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Biomedical subjects

F Kee

Publications and source records attributed to F Kee.

At least 37 records · Page 2Linked to original sources
PubMed1997

What is a safe waiting time for coronary artery bypass surgery?

To determine the factors that influenced doctors' prioritization and decisions on safe waiting time for coronary artery bypass surgery, 50 'paper patients', based on a random sample of cases who actually had surgery, were assessed by 33 clinicians. We used linear regression models to reflect the impact of clinical and non-clinical 'cues' on safe waiting time and priority decisions. The benefits of surgery tended to be over-estimated. For example, the average perceived gain in life expectancy for patients with left main-stem disease was 6.74 years. However, models incorporating only the perceptions of benefit as independent variables (i.e. the anticipated symptom reduction, MI risk reduction and life expectancy extension), had only modest explanatory power (mean R2 was 0.55 for safe waiting time, and 0.56 for priority decisions). Models which incorporated perceptions of benefit and the cases' clinical and non-clinical characteristics had generally much higher explanatory power (mean R2, 0.83 and 0.86, respectively). Lifestyle and demographic variables had much less impact on the doctors' judgements than the major clinical cues of angina severity and left main-stem stenosis. Demographic and lifestyle cues had different impacts on safe waiting time and priority for about 25% of doctors.

Angina Pectoris↗
PubMed1997

The stated and tacit impact of demographic and lifestyle factors on prioritization decisions for cardiac surgery.

In a clinical judgement analysis, we used linear regression models to reflect the impact of clinical and non-clinical cues on priority decisions, by comparing the stated prioritization policies of 30 clinicians with their actual policies as revealed by an appraisal of 50 'paper patients'. Correspondence was modest for some cues, e.g. 25 doctors said they accounted for age, but age only had a significant bearing in the derived decision models of two doctors. Correspondence between the derived and expressed weights was greatest for clinical angina grade and the presence of left main stem stenosis. Correlation between the rank order of importance between the two models was poor for most of the cues, and statistically significant only for smoking. However, stated policies made it appear that lifestyle factors such as smoking habit would influence prioritization decisions for most clinicians but policies derived from actual prioritization decisions seldom related to lifestyle or demographic variables. There were significant differences in the degree of correlation between the two models according to the experience of the clinician. However, correspondence was not significantly better for doctors with cardiological training than those without. The overall contribution of demographic and lifestyle factors to decision making appears to be small, suggesting that they should be omitted from prioritization guidelines.

Cardiac Surgical Procedures↗
PubMed1997

Prioritising the cardiac surgery waiting list: the angina patient's perspective.

OBJECTIVE: To determine patients' views on how clinical and demographic factors should affect priorities for cardiac revascularisation. DESIGN: A descriptive survey of patients' views conducted immediately after angiography and treatment counselling. SUBJECTS: 136 patients who were awaiting coronary angioplasty in either of the two regional cardiology centres in Northern Ireland. RESULTS: About half the subjects (52%) felt that certain social factors such as having dependent relatives should be taken into account when deciding priority for surgery. A sizeable minority felt that younger subjects and non-smokers (40% and 44%, respectively) should be accorded higher priority, with older subjects and smokers being more likely to hold such views. CONCLUSIONS: While there is little evidence that demographic and lifestyle factors affect the relative efficacy of surgery, the challenge remains to devise a prioritisation guideline that can properly reflect societal values and the evidence base.

Age Factors↗
PubMed1997

Risks and benefits of coronary angioplasty: the patients perspective: a preliminary study.

OBJECTIVES: To describe what cardiac patients in Northern Ireland understand to be the benefits of coronary angioplasty and assess the extent to which they have been able to make informed choices about their treatment. DESIGN: An interview based questionnaire survey completed after the patients had undergone coronary angiography, within hours of treatment counselling. SUBJECTS: 150 patients consecutively recruited from two regional cardiology centres in Belfast, Northern Ireland. MAIN OUTCOME MEASURES: The perceived complication rate and the perceived gain in life expectancy from coronary angioplasty. RESULTS: Although most subjects had asked the consultant questions, 70% (n = 104) thought that they contributed negligibly or not at all to the treatment decision. Although 75% (n = 112) recalled discussing the complication rate from the procedure, only 27% accurately estimated this rate (as between 0.5 and 1.5%). Eighty eight per cent (n = 131) thought that their mortality risks would be substantially or greatly reduced by having the procedure. The patients anticipated a gain in life expectancy of some 10 years (median) and this was significantly in excess of the potential gain in life expectancy which dietary prudence to lower blood cholesterol, not smoking, and taking more exercise might produce (median 5 years respectively; P < 0.0001, Wilcoxon matched pairs signed rank test). CONCLUSIONS: Patients vastly overrate the capacity of angioplasty to control their disease: angioplasty is seen as more effective than risk factor modification.

