The evidence base for healthcare related decision-making in Regional Health Authorities

OBJECTIVES: To evaluate the evidence base used in policy and healthcare decision making by the Regional Health Authorities in Trinidad. DESIGN AND METHODS: The study focused on the five Regional Health Authorities (RHAs) in Trinidad where senior administrative employees at each Regional Health Authority were purposively sampled and interviewed using a structured questionnaire. Responses were initially reviewed individually to determine types of evidence used within each RHA. All responses were secondly compared between the various RHAs. RESULTS: All RHAs participated; each had an observatory type unit which was responsible for data collection, collation and production of reports on an annual basis. Reports focused on the number of patients accessing services (e.g. specialist clinics and surgical procedures), patient demographics and patient access to health services. All RHAs had annual service agreements with the Ministry of Health which acted as a guide with targets and as a check on accountability of money spent. Decision making in each RHA was tiered by financial cap; most decisions were made by the Chief Executive Officer and/or Board of Directors within their caps; decisions requiring monetary investment over the RHA limit had to be approved by the Ministry of Health. CONCLUSION: This study revealed that RHAs had systems in place whereby they engaged in evidence-based practice utilising the Authority’s observatory data plus other information sources, ran trial periods and economic analyses for healthcare related decision making.

Lead posisoning in a rural community in Jamaica

OBJECTIVE: A proliferation of "backyard battery repair shops" in Frazer's Content (Red Pond), St Catherine led to a number of cases of lead poisoning in that community. A lead decontamination project was instituted by Blue Cross of Jamaica Environmental Health Foundation in 1994 to address this problem. The aim of the present study was to evaluate the impact of that intervention. METHODS: Questionnaire were developed and filled in during interviews with 214 volunteers in Frazer's Content. Volunteers awareness of the environmental effects of lead and the success of the socioeconomic programmes were assessed. The medical records from five nearby hospitals were also checked for new cases of lead poisoning. In addition, soil and water samples were collected and analyzed by atomic absortion spectrophotometry for levels of lead. RESULTS: The results indicated that knowledge of lead poisoning had increased significantly since 1994. However, there was a marked decrease in entrepeneurial activities. Two new cases of lead posioning were noted. Seven of the soil samples had elevated lead levels (123-317 ppm) but none of the water samples had lead concentration above the critical level (10 hg/l). CONCLUSION: Based on these findings, it would appear that the decontamination and education projects done in 1994 were mostly successful in achieving their objectives. Entrepreneurial initiatives were not sustained.(Au)

Breast masses in the augmentation mammaplasty patient: the role of ultrasound.

The detection and evaluation of breast parenchymal abnormalities in the presence of a radiodense implant are often difficult with standard techniques of physical examination and mammography. Breast lesions can be obscured on one or both views by the radiodense implant or concealed within the dense tissue at the prosthesis-breast tissue interface. We investigated the role of ultrasound as an adjunct to mammographic special views, including posterior displacement (Eklund et al.), in previously augmented patients who presented with a clinically palpable mass. The records of 125 consecutive breast augmentation patients seen by us over a 4-year period were retrospectively reviewed. Twenty-six patients presented with a palpable breast abnormality. All 26 patients underwent diagnostic mammograms and sonograms. Findings included 8 parenchymal lesions (4 cysts, 2 fibroadenomas, 1 seroma, 1 breast carcinoma), 8 implant-related irregularities (4 ruptures, 3 bulges, and 1 valve), and normal fibroglandular tissue in 10 patients. Mammography yielded a convincing diagnosis in 7 of 26 patients, whereas ultrasound characterized the abnormality in every case. Ultrasound is a useful adjunct to mammography in evaluating palpable breast abnormalities in the breast augmentation patient. It offers improved visualization of the breast tissue-prosthesis interface, and it is helpful in distinguishing breast parenchymal lesions from palpable irregularities of the implant.

The role of ultrasound-guided needle aspiration of breast masses.

Ultrasonically guided aspiration cytology is an accurate and cost-effective method for managing sonographically indeterminate breast masses (masses that do not have all the ultrasonic criteria of simple cysts). Forty-five breast masses were aspirated. Of these, fifteen (33%) were atypical cysts, twenty-one (47%) were benign solid masses, three (7%) were malignant and six (13%) were solid lesions with nondiagnostic aspirate material. Since the tip of the needle is ultrasonically identified within the mass prior to aspiration, the accuracy of tissue sampling is potentially greater than with palpation alone. Lesions over five millimeters in diameter can be reliably sampled for cytology. This method can reduce the number of surgical biopsies performed by distinguishing atypical cysts from benign solid lesions and detecting malignant lesions when small. The simplicity of the technique encourages its use whenever an ultrasound study detects a noncystic mass.