Reduced risk of emergency admission for colorectal cancer associated with the introduction of bowel cancer screening across England: a retrospective national cohort study.

AIM: We wanted to find out if roll-out of the bowel cancer screening programme (BCSP) across England was associated with a reduced risk of emergency hospital admission for people presenting with colorectal cancer (CRC) during this period. METHOD: This is a retrospective cohort study of 27 763 incident cases of CRC over a 1-year period during the roll-out of screening across parts of England. The primary outcome was the number of emergency (unplanned) hospital admissions during the diagnostic pathway. The primary exposure was to those living in an area where the BCSP was active at the time of diagnosis. Patients were categorized into three exposure groups: BCSP not active (reference group), BCSP active < 6 months or BCSP active ≥ 6 months. RESULTS: The risk of emergency admission for CRC in England was associated with increasing age, female gender, comorbidity and social deprivation. After adjusting for these factors in logistic regression, the odds ratio (OR) for emergency admission in patients diagnosed ≥ 6 months after the start-up of local screening was 0.83 (CI 0.76-0.90). The magnitude of risk reduction was greatest for cases of screening age (OR 0.75; CI 0.63-0.90) but this effect was apparent also for cases outside the 60-69-year age group (OR 0.85; CI 0.77-0.94). Living in an area with active BCSP conferred no reduction in risk of emergency admission for people diagnosed with oesophagogastric cancer during the same period. CONCLUSION: The start-up of bowel cancer screening in England was associated with a substantial reduction in the risk of emergency admission for CRC in people of all ages. This suggests that the roll-out of the programme had indirect benefits beyond those related directly to participation in screening.

Commissioning for COPD care: a new, recordable metric that supports the patient interest.

BACKGROUND: Healthcare metrics have been used to drive improvement in outcome and delivery in UK hospital stroke and cardiac care. This model is attractive for chronic obstructive pulmonary disease (COPD) care because of disease frequency and the burden it places on primary, secondary and integrated care services. METHODS: Using 'hospital episode statistics' (UK 'coding'), we examined hospital 'bed days/1000 population' in 150 UK Primary Care Trusts (PCTs) during 2006-07 and 2007-08. Data were adjusted for COPD prevalence. We looked at year-on-year consistency and factors which influenced variation. RESULTS: There were 248 996 COPD admissions during 2006-08. 'Bed days/1000 PCT population' was consistent between years (r = 0.87; P < 0.001). There was a >2-fold difference in bed days between the best and worst performing PCTs which was primarily a consequence of variation in emergency admission rate (P < 0.001) and proportion of emergency admissions due to COPD (P < 0.001) and to only a lesser extent length of hospital stay (P < 0.001). CONCLUSIONS: Bed days/1000 population appears a useful annual metric of COPD care quality. Good COPD care keeps patients active and out of hospital and requires co-ordinated action from both hospital and community services, with an important role for integrated care. This metric demonstrates that current care is highly variable and offers a measurable target to commission against.

Use of mortality within 30 days of a COPD hospitalisation as a measure of COPD care in UK hospitals.

Mortality rate has been proposed as a metric of hospital chronic obstructive pulmonary disease (COPD) care in light of variation seen in national COPD audits. Using Hospital Episode Statistics (hospital 'coding') we examined 30-day mortality after COPD hospitalisation in 150 UK hospitals during 2006-2007 and 2007-2008. Mean and median 30-day mortalities were similar each year but the coefficient of variation was >20% and hospitals could change from a low or high quartile to the median by chance. We could not detect any reasons for hospitals being at the extremes. 30-day mortality after COPD hospitalisation is a complex variable and unlikely to be useful as a primary annual COPD metric.

The feasibility and impact of implementing a computer-guided consultation to target health inequality in Asthma.

