Journal of public health medicine最新文献

Background: Wide variation in rates of angiography and revascularization exist that are not explained by the level of need for these services. The National Service Framework for Coronary Heart Disease has set out a number of standards with the aim of increasing the number of revascularizations and reducing inequalities in access to care. In this study we aimed to investigate inequity in angiography and revascularization rates between the four Primary Care Group (PCG) areas in Camden and Islington Health Authority and to put in place measures to address the problems identified.

Methods: Routinely available data were collected on all residents within Camden and Islington Health Authority undergoing angiography, angioplasty (PTCA) or coronary artery bypass grafting (CABG) between 1997 and 2001. These were used to calculate intervention rates per million population for each of the three procedures within each PCG. Semi-structured interviews were carried out with a sample of clinicians to explore their views on the provision of revascularization services within the Health Authority.

Results: Angiography and revascularization rates varied widely between the four PCGs. In 2001 there was a two-fold difference for angiography and CABG and a 3.5-fold difference for PTCA. The variations were not explained by a measure of the level of need for these services. The highest rates were in the area with the lowest standardized mortality ratio for coronary heart disease. The interviews identified a number of possible explanations for the variations that related to differences in clinical behaviour atthe consultant level and barriers in access to interventional cardiology and cardiac services. Following this research, a further interventional cardiologist appointment is planned, joint protocols of care are being established and barriers to access are being addressed.

Conclusions: The new strategic health authorities should make it a priority to assess inequity in the provision of services within their areas, investigate the possible causes and support the primary care trusts to implement plans to address them.

Background: This paper evaluates claims in a recent study that inequalities in small area mortality rates have lessened. We examine the effect of differently estimated populations on time trends in age-specific mortality rates for Yorkshire and the Humber and East of England.

Methods: Populations were estimated for wards using four methods that introduce increasing amounts of information. Age-specific mortality rates for age-groups 45-54, 55-64, 65-74 and 75-84 for both sexes were calculated for population-weighted deprivation quintiles. Inequality was tracked using ratios of rates in the most deprived quintile divided bythose in the least.

Results: When constant 1991 populations are used, rate ratios decrease for all age-sex groups, indicating shrinking inequality. When a method adjusting small area populations to official district estimates is used, both decreases and increases are observed in the mortality rate ratios. These results differ from Trent region findings of decreases in inequality. When small area populations are cohort-survived and adjusted to district populations, most differences in rate ratios indicate increasing inequality. When a method is used that includes information on migration and special populations, then seven out of eight age-sex groups exhibit increasing inequality.

Conclusions: A judgement about trends in mortality inequality is highly dependent upon the denominator population used. Simpler estimation methods result in convergence of rate ratios, whereas more sophisticated methods result in increasing inequalities in most age-sex groups.

Background: The aim of this study was to describe population and primary care morbidity and to examine how the differences vary across the diseases and are influenced by patients' demographic characteristics.

Methods: A comparison of the prevalence of four chronic conditions for 432747 patients from the Health Search Database (HSD) and 119799 individuals from a Health Interview Survey was carried out. A linear regression was performed to study the associations between age and difference in morbidity.

Results: Similar prevalence was found for diabetes and hypertension, whereas for chronic obstructive pulmonary disease (COPD) and gastroduodenal ulcer lower HSD prevalence was reported. Among females, age was always associated with morbidity difference. Among males, significant associations were found only for COPD (R2 = 0.81; p = 0.001) and gastroduodenal ulcer (R2 = 0.93; p < 0.001).

Conclusions: The difference between population and primary care morbidity is affected by disease under investigation and patients' demographic characteristics. Therefore, in choosing the more cost-effective approach to collect data such evidence should be taken into account, and results should be interpreted with great caution.

Background: The purpose of this study was to compare the performance of the 15-item Picker Patient Experience questionnaire (PPE-15) when embedded in a short form instrument as compared with a longer form measure.

Methods: A postal questionnaire survey of patients recently discharged from two hospital trusts was carried out. Patients were randomized to receive the PPE-15 in either a four-page or a 12-page survey instrument.

Results: A total of 1445 questionnaires were mailed to patients in either four- or 12-page formats. A total of 949 (65.67 per cent) forms were returned. No difference in response rate was found between the two versions of the questionnaire. Item completion and psychometric properties of the PPE-15 were not found to differ significantly between the two arms of the trial.

Conclusion: In this survey the length of questionnaire in which the PPE-15 was embedded had no impact in terms of response rate or data quality. Consequently, the results suggest that length of questionnaire, up to the 108 items included in the 12-page survey, is unlikely to adversely affect results on the PPE-15.

Background: The aims of this study were to develop ischaemic heart disease (IHD) registers in three primary care groups (PCGs) in SW London; to determine what proportion of patients with IHD were already identified; and to estimate the workload in producing an IHD disease register.

Methods: A population-based cross-sectional study was carried out in 46 out of 49 general practices in three PCGs in SW London, using computerized and paper medical records. Outcome measures were proportion of patients with IHD on existing disease registers, and workload and cost of producing complete registers.

Results: Of 3803 patients with a pre-existing IHD Read code, 570 (15 per cent) were found to have no evidence of IHD, leaving 3233 patients with confirmed or probable IHD. A search of 7726 patients prescribed one of five cardiovascular drugs but not already coded as having IHD identified a further 1447 confirmed or probable cases. On average, coders spent 4.9 hours per 1000 list size verifying IHD cases or finding uncoded cases. Each additional IHD case required about 0.68 hours (41 minutes) of coder's time to identify and one case of IHD was identified or confirmed for about every five sets of notes examined. The cost of each additional case identified was about pounds sterling 10.20. At practice level, there was a wide variation in the proportion of IHD patients already on the register or wrongly coded as having IHD.

Conclusions: A centralized search programme can identify patients with IHD efficiently and at relatively low cost. As the identification of cases is an essential first step in implementing effective secondary prevention, other primary care trusts may also find this method useful in improving the management of patients with IHD.

Chronic disease management (CDM) is now widely available in primary care, but methods of delivery are highly variable. The focus of this study was to examine whether CDM provided in asthma clinics was more effective in reducing the severity of asthma symptoms, particularly for deprived populations. There was no evidence of 'inverse care' in the provision of CDM in clinics and good evidence that it was associated with a reduction in the severity of asthma symptoms for both deprived and affluent populations.

Background: The aim of this study was to determine whether the risk of congenital anomalies in a population resident close to a waste combustion plant located at Byker in the city of Newcastle upon Tyne, United Kingdom, was higher than in a population resident further away.

Methods: A geographical study was carried out on the prevalence of congenital anomalies in residents living within 3 km (inner zone) of the Byker combustion plant compared with those living 3-7 km (outer zone) from the plant. There were 81255 live births (1985-1999) and 1508 cases with chromosomal and non-chromosomal congenital anomalies. The cases were identified from the Northern Region Congenital Abnormality Survey.

Results: After the site commenced operation the estimated rate ratio (inner versus outer zone) was 1.11 (95 per cent confidence interval (CI) 0.96-1.28) adjusted for socio-economic deprivation. There was significant heterogeneity across years and an increasing trend, of marginal significance (p = 0.07), in the rate ratio. The inner zone rate approached or became significantly higher than that in the outer zone in some of the later years.

Conclusions: No significant overall association between the number of congenital anomalies and proximity of residence to the Byker waste combustion plant has been found in this study. Significantly increased rates near the site during the later years may suggest a possible risk but are difficult to interpret. More comprehensive, multi-site investigations around other waste combustion plants are indicated.