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Biomedical subjects

Gene Feder

Publications and source records attributed to Gene Feder.

At least 19 recordsLinked to original sources
PubMed2006

Cardiothoracic ratio within the "normal" range independently predicts mortality in patients undergoing coronary angiography.

OBJECTIVE: To determine whether cardiothoracic ratio (CTR), within the range conventionally considered normal, predicted prognosis in patients undergoing coronary angiography. DESIGN: Cohort study with a median of 7-years follow-up. SETTING: Consecutive patients undergoing coronary angiography at Barts and The London National Health Service (NHS) Trust. SUBJECTS: 1005 patients with CTRs measured by chest radiography, and who subsequently underwent coronary angiography. Of these patients, 7.3% had a CTR > or =0.5 and were excluded from the analyses. OUTCOMES: All-cause mortality and coronary event (non-fatal myocardial infarction or coronary death). Adjustments were made for age, left ventricular dysfunction, ACE inhibitor treatment, body mass index, number of diseased coronary vessels and past coronary artery bypass graft. RESULTS: The risk of death was increased among patients with a CTR in the upper part of the normal range. In total, 94 (18.9%) of those with a CTR below the median of 0.42 died compared with 120 (27.8%) of those with a CTR between 0.42 and 0.49 (log rank test p<0.001). After adjusting for potential confounders, this increased risk remained (adjusted HR 1.45, 95% CI 1.03 to 2.05). CTR, at values below 0.5, was linearly related to the risk of coronary event (test for trend p = 0.024). CONCLUSION: In patients undergoing coronary angiography, CTR between 0.42 and 0.49 was associated with higher mortality than in patients with smaller hearts. There was evidence of a continuous increase in risk with higher CTR. These findings, along with those in healthy populations, question the conventional textbook cut-off point of > or =0.5 being an abnormal CTR.

Anthropometry↗
PubMed2006

Prognosis of stable angina pectoris: why we need larger population studies with higher endpoint resolution.

The prognosis of angina was described as "unhappy" by the Framingham investigators and as little different from that of 1-year survivors of acute myocardial infarction. Yet recent clinical trials now report that angina has a good prognosis with adverse outcomes reduced to "normal levels". These disparate prognostic assessments may not be incompatible, applying as they do to population cohorts (Framingham) and selected participants in clinical trials. Comparisons between studies are further complicated by the absence of agreed case definitions for stable angina (contrast this with acute coronary syndromes). Our recent data show that for patients with recent onset symptoms attending chest pain clinics, angina remains a high-risk diagnosis and although many patients receive symptomatic benefit from revascularisation, prognosis is usually unaffected. This leaves little room for complacency and, with angina the commonest initial manifestation of coronary artery disease, there is the opportunity for early detection, risk stratification and treatment to modify outcomes. Meanwhile, larger population-based studies are needed to define the patient journey from earliest presentation through the various syndrome transitions to coronary or noncardiac death in order to increase understanding of the aetiological and prognostic differences between the different coronary disease phenotypes.

Age Distribution↗
PubMed2006

Systematic review: prognosis of angina in primary care.

BACKGROUND: Angina is a common chronic condition, largely managed in primary care in the UK. Mortality data are predominately from population or hospital studies with little known about the prognosis of angina in general practice settings. OBJECTIVE: To describe the prognosis of angina in patients identified in primary care. METHODS DESIGN: Systematic review of cohort studies of angina in primary care. Data sources. Medline, PsycINFO, EMBASE, CINAHL, HMIC, WOS, IBSS, UK National Research Register, notification via JISC, CHAIN. REVIEW METHODS SELECTION CRITERIA: Cohort studies of patients with angina, with >12 months of follow-up, recruited within primary care. VALIDITY ASSESSMENT: Database searches and abstracts were reviewed independently by two authors. Papers were assessed according to criteria derived from the cohort methodological literature. DATA ABSTRACTION: Data were abstracted by two reviewers. DATA SYNTHESIS: Narrative summary. A quantitative synthesis was planned. MAIN OUTCOME MEASURES: Total and cardiovascular death; non-fatal myocardial infarction (MI). RESULTS: Six studies fulfilled our selection criteria. The annual total mortality rate is 2.8-6.6%, an annual cardiovascular death rate of 1.4-6.5% and an annual non-fatal MI rate of 0.3-5.5%. A quantitative synthesis was not possible, because the studies were clinically heterogeneous. CONCLUSIONS: The primary studies have value in determining the prognosis of patients with angina recruited in general practice; however, the studies are old, have small numbers of events and are clinically heterogeneous. The contemporary prognosis of angina in primary care remains a key question, and further research is, therefore, required to estimate the prognosis of angina in this setting and its determinants.