Greater Manchester has a greater prevalence and worse asthma outcomes than the national average. This study aims to evaluate a digital approach to primary care asthma management and in particular the initial impact of implementing Clinical Decision Support System software in the form of a computer-guided consultation (CGC) in the setting of primary care asthma reviews in deprived areas of Greater Manchester. The CGC (LungHealth Ltd) is an intelligent decision support system ensuring accurate guideline-based staging of asthma and assessment of asthma control with the software subsequently prompting guideline-standard management. Patients on asthma registers in Greater Manchester Primary Care Networks were identified and underwent remote review by nursing staff using the CGC linked directly to the GP clinical system. Three-hundred thirty-eight patients (mean age 59 (SD 17) years; 60% Female) were reviewed. The CGC reported the patient's asthma control to be "Good" in 22%, "Partial" in 6% and "Poor" in 72%. ACT scores were significantly higher in those patients exhibiting "Good" and "Partial" control when compared to those with "Poor" control. The number of steroid courses and hospital admissions in the previous 12 months was significantly lower in those patients exhibiting "Good" and "Partial" control when compared to those with "Poor" control. Nineteen percent were found not to have a personalised asthma management plan during CGC review, which was alerted by the CGC and subsequently, all but 3 patients had this created on review completion (McNemar's test; p < 0.001). 5% were found not to have been prescribed regular inhaled steroid therapy resulting in the operator being alerted by the CGC in all cases. Overall, 44% underwent alteration in asthma therapy following the CGC review with 82% of these representing treatment escalation. An end-to-end digital service solution is feasible for Asthma within primary care and the utilisation of a CGC when conducting primary care asthma reviews increases implementation of guideline-level management thus addressing healthcare inequality while enabling identification of "high risk" asthma patients and guiding appropriate therapy escalation and de-escalation.

Stroke unit care and outcome: results from the 2001 National Sentinel Audit of Stroke (England, Wales, and Northern Ireland).

BACKGROUND AND PURPOSE: Stroke unit care is one of the most powerful interventions available to help stroke patients. There are limited data available to assess the impact of stroke units in routine clinical practice outside randomized clinical trials. This article uses data from the 2001 to 2002 National Stroke Audit to assess the effectiveness of stroke unit care in England, Wales, and Northern Ireland in delivering effective processes of care and in reducing case fatality and disability. METHODS: An observational study of the organization, structure, process of care, and outcomes for stroke in 2001. Case fatality after stroke in England was compared using data from the audit and routinely collected data from the Department of Health. 240 hospitals (196 Trusts) from England, Wales, and Northern Ireland took part in the 2001 to 2002 National Stroke Audit, a response rate of >95%. These sites assessed a total of 8200 patients using the Royal College of Physicians Intercollegiate Working Party Stroke Audit Tool. RESULTS: The availability of stroke unit care varies hugely across the country. Case fatality after stroke was higher in Trusts with least availability of stroke unit care. These differences persisted after control for case mix. The process of care was better for patients managed on stroke units compared with other settings. Overall, the risk of death for patients who received stroke unit care was estimated to be approximately 75% that of the risk for those having no stroke unit care (95% CI, 60 to 90). CONCLUSIONS: Stroke unit care as provided in routine clinical practice in England, Wales, and Northern Ireland reduces case fatality by approximately 25%, which is in line with the figures obtained from systematic analysis of stroke unit trial data.

How can the implementation of guidelines be improved?

Guidelines for a variety of diseases have now been produced. However, implementation of guidelines requires that the medical profession is willing to conform to patterns of diagnostic and treatment behavior set down by others. This may not happen in practice. Early experience in the United Kingdom was gained with the introduction of guidelines for the management of asthma. For a number of years, there have been improvements in practice, but deficiencies still exist. When the introduction of guidelines for the management of COPD was planned, a new approach was taken with a consortium of the British Thoracic Society, pharmaceutical companies, and medical equipment companies being formed to promote their use. Early studies show that COPD care starts from an even lower baseline than asthma; there is poor understanding of objective diagnosis of COPD in both primary and secondary care.

Expiratory lung crackles in patients with fibrosing alveolitis.

Inspiratory lung crackles are a diagnostic feature of interstitial pulmonary fibrosis, but expiratory crackles are not well documented. In a phonopneumographic study of 13 patients with fibrosing alveolitis, expiratory crackles were audible with the stethoscope in 12. Phonopneumographic analysis of these 12 patients showed the crackles to be fine with the initial wave deflection of the expiratory and inspiratory crackles in opposite directions. They were few in number, occurred predominantly in mid- and late expiration, and were not affected by varying the volume history or by breath holding maneuvers. These observations support the theory that some crackles are produced by vibration of the walls of peripheral airways. In addition, this group of patients showed a significant correlation between the number of expiratory crackles and the reduction in predicted transfer factor, suggesting that expiratory crackles may be a clinical indicator of the severity of disease in fibrosing alveolitis.

