Impact of a GP-led walk-in centre on NHS emergency departments.

OBJECTIVE: To determine the impact of the GP-led walk-in centre (WIC) in Sheffield (England) on the demand for emergency department (ED) care. METHODS: A survey of patients visiting the Sheffield GP WIC was conducted over 3 weeks during September and October 2011. A short, postvisit questionnaire was also sent to those who agreed to determine if the patient had used another NHS service for the same problem. Routine data were obtained from the adult and children's EDs and minor injuries unit in Sheffield, 1 year before and 1 year after the opening of the GP WIC. A linear model of the number of minor daytime attendances (GP type) per month was used to estimate the impact of opening the GP WIC, after controlling for seasonal variation and a linear time trend. RESULTS: A total of 529 patients responded to the survey (response rate 51%). Based on their self-reported intentions, 64 of these patients (53 adults and 11 children) were diverted from going to ED in the 3-week survey period as a result of the establishment of the GP WIC. From this we would have expected around a 26% monthly reduction in GP-type attendances at adult ED, and 7% reduction at children's ED. However, routine data only showed an 8% (95% CI 1% to 16%) reduction at the adult ED. Reductions in GP-type attendances at the children's ED and the minor injury unit at the time of the opening of the GP WIC were also found, but were not statistically significant. The estimated impact on children's ED was a 14% reduction (95% CI -38% to 8%), and for minor injuries unit (MIU) a 4% reduction (95% CI -18 to 9%). CONCLUSIONS: There was a statistically significant reduction in GP-type daytime attendances at the adult ED after the opening of the GP WIC. Since this reduction was not mirrored in changes in night-time attendances (when the GP WIC was closed), and our survey responses suggested some people were diverted from going to the ED, it is possible that the opening of the GP WIC caused this reduction.

Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain.

OBJECTIVES: To test whether patients with persistent non-specific low back pain, when offered access to traditional acupuncture care alongside conventional primary care, gained more long-term relief from pain than those offered conventional care only, for equal or less cost. Safety and acceptability of acupuncture care to patients, and the heterogeneity of outcomes were also tested. DESIGN: A pragmatic, two parallel group, randomised controlled trial. Patients in the experimental arm were offered the option of referral to the acupuncture service comprising six acupuncturists. The control group received usual care from their general practitioner (GP). Eligible patients were randomised in a ratio of 2:1 to the offer of acupuncture to allow between-acupuncturist effects to be tested. SETTING: Three non-NHS acupuncture clinics, with referrals from 39 GPs working in 16 practices in York, UK. PARTICIPANTS: Patients aged 18-65 years with non-specific low back pain of 4-52 weeks' duration, assessed as suitable for primary care management by their general practitioner. INTERVENTIONS: The trial protocol allowed up to ten individualised acupuncture treatments per patient. The acupuncturist determined the content and the number of treatments according to patient need. MAIN OUTCOME MEASURES: The Short Form 36 (SF-36) Bodily Pain dimension (range 0-100 points), assessed at baseline, and 3, 12 and 24 months. The study was powered to detect a 10-point difference between groups at 12 months post-randomisation. Cost--utility analysis was conducted at 24 months using the EuroQoL 5 Dimensions (EQ-5D) and a preference-based single index measure derived from the SF-36 (SF-6D). Secondary outcomes included the McGill Present Pain Index (PPI), Oswestry Pain Disability Index (ODI), all other SF-36 dimensions, medication use, pain-free months in the past year, worry about back pain, satisfaction with care received, and safety and acceptability of acupuncture care. RESULTS: A total of 159 patients were in the 'acupuncture offer' arm and 80 in the 'usual care' arm. All 159 patients randomised to the offer of acupuncture care chose to receive acupuncture treatment, and received an average of eight acupuncture treatments within the trial. Analysis of covariance, adjusting for baseline score, found an intervention effect of 5.6 points on the SF-36 Pain dimension [95% confidence interval (CI) -1.3 to 12.5] in favour of the acupuncture group at 12 months, and 8 points (95% CI 0.7 to 15.3) at 24 months. No evidence of heterogeneity of effect was found for the different acupuncturists. Patients receiving acupuncture care did not report any serious or life-threatening events. No significant treatment effect was found for any of the SF-36 dimensions other than Pain, or for the PPI or the ODI. Patients receiving acupuncture care reported a significantly greater reduction in worry about their back pain at 12 and 24 months compared with the usual care group. At 24 months, the acupuncture care group was significantly more likely to report 12 months pain free and less likely to report the use of medication for pain relief. The acupuncture service was found to be cost-effective at 24 months; the estimated cost per quality-adjusted (QALY) was 4241 pounds sterling (95% CI 191 pounds sterling to 28,026 pounds sterling) using the SF-6D scoring algorithm based on responses to the SF-36, and 3598 pounds sterling (95% CI 189 pounds sterling to 22,035 pounds sterling) using the EQ-5D health status instrument. The NHS costs were greater in the acupuncture care group than in the usual care group. However, the additional resource use was less than the costs of the acupuncture treatment itself, suggesting that some usual care resource use was offset. CONCLUSIONS: Traditional acupuncture care delivered in a primary care setting was safe and acceptable to patients with non-specific low back pain. Acupuncture care and usual care were both associated with clinically significant improvement at 12- and 24-month follow-up. Acupuncture care was significantly more effective in reducing bodily pain than usual care at 24-month follow-up. No benefits relating to function or disability were identified. GP referral to a service providing traditional acupuncture care offers a cost-effective intervention for reducing low back pain over a 2-year period. Further research is needed to examine many aspects of this treatment including its impact compared with other possible short-term packages of care (such as massage, chiropractic or physiotherapy), various aspects of cost-effectiveness, value to patients and implementation protocols.

