Background Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not been found to be consistently effective. Objectives To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes. Search strategy We searched the Cochrane Effective Practice and Organisation of Care Group's register up to January 2001. This was supplemented with searches of MEDLINE and reference lists, which did not yield additional relevant studies. Selection criteria Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes. Data collection and analysis Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. Main results We included 85 studies, 48 of which have been added to the previous version of this review. There were 52 comparisons of dichotomous outcomes from 47 trials with over 3500 health professionals that compared audit and feedback to no intervention. The adjusted RDs of non-compliance with desired practice varied from 0.09 (a 9% absolute increase in non-compliance) to 0.71 (a 71% decrease in non-compliance) (median = 0.07, inter-quartile range = 0.02 to 0.11). The one factor that appeared to predict the effectiveness of audit and feedback across studies was baseline non-compliance with recommended practice. Reviewer's conclusions Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The absolute effects of audit and feedback are more likely to be larger when baseline adherence to recommended practice is low.

Audit and feedback: effects on professional practice and healthcare outcomes

Melanoma and non-melanoma (basal and squamous cell carcinoma) skin cancer (NMSC) are now the most common types of cancer in the white populations and the incidence of skin cancer has reached epidemic proportions According to recent population-based studies from Australia the incidence rate is over 2% for basal cell carcinoma in males and 1% for squamous cell carcinoma, and there are over 50 new cases of melanoma per 100 000

The epidemiology of skin cancer.

There is persuasive evidence that each of the three main types of skin cancer, basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and melanoma, is caused by sun exposure. The incidence rate of each is higher in fairer skinned, sun-sensitive rather than darker skinned, less sun-sensitive people; risk increases with increasing ambient solar radiation; the highest densities are on the most sun exposed parts of the body and the lowest on the least exposed; and they are associated in individuals with total (mainly SCC), occupational (mainly SCC) and non-occupational or recreational sun exposure (mainly melanoma and BCC) and a history of sunburn and presence of benign sun damage in the skin. That UV radiation specifically causes these skin cancers depends on indirect inferences from the action spectrum of solar radiation for skin cancer from studies in animals and the action spectrum for dipyrimidine dimers and evidence that presumed causative mutations for skin cancer arise most commonly at dipyrimidine sites. Sun protection is essential if skin cancer incidence is to be reduced. The epidemiological data suggest that in implementing sun protection an increase in intermittency of exposure should be avoided, that sun protection will have the greatest impact if achieved as early as possible in life and that it will probably have an impact later in life, especially in those who had high childhood exposure to solar radiation.

The epidemiology of UV induced skin cancer.

Background Nonmelanoma skin cancer (NMSC) is the most common cancer affecting white-skinned individuals and the incidence is increasing worldwide. Objectives This systematic review brings together 75 studies conducted over the past half century to look at geographical variations and trends worldwide in NMSC, and specifically incidence data are compared with recent U.K. cancer registry data. Methods Following the development of a comprehensive search strategy, an assessment tool was adapted to look at the methodological quality of the eligible studies. Results Most of the studies focused on white populations in Europe, the U.S.A. and Australia; however, limited data were available for other skin types in regions such as Africa. Worldwide the incidence for NMSC varies widely with the highest rates in Australia [>1000/100, 000 person-years for basal cell carcinoma (BCC)] and the lowest rates in parts of Africa ( Conclusions NMSC is an increasing problem for health care services worldwide. This review highlights a requirement for prevention studies in this area and the issues surrounding incomplete NMSC registration. Registration standards of NMSC should be improved to the level of other invasive disease.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2133.2012.10830.x

A systematic review of worldwide incidence of nonmelanoma skin cancer.

https://www.thelancet.com/pdfs/journals/lancet/PIIS014067360961196X.pdf

Non-melanoma skin cancer

Worldwide, incidence rates of skin cancer are increasing alarmingly in populations of predominantly Caucasian origin A prospective population-based survey, set up to collect epidemiological information on all excised and histologically confirmed skin cancers, started in Townsville, Australia (population of 127,000) in December 1996 Data on the anatomical distribution of skin cancer has been collected using a detailed body map Estimations of type-specific and site-specific incidence rates were age-standardized according to world standard population Site-specific incidence rates were adjusted for surface proportion of the body site and are given per 100,000 body units Between December 1996 and December 1997, a total of 3,536 patients with 5,945 histologically confirmed skin cancer lesions were recorded Age-standardized incidence rates of basal cell carcinoma were 2,0583 for men and 1,1945 for women, 1,3323 for men and 7548 for women for squamous cell carcinoma, and 491 for men and 417 for women for cutaneous melanoma (CM) Site-specific incidence rates of non-melanocytic skin cancer were extreme on sun-exposed areas of the face, whereas site-specific incidence rates of CM were highest for neck, posterior trunk and face Less exposed body sites, such as unexposed upper limbs or thighs, showed reduced incidence rates for all types of skin cancer Tropical North Queensland has the world's highest incidence rates of skin cancer of all types Site-specific incidence rates demonstrate that highly sun-exposed body sites are at high risk of developing skin cancer and provide, therefore, strong indirect evidence for the causal relationship between sun exposure and skin cancer

https://onlinelibrary.wiley.com/doi/pdf/10.1002/%28SICI%291097-0215%2819981123%2978%3A5%3C587%3A%3AAID-IJC10%3E3.0.CO%3B2-E