Does cold air affect exercise capacity and dyspnea in stable chronic obstructive pulmonary disease?

Cold air may worsen asthmatic bronchoconstriction but can lessen breathlessness in normal individuals. Patients with COPD sometimes report improvement in their dyspnea in cold weather. We examined the effect of breathing cold air on exercise tolerance and the perception of breathlessness in 19 patients with stable COPD (age [+/- SD], 63 +/- 6 years; FEV1, 0.99 +/- 0.28 L) in a randomized open study. Patients exercised on a cycle ergometer breathing either room or cold air (-13 degrees C), breathlessness being assessed by Borg scaling. Peak exercise performance improved when breathing cold air (mean +/- SE), 46 +/- 6 W compared with 37 +/- 7 W (p < 0.05) while end-exercise breathlessness fell from 4.6 +/- 0.4 compared with 4.1 +/- 0.5 (p < 0.05) when breathing cold air. End-exercise ETCO2 was higher breathing cold air (6.1 +/- 0.3 kPa compared with 5.5 +/- 0.3 kPa) (p < 0.005). There was no difference in breathlessness at equivalent levels of ventilation. Cold air reduces breathlessness in COPD, probably by inducing relative hypoventilation.

Effort sensation, chemoresponsiveness, and breathing pattern during inspiratory resistive loading.

Although inspiratory resistive loading (IRL) reduces the ventilatory response to CO2 (VE/PCO2) and increases the sensation of inspiratory effort (IES), there are few data about the converse situation: whether CO2 responsiveness influences sustained load compensation and whether awareness of respiratory effort modifies this behavior. We studied 12 normal men during CO2 rebreathing while free breathing and with a 10-cmH2O.l-1.s IRL and compared these data with 5 min of resting breathing with and without the IRL. Breathing pattern, end-tidal PCO2, IES, and mouth occlusion pressure (P0.1) were recorded. Free-breathing VE/PCO2 was inversely related to an index of effort perception (IES/VE; r = -0.63, P less than 0.05), and the reduction in VE/PCO2 produced by IRL was related to the initial free-breathing VE/PCO2 (r = 0.87, P less than 0.01). IRL produced variable increases in inspiratory duration (TI), IES, and P0.1 at rest, and the change in tidal volume correlated with both VE/PCO2 (r = 0.63, P less than 0.05) and IES/VE (r = -0.69, P less than 0.05), this latter index also predicting the changes in TI with loading (r = -0.83, P less than 0.01). These data suggest that in normal subjects perception of inspiratory effort can modify free-breathing CO2 responsiveness and is as important as CO2 sensitivity in determining the response to short-term resistive loading. Individuals with good perception choose a small-tidal volume and short-TI breathing pattern during loading, possibly to minimize the discomfort of breathing.

Regional deposition of particles in the lung during cigarette smoking in humans.

Studies were carried out on 11 habitual cigarette smokers to ascertain whether there was a difference in the regional deposition of particles during cigarette smoking compared with tidal breathing and also to investigate whether the ventilatory maneuvers associated with smoking influence the deposition site. A cigarette holder was constructed that permitted cigarette smoke to mix with a radioaerosol. An added resistance simulated the airflow resistance present in a filter-tipped cigarette. Respiratory patterns for the control period of tidal breathing and during smoking were monitored with a respiratory inductance plethysmograph. Smoking resulted in greater apical and central deposition than expected from the distribution of resting ventilation. The changes in the site of deposition during smoking are probably influenced mainly by the properties of the particles concerned, namely, its size, reactivity, and hygroscopicity. Changes in respiratory patterns that occur during inhalation of cigarette smoke may also have an effect but are difficult to quantify and show marked intersubject variation. In selected subjects smoking caused apical deposition to exceed that of the lower zones.

Oral corticosteroid trials in the management of stable chronic obstructive pulmonary disease.

