation of faecal indicator bacteria in combination with other quantitative and qualitative techniques to gain information regarding hygiene behaviour. The microbiological samples included, samples from stored drinking water and water sources; eating plates; infant feeding bottles; dishcloths and the fingertips of carers and children. Water was usually clean at source but contaminated after storage. Presumptive faecal coliforms contaminated 31% of the eating plates, 29% of the dishcloths and 40% of the infant feeding bottles. Many of the presumptive faecal coliform isolates were not identified as Escherichia coli, indicating the need for further research into methodologies appropriate for isolating E. coli in tropical climates.

Faecal contamination on children's hands and environmental surfaces in primary schools in Leeds.

Gastro-intestinal diseases continue to be a major health problem in primary schools in the UK. This study, which took place in 20 primary schools in the Leeds area, investigated the presence of faecal indicator bacteria on children's hands and environmental surfaces. Faecal streptococci were used as an indicator of faecal contamination. A handwashing knowledge score was developed for each child. Those children with good hygiene knowledge had less faecal contamination on their hands (relative risk: 1.4, 95% CI = 1.09-1.81, P = 0.005). Those schools with higher hand counts were more likely to have had a reported outbreak of gastroenteritis in the past. Values of the Townsend Deprivation Index, an indicator of deprivation, were compared with the hand results and those schools in high deprivation areas had higher hand counts. Of the swabs taken from surfaces in the toilet areas and classrooms, the carpets in the classrooms were the most frequently contaminated surfaces.

Microbiological methods for assessing handwashing practice in hygiene behaviour studies.

Personal hygiene, especially handwashing, is frequently mentioned as an important aspect of diarrhoeal disease prevention in water and sanitation programmes. Handwashing practice is difficult to assess but the microbiological analysis of hands shows promise as an indicator of this behaviour. Most methods for isolating bacteria from the hands have been developed for use in hospitals in order to investigate the spread of nosocomial infections. However, reliable and inexpensive methods which need only limited expertise are needed for use in developing countries where diarrhoeal diseases remain a major health risk. Techniques for sampling hands and bacteriological analysis methods are discussed with special emphasis on practical considerations for conducting tests in developing countries. Several studies have used these methods successfully and have investigated hygiene behaviour and how living conditions affect behaviour and the role of hands in diarrhoeal disease transmission. We recommend the use of impression plates for isolating faecal indicator bacteria from the hands and also recommend faecal streptococci as an indicator of faecal contamination.