Adult↗
PubMed1996

Patients' prerogatives and perceptions of benefit.

Patients today demand more information about their treatment. Doctors, however, seem reluctant to cast aside ingrained habits of paternalism, believing they can best interpret therapeutic choices for their patients. Whether doctors can be more objective and effective than patients in interpreting the "probabilities" of medical evidence is open to question. On the other hand, the exercise of choice by patients may itself have a bearing on the probabilities of outcome. Involving patients more in making therapeutic choices is justified if doctors can present options in an unbiased and effective manner and if the process improves the outcome of the care delivered.

Attitude to Health↗
PubMed1996

Natural history of reflux oesophagitis: a 10 year follow up of its effect on patient symptomatology and quality of life.

BACKGROUND: Although oesophagitis is the most common diagnosis made at upper gastrointestinal endoscopy, data on the longterm outcome of affected patients are sparse. AIMS: This study assessed the level of reflux symptoms, quality of life, drug consumption, and complications in patients at least 10 years after diagnosis of oesophagitis at one centre. PATIENTS: One hundred and fifty two patients with typical reflux symptoms and a first time diagnosis by endoscopy of grade I-III oesophagitis between 1981 and 1984, were followed up using a postal questionnaire and telephone interview. RESULTS: Eighteen of 152 patients had died, 33 failed to respond, and 101 replied (mean follow up 11 years, range 121-160 months). Over 70% of patients still had heartburn at least daily (32%) or weekly (19%) or required daily acid suppression treatment (20%). Two patients (2%) had developed oesophageal strictures and one had Barrett's oesophagus. Two of eight quality of life scores (physical function and social function) measured by the Short Form-36 were significantly lower than Northern Ireland population scores. CONCLUSION: Nearly three quarters of patients previously diagnosed as having oesophagitis still had significant morbidity related to gastro-oesophageal reflux disease more than 10 years after diagnosis. Some quality of life scores were significantly lower than those of the general population.

Adult↗
PubMed1996

Socioeconomic circumstances and the risk of bowel cancer in Northern Ireland.

OBJECTIVE: To describe the variation in the incidence of colorectal cancer across Northern Ireland and relate it to factors associated with community deprivation. DESIGN: This was a cross sectional descriptive study. SETTING: Incidence data were obtained from a population based register for the period 1990-91. Small areas were characterised by their "affluence", or lack of it, by deriving a Townsend deprivation score for each electoral ward, using information from the 1991 census. PARTICIPANTS, MAIN OUTCOME MEASURES, AND STATISTICAL METHODS: The age standardised incidence was calculated for all colorectal cancer cases diagnosed histologically in 1990-91. Electoral wards were grouped into quintiles of the population after ranking of their Townsend scores and the association with incidence was studied using Poisson regression. RESULTS: The age standardised colorectal cancer incidence ranged from 22.5 (for quintile 1) to 29.9/100,000 (quintile 5) for men but the trend for women was less regular and rates were 18.4, 23.8, 27.3, 26.5, and 23.9/100,000 for quintiles 1-5 respectively (that is, from the most "affluent" to the most "deprived" fifths of the population). After adjusting for age and sex in Poisson regression, there was a significant association between the total colorectal cancer incidence and levels of community deprivation. The rate ratio for the most deprived quintile of the population (compared with the least) was 1.28 (95% CI 1.06,1.53). The effect was stronger for rectal cancer than for colonic cancer. There was no association between community deprivation and the cancer stage at diagnosis. CONCLUSIONS: In this population, the colorectal cancer incidence is associated with the level of material deprivation. The disease stages at the time of diagnosis in patients from more deprived areas seem to be comparable with those of patients from affluent areas. As others have shown, associations such as these are not explicable entirely on the basis of the distribution of known risk factors. Further research is needed to determine plausible mechanisms for the association.

Adolescent↗
PubMed1995

Prevention and detection of oral cancer: the views of primary care dentists in Northern Ireland.

