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Background: Induction of labour is a common clinical intervention. There has been a recent rise in rates of induction of labour and wide variation between published hospital rates without obvious explanation. Clinician variation has been suggested as a reason., Objective: The study described aimed to examine clinical decision making, whilst removing individual patient bias. To achieve this clinical behaviour was studied by the use of imaginary clinical scenarios presented to clinicians by computer. Unlike retrospective audit, the rates thus generated are unaffected by differences in casemix, pressure of time, work or other factors and allow direct comparison between clinicians and comparison with clinical guidelines., Methods: Data about 15 imaginary pregnant women are presented to the clinician, each may have symptoms or signs of hypertensive disorders, intrauterine growth restriction (IUGR) and/or postdates. From the decision made in each scenario, and the information revealed about each scenario, a set of 'decision rules' is created for each clinician, describing in what circumstances they would induce labour. Data from the National Women's Hospital (Auckland, New Zealand) is then examined using these rules and the induction of labour rate thus generated presented to the clinician., Results: Sixteen clinicians were interviewed. Their induction of labour rate ranged from 10-31%., Conclusions: Clinician variation in decision making is evident about the intervention when to induce labour. The system is available on the WWW at http://csrs2.aut.ac.nz/scenario

Patient compliance with an inhaled corticosteroid may be greater if it is combined with a beta-agonist. This study compared compliance with an inhaled corticosteroid (budesonide), and a short-acting inhaled beta-agonist (terbutaline sulphate), and a Turbuhaler inhaler containing a combination of the two drugs. In an open, multicentre, parallel group study 102 asthmatic patients were randomly divided into two groups, either receiving the two drugs in separate Turbuhalers or combined into one Turbuhaler. A twice daily regimen was prescribed and a preweighed metered-dose inhaler (MDI) of salbutamol was provided for rescue use. Compliance was measured using the Turbuhaler Inhalation Computer (TIC), which recorded the time and date of each inhalation over a 12 week period. Forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) measurements were carried out at week 0, 6 and 12. Results from 72 patients were analysed. The average compliance was 60-70%. Treatment was taken as prescribed on 30-40% of the study days, and over-usage occurred on less than 10% of days. Only 15% of patients took the drugs as prescribed for more than 80% of the days. Compliance was no greater in patients using the combined inhalers. Other ways of improving patient self-management need further investigation.

Morbidity and mortality from asthma in the Western world is increasing despite effective prophylactic drugs. Beta agonists are increasingly considered causal; while under-prescribing of inhaled steroids or other anti-inflammatories are accepted as causes for the problems, but the role of non-compliance with inhaled asthma therapy is rarely mentioned. Using a novel electromechanical counter MDI actuations have been recorded in three small (9-11 patients), short (2-3 weeks) studies. When aware compliance with prescribed inhaled steroids was under scrutiny, six patients were fully compliant, two took just 70% of the prescribed regimen, but two did not follow the prescribed regimen at all. When unaware of scrutiny, six out of 11 were compliant but five patients were estimated as taking less than 30-51% of the prescribed dose of inhaled steroid. When asked to monitor rescue bronchodilator usage patients consistently under-recorded. Under-use as well as under prescription of inhaled steroids and under-estimation (8) of beta 2-agonists use may be contributory factors to the present increase in asthma mortality and morbidity. These potential problems of poor compliance need larger scale studies to show how and if behaviour can be altered to improve compliance.