clinical audit team 6 may 2006 1 an audit of the cost effectiveness of implanon use presented by: dr...
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6 May 20066 May 2006 11Clinical Audit TeamClinical Audit Team
An Audit of the Cost EffectivenessAn Audit of the Cost Effectivenessof Implanon Useof Implanon Use
An Audit of the Cost EffectivenessAn Audit of the Cost Effectivenessof Implanon Useof Implanon Use
Presented by: Dr J Seres, Presented by: Dr J Seres, House OfficerHouse Officer
East & North Hertfordshire NHS Trust East & North Hertfordshire NHS Trust United KingdomUnited Kingdom
Presented by: Dr J Seres, Presented by: Dr J Seres, House OfficerHouse Officer
East & North Hertfordshire NHS Trust East & North Hertfordshire NHS Trust United KingdomUnited Kingdom
9th CONGRESS OF THE EUROPEAN SOCIETY OF CONTRACEPTION9th CONGRESS OF THE EUROPEAN SOCIETY OF CONTRACEPTION9th CONGRESS OF THE EUROPEAN SOCIETY OF CONTRACEPTION9th CONGRESS OF THE EUROPEAN SOCIETY OF CONTRACEPTION
6 May 20066 May 2006 22Clinical Audit TeamClinical Audit Team
IntroductionIntroductionIntroductionIntroduction
Subdermal implant method of contraceptionSubdermal implant method of contraception
In use in UK since October 1999In use in UK since October 1999
Expensive method, Expensive method, (£94 91p per implant),(£94 91p per implant), but long term but long term (up to 3yrs)(up to 3yrs)
‘‘Forgettable’ protectionForgettable’ protection
No oestrogenNo oestrogen
Rapid return to fertility after discontinuationRapid return to fertility after discontinuation
Efficacious method of contraceptionEfficacious method of contraception
Quick and easy insertion and removalQuick and easy insertion and removal
Frequent and/or heavy/irregular bleeding may lead to earlyFrequent and/or heavy/irregular bleeding may lead to early discontinuationdiscontinuation
Subdermal implant method of contraceptionSubdermal implant method of contraception
In use in UK since October 1999In use in UK since October 1999
Expensive method, Expensive method, (£94 91p per implant),(£94 91p per implant), but long term but long term (up to 3yrs)(up to 3yrs)
‘‘Forgettable’ protectionForgettable’ protection
No oestrogenNo oestrogen
Rapid return to fertility after discontinuationRapid return to fertility after discontinuation
Efficacious method of contraceptionEfficacious method of contraception
Quick and easy insertion and removalQuick and easy insertion and removal
Frequent and/or heavy/irregular bleeding may lead to earlyFrequent and/or heavy/irregular bleeding may lead to early discontinuationdiscontinuation
ImplanonImplanonImplanonImplanon
6 May 20066 May 2006 33Clinical Audit TeamClinical Audit Team
Aims & ObjectivesAims & ObjectivesAims & ObjectivesAims & Objectives
To determine if Implanon is cost effective:To determine if Implanon is cost effective:
By reviewing continuation and discontinuation ratesBy reviewing continuation and discontinuation ratesat 3 yearsat 3 years
Where Implanon discontinued <3 yrs:Where Implanon discontinued <3 yrs:
To determine reasons for removalTo determine reasons for removal
To see if improvements are required in the wayTo see if improvements are required in the way Implanon is prescribed and managed Implanon is prescribed and managed
To determine if Implanon is cost effective:To determine if Implanon is cost effective:
By reviewing continuation and discontinuation ratesBy reviewing continuation and discontinuation ratesat 3 yearsat 3 years
Where Implanon discontinued <3 yrs:Where Implanon discontinued <3 yrs:
To determine reasons for removalTo determine reasons for removal
To see if improvements are required in the wayTo see if improvements are required in the way Implanon is prescribed and managed Implanon is prescribed and managed
6 May 20066 May 2006 44Clinical Audit TeamClinical Audit Team
BackgroundBackgroundBackgroundBackground
In April 2000, Implanon introduced as an additional In April 2000, Implanon introduced as an additional contraceptive choice in 2 Family Planning Clinics run by the contraceptive choice in 2 Family Planning Clinics run by the then* East & North Hertfordshire NHS Trust:then* East & North Hertfordshire NHS Trust:
Queensway Clinic – HatfieldQueensway Clinic – Hatfield
Danestrete Clinic – StevenageDanestrete Clinic – Stevenage