Our objective was to describe the management of oral cancer and pre-cancer as stated by primary care dentists and their views on screening. We conducted a survey of all general dental practitioners and community dentists in Northern Ireland (n = 635), to which 428 replied (response rate: 67%). 94% stated that examination of the oral soft tissues constituted part of their usual practice during the regular dental check-up. Suspicious lesions were generally referred early, 68.5% of dentists referring white lesions within one month of presentation. The corresponding figures for red lesions, lumps and persistent ulcers were 80.1%, 89.7% and 91.7%. The incidence of oral cancer was over-estimated (median '70' cases/year, versus the true figure of approximately 40/year) as, in all likelihood, was the percentage by which mortality could be reduced by screening (median: 50%). Accordingly the adoption of a screening programme was favoured over investment in health promotion. Indeed, only 14% said that their patients records routinely contained information about smoking or alcohol habits. Although there are some areas of practice which could improve and the potential of screening is probably over-valued, primary care dentists in Northern Ireland already opportunistically screen and refer patients promptly.

Alcohol Drinking↗
PubMed1995

Treatment of angina pectoris in the community: is medical therapy given a chance?

OBJECTIVE: To describe the routine management of patients with chronic stable angina by GPs in Northern Ireland and the factors which they perceived affected the success of medical therapy. DESIGN: A questionnaire survey of all general practitioners in Northern Ireland (n = 962). SETTING: A survey conducted collaboratively by the Departments of Public Health Medicine in each of the four Health Boards in the province. Total population served, 1.5 million. MAIN OUTCOME MEASURES: The relationship between the perceived reasons for medical treatment failure and the stated referral and prescribing practice of the GPs. RESULTS: A total of 541 GPs replied; the response rate was 56%. The two most important reasons given for the perceived failure of medical therapy were (i) underlying disease progression and (ii) an adverse patient lifestyle such as smoking or obesity (cited as of primary importance by (i) 264 and (ii) 225 doctors respectively). The ranking differed significantly according to the doctor's propensity to prescribe triple therapy, with those doctors in the highest tertile of this distribution being less likely to cite the patient's lifestyle as a primary reason for treatment failure (chi-squared = 6.7, d.f. = 2, P = 0.035) and more likely to cite underlying disease progression as a primary reason (chi-square = 7.0, d.f. = 2, p = 0.031). The overall ranking of the primary reasons for referral differed significantly according to the proportion of patients given a trial of triple therapy and to the doctor's propensity to refer. Doctors who had given a greater proportion of their patients at least a trial of triple therapy (in the highest tertile of the distribution) were more likely to cite the need for revascularisation assessment as the primary reason (chi-square = 12.5, d.f. = 2, P = 0.0019). On the other hand, the need for further advice on medical therapy was generally ranked higher by those doctors who had given fewer of their patients at least a trial of triple therapy (chi-square = 7.3, d.f. = 2, P = 0.027). GPs who had referred fewer of their new patients to hospital were more likely to be those doctors with fewer patients given at least a trial of triple therapy. Doctors with a greater percentage of their patients managed primarily by a hospital specialist tended to have more who had had a trial of triple therapy for their symptoms. CONCLUSIONS: The results suggest the need for clearer definition for GPs of the place of revascularisation and of medical therapy for patients with stable angina.

Angina Pectoris↗
PubMed1995

Expanding access to coronary artery bypass surgery: who stands to gain?

OBJECTIVE: To determine the perceptions of general practitioners (GPs) about the benefits of coronary artery bypass surgery, in terms of gains in life expectancy, for different groups of patients. DESIGN: A questionnaire survey of all GPs in Northern Ireland. SETTING: A survey conducted collaboratively by the departments of public health medicine in each of the four health boards in the province, serving a total population of 1.5 million. MAIN OUTCOME MEASURES: The median and mean gain in life expectancy perceived by groups of doctors for smoking and non-smoking male and female 55 year old patients. The percentage of 50 year old and 70 year old non-smoking patients considered likely to have their lives extended with bypass surgery. Differences were assessed using the Mann-Whitney U test for unpaired samples and the Wilcoxon signed rank tests for paired. RESULTS: 541 GPs replied (response rate 56%). The median (and mean) perceived gain in life expectancy after cardiac surgery for non-smoking 55 year old subjects was 120 (104) months for men and 120 (112) months for women (z = 6.42; P < 0.0001; Wilcoxon signed rank test). For male and female smokers of the same age, the perceived gains were 48 (47) and 60 (52) months respectively (z = 6.72; P < 0.0001; Wilcoxon signed ranks test), both figures being significantly different than for non-smokers. The median (and mean) percentage of patients that the doctors considered would have their lives extended by bypass surgery was 70 (64) of every 100 "young" patients and 40 (42) of every 100 "old" patients, (z = 16.2; P < 0.0001). CONCLUSIONS: These results point to a significant overestimation of the benefits of coronary artery bypass surgery by GPs in Northern Ireland and to a need to develop guidelines for referral.