Angina Pectoris↗
PubMed2006

Comparison of the relation between renal impairment, angiographic coronary artery disease, and long-term mortality in women versus men.

Mild to moderate renal impairment has recently been associated with increased cardiovascular mortality. However, gender differences in the association of mild to moderate renal impairment with the presence of angiographic coronary artery disease and long-term mortality remain unknown. We examined a prospective cohort of consecutive patients who underwent coronary angiography from the ACRE study in the Royal Hospitals Trust (London, United Kingdom) with referral from 5 contiguous health authorities. Among 1,609 patients (465 women) who had angiographic and serum creatinine measurements at baseline, renal impairment at modification of diet in renal disease glomerular filtration rates of 45 to 59, 30 to 44, and <30 ml/min/1.73 m(2) was more common in women than in men and was significantly associated with the presence of angiographic coronary artery disease in women but not in men. At each level of glomerular filtration rate, multivariate adjusted hazard ratios of 7-year all-cause mortality for women compared with men were higher: 2.64 (95% confidence intervals [CI] 1.21 to 5.73) versus 1.34 (95% CI 0.995 to 1.79); 2.62 (95% CI 1.12 to 16.12) versus 2.35 (95% CI 1.60 to 3.43); and 10.42 (95% CI 3.97 to 27.39) versus 4.77 (95% CI 2.95 to 7.70), respectively. Similar patterns were observed in cardiovascular and coronary deaths. In conclusion, mild to moderate renal impairment may be a marker for unmeasured proatherogenic factors for women only, and women may bear a greater mortality burden that is attributable to renal impairment compared with men. Gender may influence the prognostic effect of renal impairment in coronary disease.

Aged↗
PubMed2005

Recruiting patients to medical research: double blind randomised trial of "opt-in" versus "opt-out" strategies.

OBJECTIVE: To evaluate the effect of opt-in compared with opt-out recruitment strategies on response rate and selection bias. DESIGN: Double blind randomised controlled trial. SETTING: Two general practices in England. PARTICIPANTS: 510 patients with angina. INTERVENTION: Patients were randomly allocated to an opt-in (asked to actively signal willingness to participate in research) or opt-out (contacted repeatedly unless they signalled unwillingness to participate) approach for recruitment to an observational prognostic study of patients with angina. MAIN OUTCOME MEASURES: Recruitment rate and clinical characteristics of patients. RESULTS: The recruitment rate, defined by clinic attendance, was 38% (96/252) in the opt-in arm and 50% (128/258) in the opt-out arm (P = 0.014). Once an appointment had been made, non-attendance at the clinic was similar (20% opt-in arm v 17% opt-out arm; P = 0.86). Patients in the opt-in arm had fewer risk factors (44% v 60%; P = 0.053), less treatment for angina (69% v 82%; P = 0.010), and less functional impairment (9% v 20%; P = 0.023) than patients in the opt-out arm. CONCLUSIONS: The opt-in approach to participant recruitment, increasingly required by ethics committees, resulted in lower response rates and a biased sample. We propose that the opt-out approach should be the default recruitment strategy for studies with low risk to participants.

Adult↗
PubMed2005

How do clinical nurse specialists influence primary care management of asthma? A qualitative study.

