Uncertainties in medical audit.
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Forecasting↗
Biomedical subjects
D P Forster
Publications and source records attributed to D P Forster.
Risk factors in clinically diagnosed presenile dementia of the Alzheimer type: a case-control study in northern England.
STUDY OBJECTIVE: To investigate the relationship between presenile dementia of the Alzheimer type (PDAT) and family history, medical history, cigarette smoking, and exposure to aluminum. DESIGN: A case-control study in which 109 cases of clinically diagnosed PDAT and 109 controls matched for age and sex were compared for exposure to the risk factors. Odds ratios (ORs) were calculated using McNemar's test. SETTING: The northern health region of England. PATIENTS: Cases comprised those under 65 years diagnosed as having dementia by specialist services, who met clinical algorithm criteria for Alzheimer's disease (AD). Cases were confirmed at interview. MAIN RESULTS: Comparing cases with controls, (ORs) significantly greater than unity were obtained when there was a first degree relative with dementia (OR 2.5, 95% confidence interval 1.05, 6.56), any relative with dementia (OR 2.1, 95% CI 1.01, 4.55), and any relative aged less than 65 with dementia (OR 8.0, 95% CI 1.07, 348). Exposure to moderate levels of cigarette smoking (cumulative) was not significant; nor was exposure to aluminum in drinking water, diet, and medicinal sources. CONCLUSION: In this study of modest statistical power, a family history of dementia was confirmed as a risk factor in PDAT. No significant relationship between exposure to aluminium in water supplies, tea, and antacids was found. What is important, however, is the bioavailability of all dietary aluminium, determined by the concentrations of dissolved silicon in water: this requires further investigation.
Age of Onset↗
Alzheimer's disease and the relationship between silicon and aluminium in water supplies in northern England.
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Aluminum↗
Dependency and community care in presenile Alzheimer's disease.
BACKGROUND: In a study of patients with presenile dementia of Alzheimer type (PDAT), we aimed to investigate functional dependency in relation to the time since diagnosis and place of residence. Use of community and support services and the time between diagnosis and entry to permanent residential care were also studied. METHOD: Interviews with 109 cases of PDAT (diagnosed before age 65) and their carers. RESULTS: The need for assistance in activities of daily living (ADL) was progressive with time from diagnosis. Five years after diagnosis, 57% of patients remained at home, 20% of whom required some assistance in each of six areas of ADL. The need for assistance in each ADL category was significantly greater for cases in permanent residential care than for those at home. There were no significant differences between the Mini-Mental State Examination (MMSE) scores of patients at home and those of patients in permanent care. Incontinence and the relationship of the carer to the patient were the strongest predictors of permanent residential care. Respite care had been offered in 63% of cases; 71% of these offers had been accepted. CONCLUSIONS: Patients with PDAT who have a living relative are cared for at home for a considerable period of time despite severe cognitive impairment and loss of independence measured by ADL. The reports of carers suggest there is scope for improvement in supportive services to meet this community need.
Activities of Daily Living↗
Public health medicine training and the NHS changes.
The current round of mergers between Health Authorities and Family Health Service Authorities (FHSAs), when set in the competitive context of markets, has profound implications for training in Public Health Medicine. This paper considers the phases in the management of change and the costs, benefits and principles for trainers, trainees and organisations as mergers take place. Particular emphasis is placed on understanding the motives of and learning from the change that is taking place.
Health Facility Merger↗
Referral patterns and diagnosis in presenile Alzheimer's disease: implications for general practice.
BACKGROUND: Presenile dementia of alzheimer type is a rare condition, and a report drawn from a large population may be useful to general practitioners. AIM: A study was undertaken in the Northern Regional Health Authority area to investigate general practitioner referral practice, hospital investigations and diagnosis in cases of presenile alzheimers disease. METHOD: Reviews of 186 sets of case notes of patients diagnosed between 1985 and 1989, and follow-up interviews with the principal carer in a subsample of 73 surviving patients were undertaken. RESULTS: In 63% of cases, formal diagnosis of presenile alzheimers disease was made by a neurologist, in 27% of cases by a psychiatrist and in 9% by a physician. Symptoms of depression had been noted in 45 patients (24%) and 21 had been prescribed antidepressant drugs prior to specialist referral. Computerized tomography scans were requested significantly more frequently by neurologists than other specialists and lumbar puncture was virtually only done by neurologists, but there were no significant differences between specialists regarding other clinical investigations. Domiciliary care or day centre attendance were more likely to be arranged at hospital discharge by psychiatrists than other specialists, but at follow-up interview no differences in community care provision were found according to initial specialty. Interviews with relatives of surviving patients revealed that at initial contact with general practitioners 48% of patients were unaware that they had any problem. Only 13 relatives (18%) felt they had been given sufficient information at diagnosis concerning the chronic and progressive nature of the disease, and at follow up 26% remained unaware of the existence of the Alzheimer's Disease Society. CONCLUSION: These results reinforce the importance of the role of general practitioners in arranging and coordinating appropriate support for patients and their relatives, in providing continuity of care and in advising the families of the existence of voluntary organizations.