Although recent guidelines for managing chronic obstructive pulmonary disease (COPD) recommend a trial of oral corticosteroids in the initial assessment, its prognostic value remains unclear. We prospectively studied 127 adults (64% men) with stable COPD (FEV1/FVC < 60%) over 1 year. At entry, we measured lung volumes, gas transfer factor, respiratory symptoms (by questionnaire), and peripheral blood eosinophil count. Skin-prick testing was done, and spirometry after nebulized 5 mg salbutamol and, after 2 weeks, oral prednisolone. Physician A gave all patients inhaled beclomethasone dipropionate (800 mcg/day), whereas physician B prescribed this only to those with a positive oral corticosteroid trial. At 1 year, spirometry and respiratory questionnaire were repeated, with an estimate of overall symptom severity on a visual analogue scale. Follow-up data were available in 104 (82%) patients. Of these, 32 (31%) were unresponsive to salbutamol and prednisolone; 48 (46%) were responsive to beta agonists but not to corticosteroids, and 24 (23%) responded to corticosteroids and salbutamol. Patients in all groups were comparable, except that the prednisolone responders had a higher mean eosinophil count (p < 0.001) and more were ex-smokers (p < 0.001). Only the response to oral prednisolone correlated with the change in prebronchodilator FEV1 over 1 year. Oral prednisolone responders had higher FEV1 at 1 year (p < 0.02) and significantly lower symptom scores (p < 0.02). In COPD, corticosteroid trials contribute information additional to that gained from nebulized bronchodilator reversibility testing. Patients with a positive response to a corticosteroid trial are more likely to have improved symptomatically and spirometrically at 1 year.

Comparison of the process of care of acute severe asthma in adults admitted to hospital before and 1 yr after the publication of national guidelines.

This study set out to assess the effect of publication of the British Guidelines on Asthma Management on the processes and outcomes of the inpatient care of acute severe asthma in the U.K. A criterion-based audit of all acute asthma admissions during August and September 1990 (immediately before) and in 1991 (1 yr after publication of the Guidelines) using eight criteria of process and outcome was performed. Thirty-six teaching and district general hospitals in England, Scotland and Wales took part. In total, 766 patients admitted in 1990, and 900 patients admitted in 1991, were studied. The 1990 and 1991 cohorts were very similar demographically and had asthma of comparable severity. Respiratory physicians achieved similar high performance rates of between 75 and 91% for seven of the eight criteria for both years. Respiratory physicians were significantly more likely to provide patients with a written management plan in 1991. General physicians' performance was significantly lower in both years, but overall there was a very small, but just significant, improvement in their performance in 1991. Some hospitals performed consistently well in both years. It is concluded that respiratory physicians consistently provide better asthma care than general physicians. Though statistically significant, the small degree of improvement was disappointing. Possible reasons include: insufficient time for the Guidelines to be incorporated into practice; inaccessibility of the Guidelines to general physicians; failure to accept responsibility for implementing the good practice reflected in the Guidelines; and an explicit need for strategies to implement the Guidelines beyond publication in a widely-read general medical journal.

Association of spatial distribution of childhood respiratory morbidity with environmental dust pollution.

The objective of this study was to investigate the spatial distribution of respiratory morbidity and asthma in children in relation to high levels of airborne dust pollution. A cross-sectional survey of 2035 children (aged 5-11 yr) by parent-completed questionnaire, with concurrent monitoring of dust deposition rates in the vicinity of children's homes, was performed in 15 primary schools (5 in each of 3 areas of Merseyside). The main outcome measures were (1) doctor-diagnosed asthma, (2) parent-reported respiratory symptoms of recent excess cough, wheeze, and breathlessness, and (3) school absenteeism due to respiratory ill health. Proximity to the source of dust pollution was associated with increased prevalence of excess cough, breathlessness, school absence due to respiratory ill health, and doctor-diagnosed asthma, after adjusting for a range of socioeconomic, environmental, and other confounding factors. The adjusted odds for excess cough and breathlessness for children living within 2 km of the source (dock area) are estimated to be almost twice those for children living more than 2 km away: excess cough 1.9 (95% CI 1.4-2.6); breathlessness 1.9 (1.3-2.7); school absence 1.5 (1.2-1.9); and doctor-diagnosed asthma 1.5 (1.1-2.0). Excess cough was significantly associated with the mean annual dust deposition recorded in the vicinity of the child's home. The adjusted odds ratio for excess cough corresponding to an increase in mean annual dust deposition of 50 mg/m2/d was 3.1 (95% CI 1.1-8.2). These results suggest that airborne dust was associated with respiratory morbidity in these children, which could relate to the high prevalence of childhood doctor-diagnosed asthma in this community.

National audit of acute severe asthma in adults admitted to hospital. Standards of Care Committee, British Thoracic Society.