In April 2000, Implanon introduced as an additional In April 2000, Implanon introduced as an additional contraceptive choice in 2 Family Planning Clinics run by the contraceptive choice in 2 Family Planning Clinics run by the then* East & North Hertfordshire NHS Trust:then* East & North Hertfordshire NHS Trust:
Queensway Clinic – HatfieldQueensway Clinic – Hatfield
Danestrete Clinic – StevenageDanestrete Clinic – Stevenage
* These Family Planning Clinics now within the remit of S E Herts PCT* These Family Planning Clinics now within the remit of S E Herts PCT* These Family Planning Clinics now within the remit of S E Herts PCT* These Family Planning Clinics now within the remit of S E Herts PCT
6 May 20066 May 2006 55Clinical Audit TeamClinical Audit Team
Standards* Standards* Standards* Standards* Be counselled prior to insertion of Implanon re:Be counselled prior to insertion of Implanon re:
Effectiveness of implantEffectiveness of implant
Duration of useDuration of use
Possible side effectsPossible side effects
Symptoms that require urgent assessmentSymptoms that require urgent assessment
Be given an Implanon information leaflet, and this to be documentedBe given an Implanon information leaflet, and this to be documented
If no problems experienced, to have their Implanon removedIf no problems experienced, to have their Implanon removed3 years after insertion3 years after insertion
Be counselled prior to insertion of Implanon re:Be counselled prior to insertion of Implanon re: Effectiveness of implantEffectiveness of implant
Duration of useDuration of use
Possible side effectsPossible side effects
Symptoms that require urgent assessmentSymptoms that require urgent assessment
Be given an Implanon information leaflet, and this to be documentedBe given an Implanon information leaflet, and this to be documented
If no problems experienced, to have their Implanon removedIf no problems experienced, to have their Implanon removed3 years after insertion3 years after insertion
All clients to:All clients to:All clients to:All clients to:
* Based on Family Planning Association and local guidelines, and * Based on Family Planning Association and local guidelines, and manufacturers’ information manufacturers’ information * Based on Family Planning Association and local guidelines, and * Based on Family Planning Association and local guidelines, and manufacturers’ information manufacturers’ information
6 May 20066 May 2006 66Clinical Audit TeamClinical Audit Team
Data were collected on all clients fitted with Implanon from its Data were collected on all clients fitted with Implanon from its introduction in April 2000, until Autumn 2002introduction in April 2000, until Autumn 2002
Data collected from the clients’ Family Planning Records by Dr Data collected from the clients’ Family Planning Records by Dr Seres and Dr UthayakumarSeres and Dr Uthayakumar
Data entered on Access database and analysed by Clinical Audit Data entered on Access database and analysed by Clinical Audit Team Team
Data were collected on all clients fitted with Implanon from its Data were collected on all clients fitted with Implanon from its introduction in April 2000, until Autumn 2002introduction in April 2000, until Autumn 2002
Data collected from the clients’ Family Planning Records by Dr Data collected from the clients’ Family Planning Records by Dr Seres and Dr UthayakumarSeres and Dr Uthayakumar
Data entered on Access database and analysed by Clinical Audit Data entered on Access database and analysed by Clinical Audit Team Team
Audit MethodologyAudit MethodologyAudit MethodologyAudit Methodology
6 May 20066 May 2006 77Clinical Audit TeamClinical Audit Team
Methodology Methodology (cont’d)(cont’d)Methodology Methodology (cont’d)(cont’d)
Data extraction form designed by Clinical Audit Team in conjunction Data extraction form designed by Clinical Audit Team in conjunction with Dr Uthayakumar, Consultant in Sexual Health with Dr Uthayakumar, Consultant in Sexual Health
Data were collected on, inter alia:Data were collected on, inter alia:
Initial fittingInitial fitting
First follow up First follow up
Reasons for removalsReasons for removals
Timing of removalsTiming of removals
Data extraction form designed by Clinical Audit Team in conjunction Data extraction form designed by Clinical Audit Team in conjunction with Dr Uthayakumar, Consultant in Sexual Health with Dr Uthayakumar, Consultant in Sexual Health
Data were collected on, inter alia:Data were collected on, inter alia:
Initial fittingInitial fitting
First follow up First follow up
Reasons for removalsReasons for removals
Timing of removalsTiming of removals
6 May 20066 May 2006 88Clinical Audit TeamClinical Audit Team
ResultsResultsResultsResults
6 May 20066 May 2006 99Clinical Audit TeamClinical Audit Team
Sample SizeSample SizeSample SizeSample Size
121 clients had an Implanon device fitted121 clients had an Implanon device fitted
50 @ Queensway Clinic50 @ Queensway Clinic
71 @ Danestrete Clinic71 @ Danestrete Clinic
31 (26%) clients were lost to any follow-up31 (26%) clients were lost to any follow-up
121 clients had an Implanon device fitted121 clients had an Implanon device fitted
50 @ Queensway Clinic50 @ Queensway Clinic
71 @ Danestrete Clinic71 @ Danestrete Clinic
31 (26%) clients were lost to any follow-up31 (26%) clients were lost to any follow-up
6 May 20066 May 2006 1010Clinical Audit TeamClinical Audit Team
Client Information Client Information (n = 121)(n = 121)Client Information Client Information (n = 121)(n = 121)
Clients ranged from 15 – 44 years oldClients ranged from 15 – 44 years old
Mean age 29.5yrsMean age 29.5yrs
43 (36%) were nulliparous43 (36%) were nulliparous
61 (50%) clients had previously attended the FP Clinic61 (50%) clients had previously attended the FP Clinic
The majority, 101 (84%), were self referralsThe majority, 101 (84%), were self referrals
Most common reason for use, 37 (31%), – client wantedMost common reason for use, 37 (31%), – client wanted long term protection long term protection
10 (8%) had used an implant method of contraception10 (8%) had used an implant method of contraception immediately prior to this Implanon insertion immediately prior to this Implanon insertion
Clients ranged from 15 – 44 years oldClients ranged from 15 – 44 years old
Mean age 29.5yrsMean age 29.5yrs
43 (36%) were nulliparous43 (36%) were nulliparous
61 (50%) clients had previously attended the FP Clinic61 (50%) clients had previously attended the FP Clinic
The majority, 101 (84%), were self referralsThe majority, 101 (84%), were self referrals
Most common reason for use, 37 (31%), – client wantedMost common reason for use, 37 (31%), – client wanted long term protection long term protection
10 (8%) had used an implant method of contraception10 (8%) had used an implant method of contraception immediately prior to this Implanon insertion immediately prior to this Implanon insertion
6 May 20066 May 2006 1111Clinical Audit TeamClinical Audit Team
Counselling and InformationCounselling and InformationCounselling and InformationCounselling and Information
110 (91%) 110 (91%) clients recorded as having beenclients recorded as having been counselled prior to insertion counselled prior to insertion
48 (44%) of these clients counselled on day of fitting48 (44%) of these clients counselled on day of fitting
76 (63%) clients were given an information sheet76 (63%) clients were given an information sheet
In 44 (36%) cases, it was not recorded whether orIn 44 (36%) cases, it was not recorded whether or not client had been given information sheet not client had been given information sheet
110 (91%) 110 (91%) clients recorded as having beenclients recorded as having been counselled prior to insertion counselled prior to insertion
48 (44%) of these clients counselled on day of fitting48 (44%) of these clients counselled on day of fitting
76 (63%) clients were given an information sheet76 (63%) clients were given an information sheet
In 44 (36%) cases, it was not recorded whether orIn 44 (36%) cases, it was not recorded whether or not client had been given information sheet not client had been given information sheet
(n = 121)(n = 121)(n = 121)(n = 121)
6 May 20066 May 2006 1212Clinical Audit TeamClinical Audit Team
Continuation RatesContinuation RatesContinuation RatesContinuation Rates
0
20
40
60
80
No
. o
f cl
ien
ts
63 (70%)63 (70%)
44 (49%)44 (49%)
34* (38%)34* (38%)
* includes 7 >3yrs, max 44mthsincludes 7 >3yrs, max 44mths* includes 7 >3yrs, max 44mthsincludes 7 >3yrs, max 44mths
(n = (n = 90)90)(n = (n = 90)90)
At 1 yrAt 1 yr At 2 yrsAt 2 yrs At 3 yrsAt 3 yrs
6 May 20066 May 2006 1313Clinical Audit TeamClinical Audit Team
Reasons for ‘Early’ Implanon Reasons for ‘Early’ Implanon RemovalRemoval
Reasons for ‘Early’ Implanon Reasons for ‘Early’ Implanon RemovalRemoval
Side effects:Side effects:
Irregular/frequent/heavy bleeding - cited in 42 cases (75%)Irregular/frequent/heavy bleeding - cited in 42 cases (75%)
Mood changes/panic attacks - 11 cases (20%)Mood changes/panic attacks - 11 cases (20%)
Weight gain - 5 cases (9%)Weight gain - 5 cases (9%)
Other:Other:
Change of mind re method of contraception - 8 cases (14%)Change of mind re method of contraception - 8 cases (14%)
Contraception no longer needed Contraception no longer needed (inc. no longer sexually active, wishes to get (inc. no longer sexually active, wishes to get
pregnant) - pregnant) - 7 cases (13%)7 cases (13%)
Side effects:Side effects:
Irregular/frequent/heavy bleeding - cited in 42 cases (75%)Irregular/frequent/heavy bleeding - cited in 42 cases (75%)
Mood changes/panic attacks - 11 cases (20%)Mood changes/panic attacks - 11 cases (20%)
Weight gain - 5 cases (9%)Weight gain - 5 cases (9%)
Other:Other:
Change of mind re method of contraception - 8 cases (14%)Change of mind re method of contraception - 8 cases (14%)
Contraception no longer needed Contraception no longer needed (inc. no longer sexually active, wishes to get (inc. no longer sexually active, wishes to get
pregnant) - pregnant) - 7 cases (13%)7 cases (13%)
(Multiple (Multiple response)response)(Multiple (Multiple response)response)
(n = (n = 56)56)(n = (n = 56)56)
6 May 20066 May 2006 1414Clinical Audit TeamClinical Audit Team
3yr Follow Up3yr Follow Up3yr Follow Up3yr Follow Up
7 (11%) 3yr follow up appt letters sent7 (11%) 3yr follow up appt letters sent
Only 1 of these clients attended her 3yr follow up apptOnly 1 of these clients attended her 3yr follow up appt
Blank/NR – 38 (58%)Blank/NR – 38 (58%)
(Not current practice to send these letters)(Not current practice to send these letters)
34 (58%) attended 34 (58%) attended 3yrs post insertion 3yrs post insertion
31 (42%) lost to 3yr follow up31 (42%) lost to 3yr follow up
7 (11%) 3yr follow up appt letters sent7 (11%) 3yr follow up appt letters sent
Only 1 of these clients attended her 3yr follow up apptOnly 1 of these clients attended her 3yr follow up appt
Blank/NR – 38 (58%)Blank/NR – 38 (58%)
(Not current practice to send these letters)(Not current practice to send these letters)
34 (58%) attended 34 (58%) attended 3yrs post insertion 3yrs post insertion
31 (42%) lost to 3yr follow up31 (42%) lost to 3yr follow up
(n = 65*)(n = 65*)(n = 65*)(n = 65*)
* ie those known NOT to have had Implanon removed * ie those known NOT to have had Implanon removed ‘early’‘early’
* ie those known NOT to have had Implanon removed * ie those known NOT to have had Implanon removed ‘early’‘early’
6 May 20066 May 2006 1515Clinical Audit TeamClinical Audit Team
Method of Contraception -Method of Contraception -After Removal of 1After Removal of 1stst Implanon Implanon
Method of Contraception -Method of Contraception -After Removal of 1After Removal of 1stst Implanon Implanon
2828 (31%)(31%) had a second Implanon fitted had a second Implanon fitted
19 (19%) 19 (19%) Barrier methods Barrier methods
15 (17%) 15 (17%) Contraceptive pill Contraceptive pill
9 (10%) 9 (10%) IUD/Mirena IUD/Mirena
8 (9%) 8 (9%) Injectables Injectables
6 (7%) 6 (7%) None None
5 (6%) 5 (6%) Other/NR Other/NR
2828 (31%)(31%) had a second Implanon fitted had a second Implanon fitted
19 (19%) 19 (19%) Barrier methods Barrier methods
15 (17%) 15 (17%) Contraceptive pill Contraceptive pill
9 (10%) 9 (10%) IUD/Mirena IUD/Mirena
8 (9%) 8 (9%) Injectables Injectables
6 (7%) 6 (7%) None None
5 (6%) 5 (6%) Other/NR Other/NR
(n = (n = 90)90)(n = (n = 90)90)
6 May 20066 May 2006 1616Clinical Audit TeamClinical Audit Team
No failures of method were reportedNo failures of method were reportedNo failures of method were reportedNo failures of method were reported
EfficacyEfficacy
6 May 20066 May 2006 1717Clinical Audit TeamClinical Audit Team
ConclusionsConclusionsConclusionsConclusions 31 (26%) clients were lost to any follow-up 31 (26%) clients were lost to any follow-up
Information on these cases would alter discontinuation rate Information on these cases would alter discontinuation rate
Higher discontinuation rate than we would wish,Higher discontinuation rate than we would wish, ie 30% in first year and a further 21% in second year ie 30% in first year and a further 21% in second year
Reasonably cost effective method of contraceptionReasonably cost effective method of contraception – NB no failures! – NB no failures!