Alzheimer Disease↗
Presenile dementia. Gender difference unlikely.
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Dementia↗
Clinically diagnosed presenile dementia of the Alzheimer type in the Northern Health Region: ascertainment, prevalence, incidence and survival.
Potential cases of presenile dementia of the Alzheimer type (PDAT) in the Northern Health Region (estimated population aged 45-64, 655,800) were ascertained for the years 1979-86 from in-patient ICD-9 codes and other sources. An algorithm was applied to the casenote information to distinguish between Alzheimer-type and other forms of dementia. A search of the NHS central register was made to establish date and place of death. Estimates were made for patients with missing case records. The point prevalence rate for PDAT was estimated as 34.6 per 100,000 with an annual incidence of 7.2 per 100,000 in the 45-64 age range. These rates are compared with those reported in other studies. Five-year survival following diagnosis for incident cases of PDAT was 64% with a longevity quotient (LQ), the percentage of expected time actually survived, of 69%. There was no evidence of a more malignant course in PDAT when compared with survival in older patients with dementia of the Alzheimer type (DAT) in other studies. Sixty-six per cent of deaths occurred in hospital, 19% at home and 15% in residential homes.
Age Factors↗
A review of the costs and effectiveness of assessing the elderly in general practice.
The 1990 contract for general practitioners made annual health checks for people aged 75 and over compulsory. We review the costs and effects of different approaches to the health check, focusing on the method advised in the 1990 contract. This involves an annual home-based functional assessment by a member of the primary health care team, known as a blanket assessment. Our review of published randomized controlled trials shows such assessments have few consistent benefits. Data on the costs of assessment are usually reported in summary form, with little or no information on which costs are included. In studies where average costs are given for assessments, because of salary and travel expenses, the costs are high. Several promising methods for reducing costs in assessment, and a method with potential to improve effectiveness, are currently outside the terms of the 1990 contract. These methods are described. Revision of the 1990 contract should incorporate the flexibility to encourage more cost-effective approaches to assessing the elderly such as a two-stage assessment or using volunteers. A monitoring group is needed to establish how health checks are being implemented. This group could co-ordinate and advise on standardized criteria for methods of costing and assessing effectiveness in assessment programmes.
Aged↗
Death certification after a diagnosis of presenile dementia.
STUDY OBJECTIVES: To assess the value of death certification for the epidemiological study of dementia, the frequency with which the condition was recorded on death certificates of patients diagnosed with some form of dementia before the age of 65 years was studied. A further objective was to identify variables associated with failure to record dementia on the certificate. DESIGN: A cohort of patients with presenile dementia, differentiated by a clinical algorithm applied to hospital case records, was traced through the National Health Service Central Registry and details of certified causes of death were obtained. SETTING: The Northern Regional Health Authority in England. SUBJECTS: Prevalent cases of presenile dementia resident in the northern health region during 1986 traced up to April 1992. MEASUREMENTS AND MAIN RESULTS: The underlying cause of death was recorded as dementia or as Alzheimer's disease in 53% of cases of clinically diagnosed presenile Alzheimer's disease, 33% of cases of presenile vascular dementia, and 10% of cases of presenile dementia secondary to another neurological condition. Dementia or Alzheimer's disease was recorded in any part of the certificate in 75% of cases of Alzheimer's disease, 52% of vascular dementia, 33% of other dementias, and in 65% of cases overall. Dementia or a cerebral condition of a kind that can result in dementia was recorded in 80% of all cases. Failure to mention dementia was related to the clinical type of dementia, shorter duration of illness, and earlier period of study. CONCLUSIONS: The underlying cause of death seriously understates the frequency of dementia, but when the recording of other brain disease is taken into account the presence of potentially dementing brain disease is recorded much more frequently. It is suggested that coding chronic conditions present at death, such as dementia, in addition to those causing or contributing to death would improve the value of death certificates for epidemiological purposes.
Age Factors↗
Income distribution and life expectancy.
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Aged↗
The family study: a model for integrating the individual and community perspective in medical education.
The principles of and experience with a family study and survey undertaken by first-year medical students are reported. The family study is based on the observations made by pairs of students on a selected family, which includes a pregnant mother, in the Newcastle upon Tyne area. These observations include the family context, the pregnancy, the early development of the new-born baby, and the use of health and other services. The family survey records and analyses relevant data on the collective group of selected families. The family study acts as a preparation for clinical understanding by emphasizing the individual or family view. In addition, students learn that the collective epidemiological approach provided by the survey can guide the clinical impression gained from the observational study, yet each individual and family remains unique. An early opportunity is therefore provided for students to explore and integrate these two approaches.
Child↗
Evaluation of pure tone audiometry and impedance screening in infant schoolchildren.