A randomized, prospective, blinded comparison of postoperative pain, metabolic response, and perceived health after laparoscopic and small incision cholecystectomy.

BACKGROUND: We have previously shown that in a randomized comparison of laparoscopic (LC) versus small incision (SC) cholecystectomy, postoperative hospital stay is comparable. This randomized prospective study compares the postoperative pain, analgesic and antiemetic consumption, perceived health, and metabolic and respiratory responses after these two procedures. METHODS: Two hundred patients were recruited; postoperative stay, pain scores, analgesic and antiemetic consumption were recorded. Nottingham Health Profile questionnaires were completed by a subgroup of 100 patients, and the metabolic and respiratory responses were also compared in a further subgroup of 20 patients. RESULTS: Pain scores in both groups were low. LC, however, was associated with lower postoperative pain scores and analgesic requirements compared with SC, but the antiemetic requirements were greater after LC. The duration of hospital stay and the perceived health after operation were the same in both groups, and both procedures were associated with a similar reduction of respiratory function. Twenty-four hours after operation the inflammatory (C-reactive protein, CRP) response to LC (22 +/- 20 mg/L) was significantly lower than after SC (68 +/- 30 mg/L), but the neuroendocrine (cortisol) response was similar (LC, 475 +/- 335 nmol/L, compared with SC, 710 +/- 410 nmol/L). Independent of the technique used, the duration of postoperative hospital stay correlated significantly with the magnitude of both the 24-hour postoperative cortisol and CRP responses (cortisol: rs = 0.678, p < 0.001; CRP: rs = 0.566, p = 0.011). CONCLUSIONS: LC appears to be associated with less tissue destruction and pain than SC, but this did not confer any advantage in the degree of postoperative respiratory impairment, length of hospital stay, or postoperative perceived health. The neuroendocrine component of the metabolic response evoked by each procedure was similar and had a significant correlation to patient's postoperative hospital stay. This finding may explain the similar postoperative recovery after LC and SC.

Epidemiology of babies dying at different ages from the sudden infant death syndrome.

An analysis of data from the United Kingdom multicentre study of postneonatal mortality has been made to assess whether there are causally distinct groups of babies dying from the Sudden Infant Death Syndrome (SIDS), and to develop explicit risk factor profiles for the subgroups. The 303 SIDS babies in the multicentre study were divided into four subgroups by age at death: weeks 1-7, 8-15, 16-23, and 24 or more weeks. Contrasts between these subgroups with respect to 28 epidemiological characteristics and to pathology findings were investigated. Significant contrasts in the number of previous pregnancies, duration of the 2nd stage of labour, gestational length, family finances and repair of housing were found. Overall, very strong evidence of epidemiological differences was found (chi 2(9) = 29.3, p less than 0.001), and of contrasts in the nature and degree of any acquired terminal disease. It is concluded that there are different causes of SIDS with different distributions according to age at death.

Variation in demand for accident and emergency departments in England from 1974 to 1985.