OBJECTIVE: To ascertain the standard of care for hospital management of acute severe asthma in adults. DESIGN: Questionnaire based retrospective multicentre survey of case records. SETTING: 36 hospitals (12 teaching and 24 district general hospitals) across England, Wales, and Scotland. PATIENTS: All patients admitted with acute severe asthma between 1 August and 30 September 1990 immediately before publication of national guidelines for asthma management. MAIN MEASURES: Main recommendations of guidelines for hospital management of acute severe asthma as performed by respiratory and non-respiratory physicians. RESULTS: 766 patients (median age 41 (range 16-94) years) were studied; 465 (63%) were female and 448 (61%) had had previous admissions for asthma. Deficiencies were evident for each aspect of care studied, and respiratory physicians performed better than non-respiratory physicians. 429 (56%) patients had had their treatment increased in the two weeks preceding the admission but only 237 (31%) were prescribed oral steroids. Initially 661/766 (86%) patients had peak expiratory flow measured and recorded but only 534 (70%) ever had arterial blood gas tensions assessed. 65 (8%) patients received no steroid treatment in the first 24 hours after admission. Variability of peak expiratory flow was measured before discharge in 597/759 (78%) patients, of whom 334 (56%) achieved good control (variability < 25%). 47 (6%) patients were discharged without oral or inhaled steroids; 182/743 (24%) had no planned outpatient follow up and 114 failed to attend, leaving 447 (60%) seen in clinic within two months. Only 57/629 (8%) patients were recorded as having a written management plan. CONCLUSIONS: The hospital management of a significant minority of patients deviates from recommended national standards and some deviations are potentially serious. Overall, respiratory physicians provide significantly better care than non-respiratory physicians.

A confidential study of deaths after emergency medical admission: issues relating to quality of care.

In this retrospective pilot study we examine the feasibility of establishing a confidential enquiry into why some patients die after emergency admission to hospital. After excluding those who died in the first hour or who were admitted for palliative care, pairs of physicians were able to collect quantitative and qualitative data on 200 consecutive deaths. Both physicians reported shortfalls of care in 14 patients and one of the pair in 25 patients whose deaths would not have been the expected outcome. In 25, the shortfalls of care may have contributed to their deaths. Major problems were delays in seeing doctors, inaccurate diagnoses, delays in investigations and initiation of treatment. They occurred mostly in those admitted at night. It is possible that establishing the correct diagnosis and starting appropriate treatment may have been delayed in 64% of the 200 patients. The headline figures appear worse than some previous external assessment studies but this study did concentrate on those in whom problems were more likely. Nevertheless, the frequency is too high to be overlooked. In this feasibility study we have demonstrated that it is practicable for local staff to collect and assess data in hospitals and that the types of problems identified are relevant to anyone planning how to organise emergency care. A larger definitive study should be performed.

A prospective study of the practical issues of local involvement in national audit of COPD.

RATIONALE, AIMS AND OBJECTIVES: Variation in quality of local services is of great concern to the government and public. National audit is an important means of providing data of comparative performance but is hampered at local level by poor methodology including audit design, standard setting and data collection tools. A pilot audit of the hospital care of patients admitted with acute chronic obstructive pulmonary disease (COPD) was performed in preparation for a national audit programme and was designed and supported by experts. It was hoped to overcome these barriers. We report a prospective evaluation of the practical issues involved in local participation of hospital audit of COPD care within a national framework. METHODS: Hospitals were recruited to the study by random selection and voluntary participation. A clinical audit study was completed over an 8-week period immediately followed by a survey of clinicians and audit staff to identify positive and negative issues of participation and the process required to achieve a successful outcome. RESULTS: Forty-one hospitals were invited to participate, 26 (63%) accepted, and four others volunteered to meet the target of 30 enrolled centres. Reasons cited for non-participation were of inadequate resources amongst either clinicians or audit departments or prior engagement in other national or local audit schemes. Following completion of the audit most (81%) participating units reported it was a useful exercise and were willing to be involved in future audits. Negative aspects of involvement included the lack of dedicated time and manpower for audit, poor information technology and inadequate systems for identifying patient diagnoses either at admission or at discharge and incomplete case note entries. Methodological issues such as study design and data collection tools were not cited as important barriers to participation. CONCLUSION: There is local willingness to be involved in national audit of hospital care of COPD and central provision of expert design of methods and tools may reduce some audit barriers. Nevertheless, priority must be given to improving resources identified to support audit and in improving methods and systems for data capture. These issues appear to be important in most units and represent a potentially serious barrier to achieving widespread local involvement in a national audit programme of COPD care and may also apply to other national audits designed to provide comparative assessment of National Health Service services.

