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Satisfaction with nurse specialists in breast care clinics

BMJ 1998; 317 doi: (Published 07 November 1998) Cite this as: BMJ 1998;317:1316

Nurse led clinics may actually cost more

  1. J M Dixon, Consultant surgeon,
  2. J Lamb, Consultant pathologist,
  3. G Stones, Senior medical laboratory scientific officer,
  4. Edinburgh Breast Unit Team, Western General Hospital, Edinburgh EH4 2XU,
  5. A Rahman, Medical student,
  6. D Mitchell, Medical student
  1. Medical School, University of Edinburgh, Edinburgh EH8 9AG
  2. South Manchester University Hospital, Manchester M20 8LR
  3. Health Care Evaluation Unit, Department of Public Health Sciences, St George's Hospital Medical School, London SW17 0RE
  4. Breast Unit, St George's Hospital, London SW17 0QT

    EDITOR—Garvican et al conclude that since the results of the fine needle aspiration obtained by clinical nurse specialists in their breast clinic were better than those obtained by other clinicians the nurses' clinical expertise compared favourably with that of other clinicians.1 In a recent four month survey of fine needle aspiration cytology in our unit, 86 (20%) of 432 aspirates were classed as inadequate (C1). This is significantly lower than the rate of 276 (33.5%) of 825 samples (P<0.0001) classed as inadequate in Garvican et al's paper. Two thirds of the aspirations of palpable lesions in Edinburgh were performed by consultants; their rate of inadequate samples was 38/233 (16%). This is significantly lower than the 114 (32%) of 362 samples taken by the nurses that were classed as inadequate (P<0.0001). The nurse specialists performed 362 (44%) of 825 aspirations in their clinic; in Edinburgh non-consultant clinicians performed 35 (28%) of 124 (P=0.012). These results confirm that the experience of the clinician performing an aspiration is an important factor in the success of the technique.2

    In the breast clinic the ratio of benign samples to malignant samples was 5.1:1, while in Edinburgh it was significantly lower at 1.2:1 (P<0.0001). In Edinburgh all patients are seen by experienced consultant breast surgeons or senior doctors, and immediate access to mammography and ultrasonography is available during the clinic. This may explain the apparently better selection of patients for aspiration cytology, which is the most painful test performed in breast clinics.3

    We recently introduced a “one stop” clinic in which women have immediate access to breast imaging and to the results of imaging and aspiration. We assessed the satisfaction of patients who required ultrasound imaging or aspiration with a questionnaire which was completed before leaving the clinic. Before the introduction of the new service only 50/125 (40%) women were completely satisfied with their visits; the most common complaint was about the delay in receiving test results. After the introduction of the one stop clinic, 80/114 (70%) indicated that they were completely satisfied. Reasons for a lack of complete satisfaction with the new service were all non-medical and included problems with car parking (24/114, 21%) and poor signposting to the clinic (11/114, 10%). Difficulties in parking increased patients' anxiety, and anxiety relates to the pain experienced during investigations.3 In comparison with the breast clinic described by Garvican et al we perform fewer fine needle aspirations in cases of benign disease and obtain fewer inadequate samples. Far from cost benefits accruing from nurse led clinics there may be cost implications because of the extra aspirations performed and the higher rates of obtaining inadequate samples.


    Nurses are not as effective as consultants

    1. M Bramley, Specialist registrar,
    2. G J Byrne, Research registrar,
    3. N J Bundred, Reader in surgical oncology
    1. Medical School, University of Edinburgh, Edinburgh EH8 9AG
    2. South Manchester University Hospital, Manchester M20 8LR
    3. Health Care Evaluation Unit, Department of Public Health Sciences, St George's Hospital Medical School, London SW17 0RE
    4. Breast Unit, St George's Hospital, London SW17 0QT

      EDITOR—Garvican et al claim that patients attending a nurse led clinic screening for breast diseases were satisfied with the care they received.1 Unfortunately these women did not have the opportunity to make a meaningful comparison between clinics run by nurse specialists and standard outpatient care; the women did not experience care in both types of clinics. A surgeon saw women who had been diagnosed with cancer, who were likely to be disappointed with the results of their tests, and therefore less satisfied. Thus, it is not surprising that the women seen by the nurses, all of whom had results that were classed as benign, were satisfied. We need to know the satisfaction rate when patients with cancer are given results by the nurse as compared with the clinician.