Over the period 1974-85 the range of mean annual new attendance rates at Accident and Emergency departments among English health districts was 36-673 per 1000 residents. The socio-economic diversity of these districts explained only one-third of the variation. The rates rose significantly (p less than 0.05) in 89 per cent of districts over the twelve years. Again, socio-economic variation only partly explained differences in district trends. Increases were greater among districts with higher mean rates. In order to plan first-contact care rationally we need a better understanding of the factors underlying these trends.

Effects of subsidising bus travel on the occurrence of road traffic casualties.

Between 1975 and 1 April 1986, public transport by bus in the metropolitan county of South Yorkshire, England, was increasingly subsidised. Trends in road traffic accident casualties between 1974 and 1983 in all the six provincial English metropolitan counties have been compared in order to examine the possible effect of this unique subsidy on the incidence of road traffic accident casualties. During that period the total number of casualties in South Yorkshire did not change significantly compared to the other metropolitan counties. However, the proportion of all casualties in South Yorkshire who were bus occupants did increase relative to other metropolitan counties, indicating either an increase in the amount of bus travel or a decrease in travel by other modes. There was a large increase in bus patronage in South Yorkshire relative to the other metropolitan counties, and the conclusion is that it is the transport policy in South Yorkshire which resulted in an actual increase in distances travelled by bus. Since bus is the safest form of road travel, it is concluded that the public transport subsidy in South Yorkshire has benefited the health of the local population by providing the social amenity of additional travel at the least additional health cost.

Health and healthcare costs and benefits of exercise.

To assess the value of promoting health through exercise, we review what is known about the medical and medical care resource costs and benefits of exercise. Literature searches were undertaken to derive estimates of the relative risk, in individuals who exercise regularly compared with those who do not, of each of the major disease groups for which there is good evidence that the disease can be ameliorated by exercise (coronary heart disease, stroke, diabetes, hip fracture, and mental illness). These relative risks were used to estimate the incidence of hospital admissions and mortality, and associated healthcare costs, which could be prevented if the whole population exercised. Literature on the incidence and costs of exercise-related morbidity and mortality was also reviewed to derive estimates of both the costs to health and also the healthcare resource implications of exercise in total population. Indirect costs and benefits, and also quality-of-life effects associated with exercise were not included in this assessment. The results show that in younger adults (ages 15 to 44 years) the average annual medical care costs per person that might be incurred as a result of full participation in sport and exercise (approximately 30 pounds British sterling) exceed the costs that might be avoided by the disease-prevention effects of exercise ( less than 5 pounds British sterling per person). However, in older adults ( greater than or equal to 45) the estimated costs avoided ( greater than 30 pounds British sterling per person) greatly outweigh the costs that would be incurred ( less than 10 pounds British sterling). There was little evidence that exercise leads to deferred health or health service resource benefits. We conclude that with regard to health and medical care costs, there are strong economic arguments in favour of exercise in adults aged greater than or equal to 45 but not in younger adults. Estimates derived from the international scientific literature and routine UK data sources may have limited direct application in the healthcare systems of other countries. Nevertheless, the result that exercise costs exceed the benefits in younger adults but vice versa in older people is likely to be generally true. Indeed, a similar result has been found in a study of a Dutch population.

Access to complementary medicine via general practice.

BACKGROUND: The popularity of complementary medicine continues to be asserted by the professional associations and umbrella organisations of these therapies. Within conventional medicine there are also signs that attitudes towards some of the complementary therapies are changing. AIM: To describe the scale and scope of access to complementary therapies (acupuncture, chiropractic, homoeopathy, hypnotherapy, medical herbalism, and osteopathy) via general practice in England. DESIGN OF STUDY: A postal questionnaire sent to 1226 individual general practitioners (GPs) in a random cluster sample of GP partnerships in England. GPs received up to three reminders. SETTING: One in eight (1226) GP partnerships in England in 1995. METHOD: Postal questionnaire to assess estimates of the number of practices offering 'in-house' access to a range of complementary therapies or making National Health Service (NHS) referrals outside the practice; sources of funding for provision and variations by practice characteristics. RESULTS: A total of 964 GPs replied (78.6%). Of these, 760 provided detailed information. An estimated 39.5% (95% CI = 35%-43%) of GP partnerships in England provided access to some form of complementary therapy for their NHS patients. If all non-responding partnerships are assumed to be non-providers, the lowest possible estimate is 30.3%. An estimated 21.4% (95% CI = 19%-24%) were offering access via the provision of treatment by a member of the primary health care team, 6.1% (95% CI = 2%-10%) employed an 'independent' complementary therapist, and an estimated 24.6% of partnerships (95% CI = 21%-28%) had made NHS referrals for complementary therapies. The reported volume of provision within any individual service tended to be low. Acupuncture and homoeopathy were the most commonly available therapies. Patients made some payment for 25% of practice-based provision. Former fundholding practices were significantly more likely to offer complementary therapies than non-fundholding practices, (45% versus 36%, P = 0.02). Fundholding did not affect the range of therapies offered, and patients from former fundholding practices were no more likely to pay for treatment. CONCLUSION: Access to complementary health care for NHS patients was widespread in English general practices in 1995. This data suggests that a limited range of complementary therapies were acceptable to a large proportion of GPs. Fundholding clearly provided a mechanism for the provision of complementary therapies in primary care. Patterns of provision are likely to alter with the demise of fundholding and existing provision may significantly reduce unless the Primary Care Groups or Primary Care Trusts are prepared to support the 'levelling up' of some services.