METHODS: We carried out a qualitative interview study alongside a randomised controlled trial which tested the effectiveness of asthma nurse specialists in east London. We carried out face-to-face interviews with five asthma nurse specialists, eight general practitioners (GPs) and six practice nurses, and also held a focus group session with six people who had attended hospital with acute asthma. RESULTS: Four factors were associated with effective specialist nurse liaison: (1) primary care practices which prioritised asthma care; (2) GPs who trusted practice nurses to manage chronic disease autonomously; (3) GPs who recognised specialist nurse expertise and acted on their advice; and (4) practices which had simple systems in place to deal with recommendations. Patients found nurse specialists approachable and informative. CONCLUSIONS: Asthma specialist nurse influence was greatest in practices that prioritised asthma care and where practice nurses had clinical autonomy. Patients valued specialist nurses but found advice from a multiplicity of clinicians confusing. Ensuring that practices prioritise chronic disease care, and improving the credibility of nurse specialists amongst GPs, may improve the effectiveness of asthma nurse specialists.

Journal Article↗
PubMed2005

Why modelling a complex intervention is an important precursor to trial design: lessons from studying an intervention to reduce falls-related injuries in older people.

OBJECTIVES: To develop a cost-effectiveness model of a complex intervention from pilot study data in order to inform the viability and design of a subsequent falls prevention trial. METHODS: We used two models; the first estimated the probability of falling over a 12-month period based on a probability tree; the second used Markov simulation to assess the impact of the programme over time. RESULTS: The first model indicated that our intervention would reduce the proportion falling by only 2.8% over a 12-month period. The major reason for this small effect was that less than a quarter of older people at risk of falling were assessed using our screening tool. Even if policy-makers were willing to spend 30,000 pounds per quality-adjusted life-year gained, there is only a 40% chance that the intervention would be cost-effective. Sensitivity analyses showed that the only scenarios that produced a substantial increase in the effect of the intervention were those in which all older people are assessed. CONCLUSIONS: The model-building approach described in this paper is vital when designing complex trials and where a trial is not possible. Information from the modelling can be used to re-design the intervention. The effectiveness of our proposed intervention appears very small due to its inability to reach those at risk of falling. It is most likely not to be cost-effective. If inability to reach the target group is a weakness common to other similar interventions, this suggests an area for further research.

Accidental Falls↗
PubMed2005

Ethical principles and the rationing of health care: a qualitative study in general practice.

BACKGROUND: Researching sensitive topics, such as the rationing of treatments and denial of care, raises a number of ethical and methodological problems. AIM: To describe the methods and findings from a number of focus group discussions that examined how GPs apply ethical principles when allocating scarce resources. DESIGN OF STUDY: A small-scale qualitative study involving purposive sampling, semi-structured interviews and focus groups. SETTING: Twenty-four GPs from two contrasting areas of London: one relatively affluent and one relatively deprived. METHOD: Initial interviews asked GPs to identify key resource allocation issues. The interviews were transcribed and themes were identified. A number of case studies, each illustrative of an ethical issue related to rationing, were written up in the form of vignettes. In focus group discussions, GPs were given a number of these vignettes to debate. RESULTS: With respect to the ethical basis for decision making, the findings from this part of the study emphasised the role of social and psychological factors, the influence of the quality of the relationship between GPs and patients and confusion among GPs about their role in decision making. CONCLUSION: The use of vignettes developed from prior interviews with GPs creates a non-threatening environment to discuss sensitive or controversial issues. The acceptance by GPs of general moral principles does not entail clarity of coherence of the application of these principles in practice.

Adult↗
PubMed2005

Randomised controlled trial of a lay-led self-management programme for Bangladeshi patients with chronic disease.

