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Systematic reviews in obstetrics
- Richard Edmondson (23 October 1998)
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Educational visits to enhance the use of systematic reviews in obstetrics
- Philip Banfield (30 October 1998)
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Richard Edmondson
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Editor - I read with interest the paper by Wyatt et al (1) assessing the benefits of educational visits to enhance the use of systematic reviews in 25 obstetric units. Both the authors and the accompanying editorial (2) comment on the wide variation in ventouse delivery rates. There is wide variety within and between the study and control groups, with 22 of the 25 units having a baseline ventouse rate at or outside the 95% confidence interval for the average. This must cast doubt on the signifcance of the finding that the use of the ventouse increased in the study group. One possible reason for this wide variation in ventouse delivery rates and the subsequent change over nine months is overlooked by the authors. Most instrumental deliveries are performed by registrars(52%) and senior house officers(45%) (3). Their own personal preference for the ventouse versus forceps is unlikely to be affected by unit policy as much as by their own education and previous experience. More significantly most junior staff rotate between units on an annual basis. Wyatt et al do not specify at what time of the year their study was performed but it is entirely possible that between their baseline and follow up observations there had been an entire change of junior medical staff who would have imported their instrumental delivery rates and preferences from their previous units. The same argument can be extrapolated, although less convincingly, to the other markers identified. Many, although certainly not all, perineal repairs are performed by junior medical staff, who are also responsible for prescribing steroids in threatened preterm labour, often without input from senior colleagues. Perhaps a greater effect would have been demonstrated if, instead of using obstetric units as subjects, junior staff, such as registrars, had been chosen as subjects for randomisation and their personal practices studied. Yours faithfully Richard Edmondson Specialist Registrar Dept of Obstetrics and Gynaecology Royal Victoria Infirmary Newcastle upon Tyne NE1 4LP References 1 Wyatt JC, Paterson-Brown S, Johanson R, Altman DG, Bradburn MJ, Fisk NM. Randomised trial of educational visits to enhance use of systematic reviews in 25 obstetric units. BMJ 1998;317:1041-6 2 Keirse MJNC. Changing practice in maternity care.BMJ 1998;317:1027- 8 3 Drife JO. Choice and instrumental delivery.Br J Obstet Gynaecol 1996;103:608-11 |
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Philip Banfield
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Many factors influence a change in clinical practice, and the paper by Wyatt et al1 cannot conclude that educational visits are any more influential than other forms of guideline or recommendation. Half the 25 obstetric units already had access to the Cochrane database at the start of the study, presumably implying a willingness to consider change. That 10/13 of the non-intervention units had the Cochrane database within the 9 month trial demonstrates a progressive background change, thus questioning the validity of conclusions about the educational intervention itself. It is not surprising that there were wide variations in baseline rates from the randomisation of such small numbers. This variation has been demonstrated before, both between hospitals and from year to year2. The use of the ventouse is particularly dependent on the operator. There are no data provided on any changes in the non-consultant grade staff, who perform the vast majority of such interventions, over the time of the study period. Statistical 'power' is implied by the use of the statement that this was a "rigorous randomised trial", and by the eminence of the statistician author, but there are several question marks about the methodology and results emphasised by Professor Keirse in the same BMJ3. One of the most rapid changes in clinical practice seen recently was the immediate withdrawal of Albumin from clinical practice in our hospital after the BMJ paper in July4, which has since lead to much comment about the use and abuse of such 'powerful' evidence (letters, BMJ 26th September). Systematic reviews play just one part of the assessment of clinical effectiveness. We must know how they apply to our patients and be able to respond to innovations and new data. We must implement more thorough clinical audit and start allocating real time, personnel and resources to this process. This should be an ongoing exercise, constantly reviewing the appropriateness of the standard, however set5, enabling clinicians to practice effective medicine within the external constraints of the modern NHS. This is costly, but allows the clinician to know how applicable a standard or recommendation is to his or her patients. After all one person's proof will always be another person's conjecture. Philip Banfield Consultant Obstetrician and Gynaecologist, Glan Clwyd DGH NHS Trust, North Wales, LL18 5UJ References 1. Wyatt JC, Paterson-Brown S, Johanson R, Altman DG, Bradburn MJ, Fisk NM. Randomised trial of educational visits to enhance use of systematic reviews in 25 obstetric units. BMJ 1998;317:1041-6 2. Banfield PJ. The role of the feedback of clinical data in the alteration of clinical practice and the development of a working model for clinical audit in maternity care. MD Thesis 1993. University of London. 3. Keirse MJNC. Changing practice in maternity care. BMJ 1998;317:1027-8 4. Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. BMJ 1998;317:235-40 5. Banfield PJ. The audit spiral - Observations of maternity care. J Obstet Gynaecol 1992;12:403-6 |
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