Case against targeting long term non-attenders in general practice for a health check.

A study was undertaken to describe the consequences of implementing that part of the 1990 contract for general practitioners which requires them to offer health checks to all patients aged 16-74 years not seen within the previous three years. A random sample of 679 patients who had not attended for three years and 379 patients who had attended in this period were identified from 30 practice lists (including eight inner city practices) in five family health services authority areas. All patients were sent an invitation to a health check by their own practice and an attempt was made by the research team to conduct a home interview. The results showed that a considerable proportion of non-attenders were not in a position to take advantage of such an invitation; 17% of those at inner city practices were known to have received the invitation, 68% in practices elsewhere. Interviewed non-attenders (76% of those known to have received their invitation) had sociodemographic characteristics similar to the comparison group of interviewed attenders, although women aged 55-74 years were over-represented. At interview, non-attenders reported relatively less use of accident and emergency services and preventive health care and scored significantly better on all six dimensions of the perceived health status measure. Overall, 3% of all identified non-attenders in the inner city practices and 13% elsewhere accepted the invitation to a health check. Low levels of morbidity were found at health checks for those who had and who had not attended their general practitioners in the previous three years.(ABSTRACT TRUNCATED AT 250 WORDS)

Use and expenditure on complementary medicine in England: a population based survey.

OBJECTIVES: Many claims are made that complementary medicine use is a substantial and growing part of health-care behaviour. Estimates of practitioner visits in the USA and Australia indicate high levels of use and expenditure. No reliable population-based estimates of practitioner use are available for the UK. METHODS: In 1998, a previously piloted postal questionnaire was sent to a geographically stratified, random sample of 5010 adults in England. The questionnaire focuses on practitioner contacts, but also asked about the purchase of over-the-counter remedies. Additional information was requested on socio-demographic characteristics, perceived health, and recent NHS resource use. Information on use included reason for encounter, expenditure, insurance, and location of visit. MAIN OUTCOMES MEASURES: Population estimates (by age group and sex) of lifetime use and use in the past 12 months for acupuncture, chiropractic, homoeopathy, hypnotherapy, medical herbalism, osteopathy. Estimates for two additional therapies (reflexology and aromatherapy), and homoeopathic or herbal remedies purchased over-the-counter. Estimates of annual out-of-pocket expenditure on practitioner visits in 1998. RESULTS: A crude response rate of 60% was achieved (adjusted response rate 59%). Responders were older and more likely to be female than non-responders. Usable responses (n = 2669) were weighted using the age/sex profile of the sample frame. From these adjusted data we estimate that 10.6% (95% CI 9.4 to 11.7) of the adult population of England had visited at least one therapist providing any one of the six more established therapies in the past 12 months (13.6% for use of any of the eight named therapies, 95% CI 12.3 to 14.9). If all eight therapies, and self-care using remedies purchased over the counter are included, the estimated proportion rises to 28.3% (95% CI 26.6 to 30.0) for use in the past 12 months, and 46.6% (95% CI 44.6 to 48.5) for lifetime use. All types of use declined in older age groups, and were more commonly reported by women than men (P < 0.01 for all comparisons). An estimated 22 million visits were made to practitioners of one of the six established therapies in 1998. The NHS provided an estimated 10% of these contacts. The majority of non-NHS visits were financed through direct out-of-pocket expenditure. Annual out-of-pocket expenditure on any of the six more established therapies was estimated at pound 450 million (95% CI 357 to 543). CONCLUSION: This survey has demonstrated substantial use of practitioner-provided complementary therapies in England in 1998. The findings suggest that CAM is making a measurable contribution to first-contact primary care. However, we have shown that 90% of this provision is purchased privately. Further research into the cost-effectiveness of different CAM therapies for particular patient groups is now urgently needed to facilitate equal and appropriate access via the NHS.