BACKGROUND: Reducing the impact of chronic disease in minority ethnic groups is an important public health challenge. Lay-led education may overcome cultural and language barriers that limit the effectiveness of professionally-led programmes. We report the first randomised trial of a lay-led self-management programme - the Chronic Disease Self-Management Programme (CDSMP) (Expert Patient Programme) - in a south Asian group. AIM: To determine the effectiveness of a culturally-adapted lay-led self-management programme for Bangladeshi adults with chronic disease. DESIGN OF STUDY: Randomised controlled trial. SETTING: Tower Hamlets, east London. METHOD: We recruited Bangladeshi adults with diabetes, cardiovascular disease, respiratory disease or arthritis from general practices and randomised them to the CDSMP or waiting-list control. Self-efficacy (primary outcome), self-management behaviour, communication with clinician, depression scores, and healthcare use were assessed by blinded interviewer-administered questionnaires in Sylheti before randomisation and 4 months later. RESULTS: Of the 1363 people invited, 476 (34%) agreed to take part and 92% (439/476) of participants were followed up. The programme improved self-efficacy (difference: 0.67, 95% confidence interval [CI] = 0.08 to 1.25) and self-management behaviour (0.53; 95% CI = 0.01 to 1.06). In the 51% (121/238) of intervention participants attending three or more of the 6-weekly education sessions the programme led to greater improvements in self-efficacy (1.47; 95% CI = 0.50 to 1.82) and self-management behaviour (1.16; 95% CI = 0.50 to 1.82), and reduced HADS depression scores (0.64; 95% CI = 0.07 to 1.22). Communication and healthcare use were not significantly different between groups. The programme cost pound123 (181) per participant. CONCLUSION: A culturally-adapted CDSMP improves self-efficacy and self-care behaviour in Bangladeshi patients with chronic disease. Effects on health status were marginal. Benefits were limited by moderate uptake and attendance.

Adult↗
PubMed2004

Prospective validity of measuring angina severity with Canadian Cardiovascular Society class: The ACRE study.

BACKGROUND: Although the prevalence of angina remains high, the importance of grading angina severity is unclear. OBJECTIVES: To determine the extent to which angina severity is associated with angiographic findings, and the rate of revascularization, mortality and nonfatal myocardial infarction. METHODS: Prospective, population-based study with a 2.5-year follow-up of 2849 consecutive patients with angina undergoing coronary angiography at Barts and the London NHS Trust, London, United Kingdom, in the Appropriateness of Coronary Revascularisation (ACRE) study. Angina severity was assessed with the Canadian Cardiovascular Society (CCS) classification, ranging from class I (mild) to IV (severe). Outcome measures were revascularization rates, and all-cause mortality and nonfatal myocardial infarction. RESULTS: In age-adjusted analyses, a higher CCS class was linearly associated (P<0.001) with a higher number of diseased vessels and impaired left ventricular function. When adjusting for age, sex, smoking, history of hypertension, diabetes, number of diseased vessels, left ventricular function, use of acetylsalicylic acid, beta-blockers or statins, and revascularization status (for death and nonfatal myocardial infarction), a higher CCS class was linearly associated with higher coronary angioplasty (P<0.001) and bypass graft (P=0.03) rates, and lower all-cause mortality and nonfatal myocardial infarction (P<0.001; CCS IV versus I: hazard ratio 2.44, 95% CI 1.46 to 4.09). CONCLUSION: CCS class was linearly associated with angiographic findings, revascularization rates, mortality and nonfatal myocardial infarction. These findings support the importance of a four-level grading of symptom severity among angina patients.

Angina Pectoris↗
PubMed2004

Is patient involvement possible when decisions involve scarce resources? A qualitative study of decision-making in primary care.

Greater patient involvement has become a key goal of health care provision. This study explored the way in which general practitioners (GPs) in the UK manage the dual responsibilities of treating individual patients and making the most equitable use of National Health Service (NHS) resources in the context of the policy of greater patient involvement in decision-making. We undertook a qualitative study incorporating a series of interviews and focus groups with a sample of 24 GPs. We analysed GP accounts of decision-making by relating these to substantive ethical principles and the key procedural principle of explicitness in decision-making. GPs saw patient involvement in positive terms but for some GPs involvement served an instrumental purpose, for instance improving patient 'compliance'. GPs identified strongly with the role of patient advocate but experienced role tensions particularly with respect to wider responsibilities for budgets, populations, and society in general. GPs had an implicit understanding of the key ethical principle of explicitness and of other substantive ethical principles but there was incongruence between these and their interpretation in practice. Limited availability of GP time played an important role in this theory/practice gap. GPs engaged in implicit categorisation of patients, legitimating this process by reference to the diversity and complexity of general practice. If patient involvement in health care decision-making is to be increased, then questions of scarcity of resources, including time, will need to be taken into account. If strategies for greater patient involvement are to be pursued then this will have significant implications for funding primary care, particularly in terms of addressing the demands made on consultation time. Good ethics and good professional practice cost money and must be budgeted for. More explicit decision-making in primary care will need to be accompanied by greater explicitness at the national level about roles and responsibilities. Increased patient involvement has consequences for GP training and ways of addressing rationing dilemmas will need to be an important part of this training. Further research is needed to understand micro-decision-making, in particular the spaces in which processes of implicit categorisation lead to distorted communication between doctor and patient.

