There is anecdotal evidence that general practitioners are being flooded with guidelines. We set out to quantify this by conducting a survey of all guidelines retained in general practices in the Cambridge and Huntingdon Health Authority. Methods and resultsFP visited 22 urban and rural general practices, a sample of the 65 practices in the authority, and asked them to produce copies of all guidelines retained for use. Guidelines were defined as any written material used by a doctor or nurse in primary care to assist decision making in relation to health care, 1 excluding medical textbooks and electronic databases.We found 855 different guidelines-a pile 68 cm high weighing 28 kg (see fig). There were 243 single page and 195 two page guidelines. There were, however, 160 guidelines that were more than 10 pages long, including 25 presented as booklets or large folders. About 60% of the guidelines had been produced locally, of which 50% had been produced by local trusts and 30% by general practitioners. The remaining 40% were produced nationally. The pharmaceutical industry and the local health authority produced only 31 (4%) and 32 (4%) of the guidelines respectively.We found that 38% of all the guidelines collected were undated. The dated guidelines suggest an exponential rise in guideline production since 1989: eight guidelines were published in 1990, compared with 73 in 1995 and 138 in 1996. We identified 57 guidelines produced in the first third of 1997 alone.Guidelines on clinical or disease management accounted for 75% of the total. Half of the remaining guidelines related to referral pathways. Guidelines produced in general practice were almost exclusively clinical, whereas nearly half of those produced by trusts described referral pathways.

BackgroundThe management of acute myocardial infarction (AMI) has improved over the last 50 years with the more frequent use of effective medicines and procedures. The clinical benefit of the speciality of the attending physician is less clear. The United Kingdom National Service Framework for coronary heart disease (CHD) suggested that patients with CHD are likely to benefit from cardiological supervision. We set out to assess the effect of access to cardiologists on survival among AMI patients admitted in two UK hospitals.MethodsThe study was conducted in a university hospital and a district general hospital in England. Information was obtained on age, sex, ethnicity, Carstairs socioeconomic deprivation category derived from postcode of residence, comorbidity, distance from hospital and medication from all patients admitted with acute myocardial infarction in two acute trusts between July 1999 and June 2000. Record linkage to subsequent Hospital Episode Statistics and Registrar General's death records provided follow up information on procedures and mortality up to eighteen months after admission. Cox proportional hazard models were used to investigate the main hypothesis controlling for confounding. The main outcome measure was 18-month survival after myocardial infarction.ResultsAccess to a cardiologist was univariately associated with improved survival (hazard ratio 0.16, 95% CI 0.10 to 0.25). This effect remained after controlling for the effect of patient characteristics (hazard ratio 0.22, 95% CI 0.14 to 0.25). The effect disappeared after controlling for access to effective medication (hazard ratio 0.70, 95% CI 0.33 to 1.46).ConclusionsAccess to a cardiologist is associated with better survival compared to no access to a cardiologist among a cohort of patients already admitted with AMI. This effect is mainly due to the more frequent use of effective medicines by the group referred to cardiologists. Hospitals may improve survival by improving access to effective medicines and by coordinating care between cardiologists and general physicians.

Background: Primary Percutaneous Coronary Intervention (PCI) is more efficacious than thrombolysis in the management of acute myocardial infarction, but, because of the requirement for prompt treatment, there are practical challenges in developing such services. We examined the proportion of patients with ST segment Elevation Myocardial Infarction (STEMI) who could receive timely treatment from a primary Percutaneous Coronary Intervention (PCI) service assuming different geographical locations of potential treatment centres in three English counties.

The health benefit of thrombolysis in acute myocardial infarction is greatest when patients are treated soon after onset of symptoms. One approach to reducing treatment delay is to give thrombolysis before the patient reaches hospital. When an ambulance trust proposed a prehospital thrombolysis service, local commissioners requested an estimate of its possible health impact. Clinical audit and ambulance trust data were obtained for 165 patients who received thrombolysis for acute myocardial infarction in the coronary care unit of a local hospital in one year. This information was then used to estimate the health impact of prehospital thrombolysis in the local population in a mathematical model derived from the results of trials comparing prehospital and hospital thrombolysis. The best predicted local health benefit from the proposed prehospital thrombolysis service is that, if 45 minutes can be cut off the call-to-needle time, 61 cases of acute myocardial infarction need to be treated to save one additional life at 35 days. By use of published research data, the health benefits of prehospital thrombolysis can be estimated for a local population. Variables in the treatment population and ambulance service will influence the size of the health benefit that can be achieved.

The health benefit of thrombolysis in acute myocardial infarction is greatest when patients are treated soon after onset of symptoms. One approach to reducing treatment delay is to give thrombolysis before the patient reaches hospital. When an ambulance trust proposed a prehospital thrombolysis service, local commissioners requested an estimate of its possible health impact. Clinical audit and ambulance trust data were obtained for 165 patients who received thrombolysis for acute myocardial infarction in the coronary care unit of a local hospital in one year. This information was then used to estimate the health impact of prehospital thrombolysis in the local population in a mathematical model derived from the results of trials comparing prehospital and hospital thrombolysis. The best predicted local health benefit from the proposed prehospital thrombolysis service is that, if 45 minutes can be cut off the call-to-needle time, 61 cases of acute myocardial infarction need to be treated to save one additional life at 35 days. By use of published research data, the health benefits of prehospital thrombolysis can be estimated for a local population. Variables in the treatment population and ambulance service will influence the size of the health benefit that can be achieved.