Longer-term clinical and economic benefits of offering acupuncture to patients with chronic low back pain assessed as suitable for primary care management.

This paper presents the research protocol for a pragmatic study of the benefits of providing an acupuncture service to patients in primary care with chronic low back pain. The proposal was written in response to a call for bids from the NHS Executive's centrally funded research programme for Health Technology Assessment (HTA). The research question posed was 'Does acupuncture have long-term effectiveness in the management of pain in primary care?' The present study was designed as a collaboration between an interdisciplinary team drawn from health services researchers at the University of Sheffield, acupuncture researchers from the Foundation for Traditional Chinese Medicine in York, and practitioners from general practice and acupuncture in York. The proposal presented here was submitted in response to an invitation from the Commissioning Board following a successful outline bid. It is reproduced here, largely as submitted in January 1998, using the headings under which information was requested. We also present an appendix describing methodological alterations made to the design in response the Commissioning Board's comments on the proposal. We present it in this format to give an idea of the evolution of the design and the process by which the research proposal was shaped. The final working protocol comprises a combination of these two elements.

A study of the movement of nurses and nursing skills between the NHS and the private sector in England and Wales.

An investigation of 2165 qualified nurses joining eight NHS District Health Authorities (DHAs) and 72 private sector institutions was undertaken in order to measure the skills which move between these sectors and to estimate the likely impact on NHS nursing services of any future growth in the private sector. It was found that 42% (95% confidence interval: 36%, 48%) of the nurses joining private acute hospitals and 28% (95% CI: 21%, 37%) of those joining long-stay private nursing homes came directly from the NHS workforce. Fewer qualified nurses move from the private sector to the NHS. Private acute hospitals appear to attract recruits from a specific section of the NHS workforce: nurses under 30 years of age with specialist skills such as theatre nursing, renal nursing, intensive care and oncology.

NHS Direct and nurses--opportunity or monotony?

NHS Direct, the 24-hour telephone helpline providing information and advice about health problems, is available throughout England and Wales. It was envisaged as a nurse-led service presenting a new opportunity for the nursing profession. Free text comments from a postal survey of NHS Direct nurses revealed that a large proportion of nurses were happy with working in NHS Direct, and that it presented some nurses with the opportunity of a new and challenging role. However, a minority found the work monotonous and felt that NHS Direct is likely to face the challenge of staff retention.

Patient characteristics and clinical caseload of short stay independent hospitals in England and Wales, 1992-3.

OBJECTIVE: To describe and quantify the patients and clinical activities of independent short stay hospitals. DESIGN: Retrospective survey of hospital records for sampled periods of one financial year and comparison with data from 1981 to 1986. SETTING: 217 independent hospitals in England and Wales, 1992-3. MAIN OUTCOME MEASURES: Distributions of sex, age groups, and areas of residence of patients, clinical procedures, financial provision. RESULTS: Data were obtained from 201 (93%) hospitals. An estimated 429,172 inpatients (7% more than 1986) and 249,531 day cases (an increase of 154%) from 1986 were treated in the year. The number of overseas patients was half that in 1986. Clinical case mix remained similar to 1986. Abortion remained the commonest procedure (13% v 19% in 1986). Lens operations, heart operations, endoscopies, and non-surgical cases showed the largest increases from 1986. Proportionately more overseas patients had abortions (30% v 12% for England and Wales residents) and they received 41% of coronary artery bypass grafting. Three quarters of the patients were aged 15-64. The proportion of patients aged over 65 had changed little (19% v 17% in 1986). Estimated average bed occupancy was only 48%. Only one in 20 patients was treated under NHS contract; 90% of episodes were funded through private health insurance. CONCLUSIONS: The demand for treatment in private hospitals continues to increase despite additional investment in the NHS, but the overseas market is falling. Overall, the range of clinical activity has changed little.

Comparison of the activity of short stay independent hospitals in England and Wales, 1981 and 1986.