      Dixon has shown that a dedicated cytologist in a breast clinic can achieve a high rate (99%) of adequate cytology samples.2 Garvican et al report that the nurses' technical expertise in performing fine needle aspiration was as good as that of clinicians. Although this is apparently true it neglects the fact that guidelines published by the British Association of Surgical Oncology state that <20% of cytological specimens should be inadequate.3 In this clinic 276 (33.4%) of 825 of samples were inadequate; for some senior clinicians 38/66 (57%) samples were inadequate. The critical issue of the adequacy of specimens aspirated from women with cancer is not addressed.

      The guidelines also provide quality objectives to be met and outcomes to be measured.3 According to the guidelines, all new patients presenting to a breast clinic should be seen by a consultant or a higher surgical trainee. Less than 10% of all new patients should be required to attend more than twice for diagnostic purposes. The high rate of inadequate samples obtained in this clinic almost certainly means that these criteria have not been met. The authors have provided no evidence to support their claim that a clinical nurse specialist can provide adequate outpatient care (in the absence of a second consultant) in terms of the sensitivity or specificity of the detection of cancers. In view of the rate of inadequate samples in this clinic one would be concerned that cancers have been missed.

      To conclude that nurses can adequately provide outpatient care in the absence of a second consultant is inappropriate without evidence that the clinic is capable of meeting the quality standards set out in the guidelines.


      Authors' reply

      1. L Garvican, Honorary senior research fellow,
      2. P Littlejohns, Director,
      3. N P M Sacks, Consultant surgeon
      1. Medical School, University of Edinburgh, Edinburgh EH8 9AG
      2. South Manchester University Hospital, Manchester M20 8LR
      3. Health Care Evaluation Unit, Department of Public Health Sciences, St George's Hospital Medical School, London SW17 0RE
      4. Breast Unit, St George's Hospital, London SW17 0QT

        EDITOR—Unfortunately, it was not possible to provide full details of our study in a short report. Our sample did, however, include women who had been diagnosed with cancer. We also indicated that a trial would be required before claims of cost effectiveness could be made and, as suggested by Dixon et al, this clearly should include the costs of cytology. This would minimise the tendency to make spurious comparisons of performance using statistical techniques.8

        This correspondence highlights the difficulties of implementing the British Association of Surgical Oncology guidelines in the real world.9 It is inevitable that breast units will concentrate on achieving the targets they consider important at the expense of others. Our unit chose to focus on triple assessment by experts (albeit non-medical) and on minimising diagnostic delays. In the units described by Dixon et al and Bramley et al, patients are preselected for triple assessment, and it is therefore inevitable that there will be lower rates of benign or inadequate samples. This may be justified to avoid unnecessary pain but carries a risk of missed cancers, especially in younger women who have had inconclusive results on imaging or clinical examination. There is “fairly strong evidence that triple assessment increases the accuracy and reduces the overall cost of diagnosis when compared with selective use of component tests.”10

        The quality of clinical guidelines according to the St George's appraisal instrument*

        View this table:

        This raises the question of the validity of the British Association of Surgical Oncology guidelines. Our unit has undertaken extensive research with the aim of developing a valid and reliable means of assessing guideline quality.4 All national guidelines and a random sample of local guidelines on the management of asthma, breast cancer, coronary artery disease, and depression were critically appraised by six independent reviewers.5 While the British Association of Surgical Oncology guidelines certainly scored higher on attributes associated with quality than locally developed guidelines, they compared less well with the standard now expected of national guidelines (table). In the first dimension of the appraisal, reviewers assess whether those who produced the guidelines have been rigorous in utilising underlying research and minimising bias. Only half of the quality attributes were met by the surgical oncology guidelines. These guidelines were, however, clear and had sought to address the issue of implementation.

        There has been little research into the practical aspects of diagnosing breast cancer. For too long management has been based on the opinions of individuals. Well designed studies are urgently needed to provide firm evidence on which to base guidelines. Only then will it be worth auditing quality objectives against outcomes.


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