National clinical sentinel audit of evidence-based prescribing for older people.

OBJECTIVES: To audit the performance of hospitals in evidence-based prescribing. SETTING: All hospitals in England were invited to participate. The audit was completed in 62 hospitals. SUBJECTS: Prescribing and clinical data were collected on 100 consecutive medical inpatients aged >/= 65 years at each site, enabling evaluation of eight prescribing indicators before and after intervention. The data were collected using a specifically designed database. INTERVENTIONS: The results of the first audit were available immediately from the software and a national report with locally identifiable information was returned to hospitals. Hospitals were encouraged to design and deliver their own intervention strategy. A questionnaire was sent to all hospitals to document prioritization of indicators. RESULTS: Generic names were used for 36 061 (82.6%) in 1999 and 39 188 (86.4)% in 2000. In 1999, 50% (3074) of patients had documentation of allergy status. This increased to 60% (3684) in 2000. For 21.2% of patients prescribed paracetamol in 1999 and 18.1% in 2000, the prescription was written such that it was possible to exceed the maximum recommended dose of 4 g in 24 hours. Long-acting hypoglycaemic drugs were prescribed to 29 patients in 1999 and 20 patients in 2000. Anti-thrombotics were used appropriately for 54% (520/966) of patients in atrial fibrillation in the first audit and 57% (579/1019) in the second audit. The appropriate use of aspirin increased from 91% (595/651) to 94% (725/772) and the appropriate use of benzodiazepines dropped from 49% (537/1088) to 47% (460/966) between the audits. For three indicators, the allocating of a high priority translated into a bigger improvement between the audits. CONCLUSIONS: Local ownership of data and the quality improvement process, and provision of national benchmarking data did not result in a significant improvement in prescribing in the second audit.

Reliability and validity of the Intercollegiate Stroke Audit Package.

The aim of this study was to assure the validity and reliability of the Intercollegiate Stroke Audit Package as used in the National Sentinel Audit of Stroke. The Intercollegiate Working Party for Stroke, which included most stakeholders, including patients, devised the audit standards. These were submitted to a formal consensus (modified Delphi) survey before the audit questions were developed and piloted for validity and reliability. Following the pilot, Help Booklets were developed to promote the involvement of all disciplines as auditors in the national sentinel audit of stroke and ensure inter-rater reliability. During the national audit each Trust was asked to double rate the first five cases with auditors of different disciplines working independently. A total of 886 case notes were double-rated in 184 separate sites (median 5, range 1-5 per site). Trusts used auditors from different disciplines in 77% of cases. After excluding the 'No answer' cases the kappa score for items ranged from 0.49 to 0.87 (median 0.70, IQR 0.63-0.78). Very good agreement was found for seven of the 45 items, good agreement for 30 items, and moderate agreement for eight items. This large study, across a range of hospital sites and involving many disciplines, demonstrates that careful piloting of audit tools, with use of clear instructions to auditors, promotes the reliability of data.

National sentinel clinical audit of evidence-based prescribing for older people: methodology and development.

RATIONALE, AIMS AND OBJECTIVES: This national clinical audit aimed to develop and implement a methodology to assess the appropriateness of prescribing for patients over the age of 65 in hospitals, general practice and nursing homes. METHODS: Organizations providing health care in the National Health Service in these three sectors were recruited into multi-disciplinary and inter-organizational local coalition teams. Prescription data and relevant clinical data were collected electronically on a customized database. The appropriateness of prescribing for specific conditions among the patients sampled was assessed by simple computerized algorithms, and users were provided with feedback to stimulate discussion and change. Use of the software tool was demonstrated to be feasible and its data reliable. Participants were re-audited, after a period of nationally guided and locally driven intervention, to evaluate levels of change. Local efforts to stimulate change and barriers to change were collected qualitatively. RESULTS AND CONCLUSIONS: The investigation revealed encouraging results and demonstrated the ability of audit to improve the quality of clinical services in given circumstances, although a multiplicity of questions relating to cost and methodology remain to be addressed.