Incidence rates of skin cancer in Townsville, Australia

Objective To compare standard management of keeping wounds dry and covered with allowing wounds to be uncovered and wet in the first 48 hours after minor skin excision. Design Prospective, randomised controlled, multicentre trial testing for equivalence of infection rates. Setting Primary care in regional centre, Queensland, Australia. Participants 857 patients randomised to either keep their wound dry and covered (n = 442) or remove the dressing and wet the wound (n = 415). Results The incidence of infection in the intervention group (8.4%) was not inferior to the incidence in the control group (8.9%) (P < 0.05). The one sided 95% confidence interval for the difference of infection rates was ∞ to 0.028. Conclusion These results indicate that wounds can be uncovered and allowed to get wet in the first 48 hours after minor skin excision without increasing the incidence of infection.

https://www.bmj.com/content/bmj/332/7549/1053.full.pdf

Can sutures get wet? Prospective randomised controlled trial of wound management in general practice

BACKGROUND: Patients with nonmelanoma skin cancer (NMSC) frequently develop multiple skin cancers The study presents incidence rates and rates of excision of NMSC for a population living in a high-risk environment for skin cancer

METHODS: Between 1997 and 1999 a prospective population-based study collected information on all histologically confirmed NMSCs in Townsville, Australia

RESULTS: Of the 6708 patients recorded with NMSC, 385% had multiple lesions Yearly age-standardized incidence rates (per 100,000 inhabitants) of basal cell carcinoma (BCC) were 14448 for men, 9427 for women, and of squamous cell carcinoma (SCC) were 8050 for men, and 4236 for women Compared to incidence rates, age-standardized rates of lesions of BCC were 21 times higher in men, 16 times higher in women, and of SCC were 18 times higher in men and 14 times higher in women

CONCLUSIONS: The occurrence of multiple NMSCs compromises results of short-term studies on incidence Further discussions on the most appropriate strategies to describe the real burden of NMSC are warranted

Multiple nonmelanoma skin cancer in an exposed Australian population.

OBJECTIVES: To investigate whether mandatory sun protection for outdoor workers in tropical regions is associated with reduced sun damage. METHODS: Survey of 26 employees working under mandatory sun protection policy was compared to survey of 21 employees working under voluntary sun protection policy. RESULTS: Voluntary sun protection associated with employees having more solar keratoses on dorsum of right hand (P=0.006) and more previously excised self-reported skin cancers (P=0.008). CONCLUSIONS: Employees working under mandatory sun protection policy had reduced sun damage, a likely consequence of less sun exposure.

Workplace sun protection policies and employees' sun-related skin damage.

Most data on body site distribution of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) do not take into account the surface proportion occupied by body sites experiencing differing amounts of ultraviolet radiation. The recording of BCC and SCC is heterogenous and body sites are not standardized. This study was undertaken to assess the magnitude of the incidence rates of skin cancers at different body sites in a population which experiences high ultraviolet exposure and involved all primary care services in Townsville over 6 weeks in June 1993. The annual site-specific age-standardized (World Population) incidence rates of histologically diagnosed lesions, determined from data where lesions were recorded on a body map, were adjusted for surface area and expressed per 100,000 body units (BU). Relative site densities of lesions were also calculated. Annual incidence rates for BCC per 100,000 BU on the most exposed face (ears, nose and cheeks) were 25,893 (95% confidence interval (c.i.) 18,837–32,950), 13,222 (95% c.i., 8273–18,171) on the less exposed face (forehead,eyebrow, chin and jaw) and 27,837 (95% c.i., 12,560–43,115) on the least exposed face (area within the orbit and nasolabial fold). Incidence rates for SCC rates were highest on the less exposed face, 5843 (95% c.i., 2627–9058) most exposed face, 4200 (95% c.i., 1274–7126) and the exposed upper limb, 3786 (95% c.i., 2783–4789). The relative site density of histologically confirmed BCC was 14 on the most exposed face in males compared with 5 in females and 11 around the eyes (least exposed) in males and 9 in females compared with the body as a whole. Adjustment for body surface proportion demonstrates that highly exposed body sites are at very high risk. The magnitude of the incidence rates on these sites is attributed to the combination of a susceptible population and high ambient ultraviolet radiation (UVR).

Beverly A. Raasch

Papers

Incidence rates of skin cancer in Townsville, Australia

Can sutures get wet? Prospective randomised controlled trial of wound management in general practice

Multiple nonmelanoma skin cancer in an exposed Australian population.

Workplace sun protection policies and employees' sun-related skin damage.

Body site specific incidence of basal and squamous cell carcinoma in an exposed population, Townsville, Australia