STUDY OBJECTIVE: The aims were (1) to evaluate impedance measurements against pure tone audiometry as a screening method for the detection of middle ear changes associated with hearing loss in infant school children; (2) to estimate the costs of the health authority of each method. DESIGN: The study involved two stage screening in which both methods were offered, pure tone audiometry being carried out by school nurses and impedance screening by a doctor. SETTING: 18 infant or primary schools in Langbaurgh, Cleveland, UK. PARTICIPANTS: 610 previously unscreened infant school children took part in the study. MEASUREMENTS AND MAIN RESULTS: Main outcome measures were the sensitivity, specificity, and predictive value of each screening method, using clinical assessment and action as the validating technique. The sensitivity and the predictive value of a positive test in two stage impedance screening was markedly superior to that of pure tone audiometry. The specificity was similar using the two methods. In addition the impedance methods was more rapid and estimated to consume less resource as a screening procedure than pure tone audiometry. CONCLUSIONS: The superiority of the use of impedance screening established in this study should be confirmed in a subsequent audit carried out purely by school nurses.
Acoustic Impedance Tests↗
Mortality from causes amenable and non-amenable to medical care: the experience of eastern Europe.
OBJECTIVE: To investigate comparative national trends in mortality from conditions amenable to timely, appropriate medical care and from those considered not to be amenable to such care. DESIGN: Analysis of trends in direct age standardised mortality from the 1950s to 1987. SETTING: Four eastern European nations (Hungary, Czechoslovakia, Poland, the German Democratic Republic) and two western European (the Federal Republic of Germany and England and Wales) and two North American nations (United States and Canada). SUBJECTS: The total populations of the relevant countries during the period examined. MAIN OUTCOME MEASURES: Proportional changes over time in age standardised mortality. Mortality from amenable and non-amenable causes was restricted to the age group 0-64. RESULTS: A divergence in the trends for all cause mortality between eastern Europe and the western nations occurred in about 1970, when the rates in western countries steadily declined but those in eastern Europe remained fairly static. In the age group 0-64 mortality from causes considered amenable to medical care fell less quickly in eastern Europe than in the West, particularly after 1970. In the same age group, mortality from non-amenable causes rose in eastern European countries from the late 1960s compared with substantial declines in such mortality in the West. CONCLUSIONS: Non-amenable causes of death seem to be the principal, but not exclusive, reason for lack of improvement in trends in all cause mortality in eastern Europe from 1970. The agenda for action in eastern Europe should give priority to a healthier lifestyle and improvement of the environment though not neglect enhancements in the quality and efficiency of direct health services.
Adolescent↗
The role of unemployment in parasuicide.
Sixty-four in-patient cases of deliberate non-fatal self-poisoning were compared for psychosocial problems in a case-control study with a similar number of individually matched community controls. A strongly significant association was found between unemployment and self-poisoning. Further analysis revealed no firm evidence to support the hypotheses that unemployment was causally related to self-poisoning in an indirect manner or that it increased the vulnerability of individuals who self-poison to other stressful life events and difficulties. It is concluded that a possible explanation is that some third factor independently increases the risk of both unemployment and self-poisoning, giving rise to a non-causal relationship between these last two variables.
Adaptation, Psychological↗
Use of regression analysis to explain the variation in prescribing rates and costs between family practitioner committees.
There are proposals to set up prescribing budgets for family practitioner committees (now family health services authorities) and indicative prescribing amounts for practices. An intelligible model is therefore required for specifying budgetary allocations. Regression analyses were used to explain the variation in prescription rates and costs between the 98 family practitioner committees of England and Wales in 1987. Fifty one per cent of the variation in prescription rates and 44% of the variation in prescription costs per patient could be explained by variations in the age-sex structure of family practitioner committees. The standardized mortality ratio for all causes and patients in 1987, and the number of general practice principals per 1000 population in 1987, but not the Jarman under-privileged area score were found to improve the predictive power of the regression models significantly (P less than 0.01). The predictions of the model for the 10 family practitioner committees with the highest and lowest prescription rates or costs are reported and discussed. Potential improvements in models of prescribing behaviour may be thwarted by two problems. First, the paucity of readily available data on health care need at family practitioner committee and practice levels, and secondly, the increasing complexity in the statistical techniques required may render the procedure less intelligible, meaningful and negotiable in a contentious field.
Costs and Cost Analysis↗
Health in Eastern Europe.
To assess trends in health in Eastern Europe, age-standardised mortality rates since 1950 in four Eastern European countries (German Democratic Republic, Poland, Czechoslovakia, and Hungary) were compared with those in two Western European countries (Federal Republic of Germany and England and Wales). In the Eastern European countries mortality rates had increased or were virtually unchanged since the mid-1960s, especially in middle aged and elderly men. Death rates in males in Poland, Czechoslovakia, and Hungary in the mid to late 1980s were as high as those in the two Western European countries in the early 1950s. There was a shorter time lag for females. This poor health record in Eastern Europe will need to be addressed by the policy makers in the new democracies.
Adult↗