Age Factors↗
PubMed1995

Are the economically active more deserving?

OBJECTIVE: To investigate the possibility of an association between the duration of medical treatment before coronary angiography and demographic and non-clinical factors. DESIGN: A systematic review of a random sample of 500 patients undergoing their first angiographic assessment. SUBJECTS: 500 cases were selected randomly from patients investigated in 1991 at the two catheterisation centres in Northern Ireland. MAIN OUTCOME MEASURES: The duration of medical management before angiography. RESULTS: 346 had elective and 154 urgent catheterisation. The duration of medical management was adjusted for both case mix (age at onset, body mass index, angina grade, history of myocardial infarction, history of hypertension, diabetes or hyperlipidaemia, treatment intensity) and other demographic variables (sex, smoking status, an indicator of "deprivation", and distance of the patient's area of residence from the hospital). After this adjustment the mean duration of medical management before angiography was twice as long for economically inactive patients as for those who were economically active. In a multiple regression, the relevant beta coefficient was 0.44 (95% confidence interval 0.33 to 0.58, P < 0.0001). CONCLUSIONS: These results suggest that, in making discretionary decisions about when to refer patients with angina for revascularisation assessment, doctors may be influenced by non-clinical factors unrelated to disease severity.

Age Factors↗
PubMed1995

Predictors for waiting time for coronary angioplasty in a high risk population.

Objective--To describe the clinical and non-clinical factors which influence the waiting time from initial angiography to angioplasty. Design--Follow up of a random sample of 106 patients undergoing their first coronary angiography for whom a decision to revascularise by percutaneous transluminal angioplasty was made in 1991. The period between the date of angiography and the date of angioplasty and various clinical characteristics of patients were retrieved from medical notes in mid 1993. Patients were sampled from those investigated in the two Northern Ireland catheterisation laboratories in Belfast, which provide services for the whole of the province (population 1.5 million). Main measures--The dependent variable was the period between initial angiography and angioplasty, and the independent variables included age, sex, distance from cardiac catheterisation centre, referral source, characteristics of the clinical history, severity of angina, and anatomical extent of disease. Cox's proportional hazards analysis was used to derive a relative hazard, expressing the relative chances of revascularisation occurring at any time during follow up. Results--Of the 106 patients studied, 93 had had percutaneous transluminal angioplasty at follow up. The most important predictors of waiting time were the presence of severe angina (relative hazards 3.1(95 % confidence interval (95% CI) 1.4-6.8) and 2.7(1.2-6.2) for Canadian Cardiovascular grades III and IV v angina grade I angina), a recent history of myocardial infarction (relative hazard, 2.5(1.3-4.8), and whether or not the patient was economically active (relative hazard 0.6(0.4-1.0) for economically inactive v active patients). Although there was also an association with the relative deprivation of the area of residence of the patient it had no clear linear trend. Conclusions--Although waiting time for percutaneous transluminal angioplasty was predictably related to the patient's clinical presentation, demographic factors may also be important in determining access to intervention. These factors clearly merit further study; ultimately, the evaluation of equity in a waiting time distribution may more properly be a societal rather than a clinical judgment.

Angioplasty, Balloon, Coronary↗
PubMed1995

The effect of diet on lipid, apoprotein and lipoparticle variation in the ECTIM study in Belfast.