From a sample of 19,000 treatment episodes at 183 of the 193 independent hospitals with operating facilities in England and Wales that were open during 1986 it is estimated that 404,000 inpatients were treated in 1986 (an increase of 48% since 1981) and 99,000 day cases (an increase of 112%). It was found that the procedure most commonly performed was abortion, though this made up only 19% of the total caseload in 1986 compared with 30% in 1981, otherwise the case mix in 1986 was similar to that in 1981. Fewer patients came from overseas in 1986 than in 1981, but the distribution by age and sex remained the same, with three quarters of the patients aged between 15 and 65. The estimated bed occupancy in the independent hospitals in 1986 was less than 60% nationally and only 52% in the Thames regions. It is concluded that in these five years the nature of the independent hospital sector changed little, and in 1986 the activity still consisted largely of routine cold elective surgery for people of working age, and the regional differences in admission rates to independent hospitals were nearly as great as in 1981.

Role of the private sector in elective surgery in England and Wales, 1986.

From a sample of 19,000 treatment episodes at 183 of the 193 independent hospitals with operating facilities in England and Wales that were open in 1986 it is estimated that 287,000 residents of England and Wales had elective surgery as inpatients in 1986 (an increase of 77% since 1981) and 72,000 as day cases. From 1985 Hospital In-Patient Enquiry data it was estimated that a further 36,000 similar elective inpatient treatments were undertaken in NHS pay beds (a decrease of 38%) and 21,000 as day cases. Overall, an estimated 16.7% of all residents of England and Wales who had non-abortion elective surgery as inpatients were treated in the private sector, as were 10.5% of all day cases. An estimated 28% of all total hip joint replacements were done privately, and in both the North West and South West Thames regions the proportion of inpatients treated privately for elective surgery was 31%. It is concluded that mainly for reasons of available manpower private sector activity may not be able to grow much more without arresting or reversing the growth of the NHS, in which case some method of calculating NHS resource allocation which takes account of the local strength of the private sector will be needed.

Effects of London helicopter emergency medical service on survival after trauma.

OBJECTIVE: To assess the effect of the London helicopter emergency medical service on survival after trauma. DESIGN: Prospective comparison of outcomes in cohorts of seriously injured patients attended by the helicopter and attended by London ambulance service land ambulances crewed by paramedics. SETTING: Greater London. SUBJECTS: 337 patients attended by helicopter and 466 patients attended by ambulance who sustained traumatic injuries and died, stayed in hospital three or more nights, or had other evidence of severe injury and who were taken to any one of 20 primary receiving hospitals. MAIN OUTCOME MEASURE: Survival at six months after the incident. RESULTS: After differences in the nature and severity of the injuries in the two cohorts were accounted for the estimated survival rates were the same (relative risk of death with helicopter = 1.0; 95% confidence interval 0.7 to 1.4). An analysis with trauma and injury severity scores (TRISS) found 16% more deaths than predicted in the helicopter cohort but only 2% more in the ambulance cohort. There was no evidence of a difference in survival for patients with head injury but a little evidence that patients with major trauma (injury severity score > or = 16) were more likely to survive if attended by the helicopter. An estimated 13 (-5 to 39) extra patients with major trauma could survive each year if attended by the helicopter. CONCLUSION: Any benefit in survival is restricted to patients with very severe injuries and amounts to an estimated one additional survivor of major trauma each month. Over all the helicopter caseload, however, there is no evidence that it improves the chance of survival in trauma.

What is the value of routinely testing full blood count, electrolytes and urea, and pulmonary function tests before elective surgery in patients with no apparent clinical indication and in subgroups of patients with common comorbidities: a systematic review of the clinical and cost-effective literature.