Access to Information↗
PubMed2004

Development and preliminary examination of the predictive validity of the Falls Risk Assessment Tool (FRAT) for use in primary care.

BACKGROUND: There is no validated assessment of an older person's risk of falling that is easily applied in primary care. We aimed to develop a two-part tool for use in primary care or the community. Part 1 includes a rapid assessment of the individual's risk of falling for administration by clinical or non-clinical staff. Part 2 (for clinical staff) includes guidance on further assessment, referral and interventions. We assessed the predictive validity of part 1. METHODS: The tool was developed by an expert panel following the updating of an existing systematic review of community-based prospective studies identifying risk factors for falling and modified in accordance with the feedback from extensive piloting. We assessed predictive validity by a questionnaire survey sent at baseline and 6 months to a random sample of 1000 people aged over 65 in one Primary Care Group area. RESULTS: Five items were included in part 1: history of any fall in the previous year, four or more prescribed medications, diagnosis of stroke or Parkinson's disease, reported problems with balance, inability to rise from a chair without using arms. The presence of three or more risk factors had a positive predictive value for a fall in the next 6 months of 0.57 (95 per cent confidence interval 0.43-0.69). Less than three risk factors had a negative predictive value of 0.86 (0.82-0.89), and a specificity of 0.92 (0.88-0.94). CONCLUSION: The tool may be useful for identifying people who would benefit from further assessment of their risk of falling and appropriate intervention.

Accident Prevention↗
PubMed2004

Influence of practices' ethnicity and deprivation on access to angiography: an ecological study.

BACKGROUND: Coronary heart disease is more common among some ethnic minority groups (particularly people from the Indian sub-continent living in Europe and North America) and in socially deprived populations. Hospital studies in the United Kingdom (UK) suggest that these groups have less access to treatment for coronary heart disease. Studies from primary care have found reduced access to angiography for lower social class groups, but there are no studies on the ethnicity of primary care populations in relation to angiography. AIMS: To determine the influence of ethnicity and social deprivation in primary care on access to coronary angiography. DESIGN OF STUDY: Ecological study measuring general practices' ethnicity, socioeconomic status, and nitrate prescribing rates with angiography rates. SETTING: General practices (n = 143) in East London, UK. METHOD: Ecological study measuring the proportion of general practice populations with South Asian ethnicity and high social deprivation score (Carstairs). Nitrate prescriptions and admissions for myocardial infarction per 1000 population per year were used as measures of need. Distance from the tertiary centre was used as a measure of supply. The outcome measure was coronary angiography procedures data (n = 869) collected in the context of the appropriateness of coronary revascularisation study. RESULTS: Practices with a higher proportion of South Asian patients had higher rates of angiography after adjustment for age, distance, deprivation, nitrate prescribing and myocardial infarction admissions (regression coefficient B = 0.02, 95% confidence interval [CI] = 0.01 to 0.03, P<0.001). There was no association between deprivation and angiography (regression coefficient B = -0.41, 95% CI = -0.13 to 0.05, P = 0.393). CONCLUSION: General practices with a higher proportion of South Asian patients had higher rates of angiography, challenging the widely held belief that access may be inequitable. Deprivation shows no relationship with angiography in this study.

Coronary Angiography↗