Cost effectiveness would be improved by reducingCost effectiveness would be improved by reducing discontinuation rate discontinuation rate
Perhaps discontinuation rate would be reduced if Perhaps discontinuation rate would be reduced if clients were better informed, in advance, re possible clients were better informed, in advance, re possible side effects etc side effects etc
31 (26%) clients were lost to any follow-up 31 (26%) clients were lost to any follow-up
Information on these cases would alter discontinuation rate Information on these cases would alter discontinuation rate
Higher discontinuation rate than we would wish,Higher discontinuation rate than we would wish, ie 30% in first year and a further 21% in second year ie 30% in first year and a further 21% in second year
Reasonably cost effective method of contraceptionReasonably cost effective method of contraception – NB no failures! – NB no failures!
Cost effectiveness would be improved by reducingCost effectiveness would be improved by reducing discontinuation rate discontinuation rate
Perhaps discontinuation rate would be reduced if Perhaps discontinuation rate would be reduced if clients were better informed, in advance, re possible clients were better informed, in advance, re possible side effects etc side effects etc
6 May 20066 May 2006 1818Clinical Audit TeamClinical Audit Team
Conclusions Conclusions (cont’d)(cont’d)Conclusions Conclusions (cont’d)(cont’d)
Implanon is an efficacious method of contraceptionImplanon is an efficacious method of contraception
Where no problems are experienced, Implanon is veryWhere no problems are experienced, Implanon is very acceptable to clients acceptable to clients
24 (71%) of the 34 clients who had their first Implanon24 (71%) of the 34 clients who had their first Implanon removed @ 3 yrs went on to have a new Implanon inserted removed @ 3 yrs went on to have a new Implanon inserted
Most common reason for early removal wasMost common reason for early removal was irregular/frequent/heavy bleeding - 42 (75%) cases irregular/frequent/heavy bleeding - 42 (75%) cases
Recording of information in client records needs improvementRecording of information in client records needs improvement
Implanon is an efficacious method of contraceptionImplanon is an efficacious method of contraception
Where no problems are experienced, Implanon is veryWhere no problems are experienced, Implanon is very acceptable to clients acceptable to clients
24 (71%) of the 34 clients who had their first Implanon24 (71%) of the 34 clients who had their first Implanon removed @ 3 yrs went on to have a new Implanon inserted removed @ 3 yrs went on to have a new Implanon inserted
Most common reason for early removal wasMost common reason for early removal was irregular/frequent/heavy bleeding - 42 (75%) cases irregular/frequent/heavy bleeding - 42 (75%) cases
Recording of information in client records needs improvementRecording of information in client records needs improvement
6 May 20066 May 2006 1919Clinical Audit TeamClinical Audit Team
Points for DiscussionPoints for DiscussionPoints for DiscussionPoints for Discussion
How can we reduce the number of clients lost to follow-up?How can we reduce the number of clients lost to follow-up?
By emphasising at counselling that Implanon should beBy emphasising at counselling that Implanon should beremoved after 3 yrs?removed after 3 yrs?
By stressing at counselling that it is the By stressing at counselling that it is the client’s client’s responsibilityresponsibilityto remember to come back after 3 yrs?to remember to come back after 3 yrs?
By establishing a recall system?By establishing a recall system?