BACKGROUND: The evidence base which supported the National Institute for Health and Clinical Excellence (NICE) published Clinical Guideline 3 was limited and 50% was graded as amber. However, the use of tests as part of pre-operative work-up remains a low-cost but high-volume activity within the NHS, with substantial resource implications. The objective of this study was to identify, evaluate and synthesise the published evidence on the clinical effectiveness and cost-effectiveness of the routine use of three tests, full blood counts (FBCs), urea and electrolytes tests (U&Es) and pulmonary function tests, in the pre-operative work-up of otherwise healthy patients undergoing minor or intermediate surgery in the NHS. OBJECTIVE: The aims of this study were to estimate the clinical effectiveness and cost-effectiveness of routine pre-operative testing of FBC, electrolytes and renal function and pulmonary function in adult patients classified as American Society of Anaesthesiologists (ASA) grades 1 and 2 undergoing elective minor (grade 1) or intermediate (grade 2) surgical procedures; to compare NICE recommendations with current practice; to evaluate the cost-effectiveness of mandating or withdrawing each of these tests in this patient group; and to identify the expected value of information and whether or not it has value to the NHS in commissioning further primary research into the use of these tests in this group of patients. DATA SOURCES: The following electronic bibliographic databases were searched: (1) BIOSIS; (2) Cumulative Index to Nursing and Allied Health Literature; (3) Cochrane Database of Systematic Reviews; (4) Cochrane Central Register of Controlled Trials; (5) EMBASE; (6) MEDLINE; (7) MEDLINE In-Process & Other Non-Indexed Citations; (8) NHS Database of Abstracts of Reviews of Effects; (9) NBS Health Technology Assessment Database; and (10) Science Citation Index. To identify grey and unpublished literature, the Cochrane Register of Controlled Trials, National Research Register Archive, National Institute for Health Research Clinical Research Network Portfolio database and the Copernic Meta-search Engine were searched. A large routine data set which recorded the results of tests was obtained from Leeds Teaching Hospitals Trust. REVIEW METHODS: A systematic review of the literature was carried out. The searches were undertaken in March to April 2008 and June 2009. Searches were designed to retrieve studies that evaluated the clinical effectiveness and cost-effectiveness of routine pre-operative testing of FBC, electrolytes and renal function and pulmonary function in the above group of patients. A postal survey of current practice in testing patients in this group pre-operatively was undertaken in 2008. An exemplar cost-effectiveness model was constructed to demonstrate what form this would have taken had there been sufficient data. A large routine data set that recorded the results of tests was obtained from Leeds Teaching Hospitals Trust. This was linked to individual patient data with surgical outcomes, and regression models were estimated. RESULTS: A comprehensive and systematic search of both the clinical effectiveness and cost-effectiveness literature identified a large number of potentially relevant studies. However, when these studies were subjected to detailed review and quality assessment, it became clear that the literature provides no evidence on the clinical effectiveness and cost-effectiveness of these specific tests in the specific patient groups. The postal survey had a 17% response rate. Results reported that in ASA grade 1, patients aged < 40 years with no comorbidities undergoing minor surgery did not have routine tests for FBC, electrolytes and renal function and pulmonary function. The results from the regression model showed that the frequency of test use was not consistent with the hypothesis of their routine use. FBC tests were performed in only 58% of patients in the data set and U&E testing was carried out in only 57%. LIMITATIONS: Systematic searches of the clinical effectiveness and cost-effectiveness literature found that there is no evidence on the clinical effectiveness or cost-effectiveness of these tests in this specific clinical context for the NHS. A survey of NHS hospitals found that respondent trusts were implementing current NICE guidance in relation to pre-operative testing generally, and a de novo analysis of routine data on test utilisation and post-operative outcome found that the tests were not be used in routine practice; rather, use was related to an expectation of a more complex clinical case. The paucity of published evidence is a limitation of this study. The studies included relied on non-UK health-care systems data, which may not be transferable. The inclusion of non-randomised studies is associated with an increased risk of bias and confounding. Scoping work to establish the likely mechanism of action by which tests would impact upon outcomes and resource utilisation established that the cause of an abnormal test result is likely to be a pivotal determinant of the cost-effectiveness of a pre-operative test and therefore evaluations would need to consider tests in the context of the underlying risk of specific clinical problems (i.e. risk guided rather than routine use). CONCLUSIONS: The time of universal utilisation of pre-operative tests for all surgical patients is likely to have passed. The evidence we have identified, though weak, indicates that tests are increasingly utilised in patients in whom there is a reason to consider an underlying raised risk of a clinical abnormality that should be taken into account in their clinical management. It is likely that this strategy has led to substantial resource savings for the NHS, although there is not a published evidence base to establish that this is the case. The total expenditure on pre-operative tests across the NHS remains significant. Evidence on current practice indicates that clinical practice has changed to such a degree that the original research question is no longer relevant to UK practice. Future research on the value of these tests in pre-operative work-up should be couched in terms of the clinical effectiveness and cost-effectiveness in the identification of specific clinical abnormalities in patients with a known underlying risk. We suggest that undertaking a multicentre study making use of linked, routinely collected data sets would identify the extent and nature of pre-operative testing in this group of patients. FUNDING: The National Institute for Health Research Health Technology Assessment programme.