The objective of the study was to evaluate the contribution of dietary factors to variation of plasma levels of lipids, apoproteins and lipoparticles in the Northern Ireland population. This study was part of a larger case-control study of the genetic and environmental determinants of myocardial infarction in France and Northern Ireland. A random sample of 175 middle aged men was drawn from the population covered by the Belfast MONICA project register. Habitual diet was assessed by a questionnaire. A blood sample was obtained after an over-night fast for determination of plasma levels of lipids, apoproteins and lipoparticles. All participants had a medical examination and completed a lifestyle questionnaire. In a stepwise regression, after adjusting for co-factors (i) vitamin C and (ii) alcohol consumption were the only nutrients which contributed significantly to the variation in, respectively, (i) Total Cholesterol, LDL Cholesterol and Apolipoprotein B (inverse correlation) and (ii) HDL Cholesterol and LpAI (positive correlation). The amount of variation explained by the final models was modest, ranging from 4% to 15%. In conclusion, in this Northern Ireland population, habitual diet contributes to little of the variation in plasma levels of lipids, apoproteins and lipoparticles.

Adult↗
PubMed1995

Priority for coronary artery surgery: who gets by-passed when demand outstrips capacity?

We investigated the clinical and non-clinical factors which influence the waiting time from initial angiography to bypass surgery, by follow-up of a random sample of 141 patients undergoing their first coronary angiography, for whom a decision to revascularize was made in 1991. The period between the date of angiography and the date of surgery, and a variety of clinical patient characteristics, were retrieved from medical notes in mid-1993. Patients were sampled from those investigated in the two Northern Ireland catheterization laboratories in Belfast, both of which were served by one local surgical centre. Of the 141 patients studied, 86 had had surgery at follow-up. The most important predictors of waiting time were: the presence of severe stenosis of the left main-stem coronary artery [relative hazards, 3.4 (1.6-7.3)], the presence of unstable angina at the time of angiography, [relative hazards, 2.2 (0.97-5.0)], age at angiography, [relative hazards, 2.2 (1.1-4.2) for > 65 years vs. < 50 years], having a positive family history of premature coronary artery disease in a first-degree relative, [relative hazards, 1.8 (1.1-2.9)] and smoking habit at angiography, [relative hazards 0.6 (0.3-1.1), for current vs. never/ex-smokers]. More weight appears to be given to maximizing life extension rather than its quality enhancement in determining who gets priority for surgery. The exception to this may be in regard to smokers, and purchasers might find it useful to set targets for secondary prevention activities with respect to such patients.

Age Factors↗
PubMed1994

Synergistic effects of angiotensin-converting enzyme and angiotensin-II type 1 receptor gene polymorphisms on risk of myocardial infarction.

We reported from our previous multicentre case-control study that the deletion (D) polymorphism of the gene encoding angiotensin-converting enzyme (ACE) was associated with increased risk of myocardial infarction. The main function of ACE is to convert angiotensin I into angiotensin II, which exerts its known cellular actions through the angiotensin II AT1 receptor subtype (AGT1R). We have now investigated the role of a common polymorphism of the AT1 receptor gene (an A-->C transversion at position 1166 of AGT1R) and looked for an interaction between ACE and AGT1R gene polymorphisms on the risk of myocardial infarction. We analysed DNA from 613 patients with myocardial infarction and 723 age-matched population controls. We found a significant interaction between ACE and AGT1R gene polymorphisms; the odds ratio for myocardial infarction associated with the ACE DD genotype was 1.05 (95% CI 0.75-1.49) for subjects without the AGT1R C allele, 1.52 (1.06-2.18) in AC heterozygotes, and 3.95 (1.26-12.4) in CC homozygotes (test for trend, p < 0.02). Among patients defined as low risk by traditional risk factors (serum apolipoprotein B < 1.25 g/L, body-mass index < 26 kg/m2) the interaction was even stronger (odds ratios 1.64 [0.68-3.92], 7.03 [2.61-19.0], and 13.3 [p = 0.05], respectively). These findings, if confirmed, could have clinical implications for the prevention and treatment of coronary heart disease.

Adult↗
PubMed1994

A community outbreak of echovirus infection associated with an outdoor swimming pool.

Forty-six people became ill with vomiting, diarrhoea and headache within days of an outdoor swimming pool opening for the summer season in a small seaside village. During the weekend of the outbreak, 185 tickets to the pool had been sold. It was found that 34 bathers were ill, and one subject had vomited into the pool. All other cases arose after this incident. The risk of infection was greatest among those who swallowed pool water (24/28 versus 10/17, p = 0.07). Echovirus 30 was isolated from the case who vomited into the pool and from six other cases. Normal chlorine levels had not been adequate to contain the infection risk from vomitus, and, in future, pool attendants witnessing such incidents should consider closing the pool to the public and seeking advice on superchlorination.

Adolescent↗