How can we improve our record keeping?How can we improve our record keeping?
By using a customised Implanon proforma that would formBy using a customised Implanon proforma that would formpart of the client’s record?part of the client’s record?
How can we reduce the number of clients lost to follow-up?How can we reduce the number of clients lost to follow-up?
By emphasising at counselling that Implanon should beBy emphasising at counselling that Implanon should beremoved after 3 yrs?removed after 3 yrs?
By stressing at counselling that it is the By stressing at counselling that it is the client’s client’s responsibilityresponsibilityto remember to come back after 3 yrs?to remember to come back after 3 yrs?
By establishing a recall system?By establishing a recall system?
How can we improve our record keeping?How can we improve our record keeping?
By using a customised Implanon proforma that would formBy using a customised Implanon proforma that would formpart of the client’s record?part of the client’s record?
6 May 20066 May 2006 2020Clinical Audit TeamClinical Audit Team
Points for Discussion Points for Discussion (cont’d)(cont’d)
Points for Discussion Points for Discussion (cont’d)(cont’d)
How can we reduce the discontinuation rate?How can we reduce the discontinuation rate?
By counselling clients By counselling clients priorprior to fitting day? to fitting day?
By spending more time counselling clients?By spending more time counselling clients?
By ensuring all clients are given the FPA Implanon leaflet By ensuring all clients are given the FPA Implanon leaflet when counselled?when counselled?
How can we tell if we’ve made any improvements?How can we tell if we’ve made any improvements?
How can we reduce the discontinuation rate?How can we reduce the discontinuation rate?
By counselling clients By counselling clients priorprior to fitting day? to fitting day?
By spending more time counselling clients?By spending more time counselling clients?
By ensuring all clients are given the FPA Implanon leaflet By ensuring all clients are given the FPA Implanon leaflet when counselled?when counselled?
How can we tell if we’ve made any improvements?How can we tell if we’ve made any improvements?
Re-auditRe-audit Re-auditRe-audit
6 May 20066 May 2006 2121Clinical Audit TeamClinical Audit Team
My thanks to everyone My thanks to everyone involved with this study:involved with this study:My thanks to everyone My thanks to everyone
involved with this study:involved with this study: Dr Anjali Agrawal,Dr Anjali Agrawal, Ass. Specialist in Family PlanningAss. Specialist in Family Planning
Ann Ainsworth,Ann Ainsworth, Senior Clinical Audit FacilitatorSenior Clinical Audit Facilitator
Dr Brenda Bean,Dr Brenda Bean, Consultant in Family PlanningConsultant in Family Planning
Heather Davies,Heather Davies, Clinical Audit ManagerClinical Audit Manager
Maureen Jones,Maureen Jones, Clinic SupervisorClinic Supervisor
Juliet Lai,Juliet Lai, Clinical Audit OfficerClinical Audit Officer
Dr H Maiti,Dr H Maiti, Consultant in Sexual HealthConsultant in Sexual Health
Dr Farah Paruk,Dr Farah Paruk, Senior House OfficerSenior House Officer
Dr Uthayakumar,Dr Uthayakumar, Consultant in Sexual HealthConsultant in Sexual Health
Dr Anjali Agrawal,Dr Anjali Agrawal, Ass. Specialist in Family PlanningAss. Specialist in Family Planning
Ann Ainsworth,Ann Ainsworth, Senior Clinical Audit FacilitatorSenior Clinical Audit Facilitator
Dr Brenda Bean,Dr Brenda Bean, Consultant in Family PlanningConsultant in Family Planning
Heather Davies,Heather Davies, Clinical Audit ManagerClinical Audit Manager
Maureen Jones,Maureen Jones, Clinic SupervisorClinic Supervisor
Juliet Lai,Juliet Lai, Clinical Audit OfficerClinical Audit Officer
Dr H Maiti,Dr H Maiti, Consultant in Sexual HealthConsultant in Sexual Health
Dr Farah Paruk,Dr Farah Paruk, Senior House OfficerSenior House Officer
Dr Uthayakumar,Dr Uthayakumar, Consultant in Sexual HealthConsultant in Sexual Health
6 May 20066 May 2006 2222Clinical Audit TeamClinical Audit Team
Thank Thank youyou
Thank Thank youyou
6 May 20066 May 2006 2323Clinical Audit TeamClinical Audit Team
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