National audit of anaesthesia for major abdominal surgery

A postal survey was conducted of all hospitals in Australia known to have a department of anaesthesia and an intensive care or high dependency unit. Each hospital was asked to report the anaesthetic and postoperative analgesic techniques used for the last ten cases of four common major surgical procedures-aorto-femoral bypass, repair of an abdominal aortic aneurysm, hemicolectomy and anterior resection of the rectum. Half of 76 hospitals sent a survey form completed and returned it. Responding hospitals were larger on average, than non-responding ones, but otherwise typical of them in terms of university affiliation and metropolitan versus rural location. For each of the procedures studied the proportion of cases in which epidural block was used intra- or postoperatively varied from 0% to 100%. Depending on the procedure, between 65% and 85% of hospitals used epidural block sometimes, with between 10% and 90% of patients in these hospitals being managed with this technique. There is wide variation in the use of epidural block, intra- and postoperatively, in Australia, variation that is unlikely to be explained by systematic differences between institutions in the patients seen or their suitability for one or other technique. This pattern of practice mirrors the lack of agreement about the proper place for epidural techniques evident in the recent literature. There is a widespread belief among clinicians that this is a question of great importance. Accordingly, we believe that anaesthetists and surgeons share an ethical responsibility to enter suitable patients in an appropriately designed randomized controlled trial in order to resolve this question.

National audit of post-operative management in spinal surgery

Background: There is some evidence from a Cochrane review that rehabilitation following spinal surgery may be beneficial. Methods: We conducted a survey of current post-operative practice amongst spinal surgeons in the United Kingdom in 2002 to determine whether such interventions are being included routinely in the post-operative management of spinal patients. The survey included all surgeons who were members of either the British Association of Spinal Surgeons ( BASS) or the Society for Back Pain Research. Data on the characteristics of each surgeon and his or her current pattern of practice and post-operative care were collected via a reply-paid postal questionnaire. Results: Usable responses were provided by 57% of the 89 surgeons included in the survey. Most surgeons (79%) had a routine post-operative management regime, but only 35% had a written set of instructions that they gave to their patients concerning this. Over half (55%) of surgeons do not send their patients for any physiotherapy after discharge, with an average of less than two sessions of treatment organised by those that refer for physiotherapy at all. Restrictions on lifting, sitting and driving showed considerable inconsistency both between surgeons and also within the recommendations given by individual surgeons. Conclusion: Demonstrable inconsistencies within and between spinal surgeons in their approaches to post-operative management can be interpreted as evidence of continuing and significant uncertainty across the sub-speciality as to what does constitute best care in these areas of practice. Conducting further large, rigorous, randomised controlled trials would be the best method for obtaining definitive answers to these questions.

Auditor independence and fee dependence

This study investigates whether fee dependence within the audit firms' offices jeopardises auditor independence. Fee dependence is examined at both the national audit firm level as well as the local office level and in a setting where public disclosure of fees is mandatory. We focus our tests on audit fee dependence and at the same time we control for the effects of non-audit service fee dependence post the 1989 mergers. We operationalise the exercise of independent judgement in auditing by the propensity to issue qualified audit opinions. If fee dependence affects auditors' independent judgement, then auditors are less likely to qualify the accounts. The study's results show that the level of auditor fee dependence does not affect auditor propensity to issue unqualified audit opinions. The findings remain robust to a number of sensitivity tests including the analyses controlling for the effects of non-audit service fee dependence and other settings in which there is heightened pressure on auditors to confront the effects of fee dependence on exercising independent audit judgement. (C) 2002 Elsevier Science B.V. All rights reserved.

The validity of an Australian modification of the AUDIT questionnaire

The Alcohol Use Disorders Identification Test (AUDIT) has been used widely and is reported to be superior to conventional questionnaires in detection of current hazardous and harmful alcohol use. We assessed the validity of an Australian modification of the AUDIT (the AusAUDIT), which has been employed widely in Australian and New Zealand early intervention programmes. We used a cross-sectional study of 370 subjects from the follow-up phase of a randomized controlled trial of early intervention to reduce hazardous alcohol consumption. Scores on the AusAUDIT were compared against 12-month ICD-10 diagnoses of harmful alcohol use and dependence, as determined by the Composite International Diagnostic Interview, and against self-report of alcohol consumption exceeding Australian National Health and Medical Research Council (NH&MRC) recommended limits. AusAUDIT had good internal consistency and discriminated significantly between persons meeting criteria for ICD-10 alcohol use disorders, and drinkers who did not. At currently recommended cut-off scores, AusAUDIT detected more than 85% of people meeting criteria for ICD-10 alcohol use disorders, or drinking over NH&MRC recommended limits, but its specificity was limited (29% in men, and 58% in women for drinking over NH&MRC limits). No subset of questions performed as well as the full AusAUDIT in detection of drinking problems, but the alcohol consumption items provided a reasonable screen for drinking over NH&MRC limits. We conclude that AusAUDIT is effective in detecting problematic drinking, but positive cases should be confirmed by clinical assessment. The findings illustrate the need for validation of questionnaire modifications, and the difficulty in increasing test sensitivity without reducing specificity.