Biomedical subjects

H Doll

Publications and source records attributed to H Doll.

At least 19 recordsLinked to original sources

PubMed2005

Assessment of the Lequesne index of severity for osteoarthritis of the hip in an elderly population.

OBJECTIVE: To assess the measurement properties of the Lequesne index of severity for osteoarthritis of the hip (LISOH) together with its overall usefulness with reference to the original stated aims. METHOD: Postal questionnaire was sent to a random sample of 5500 Oxfordshire residents, aged 65 and above. Respondents with hip symptoms at baseline (but without verification of a diagnosis) were sent an identical follow-up questionnaire 12 months later. The questionnaire included a general health section, including the Short Form-36 survey, and a hip section which began with a screening question about hip pain. Respondents who reported having a prolonged episode of hip pain were asked to complete the LISOH. RESULTS: At baseline, response rate of 66.3% (3341/5039) was obtained from eligible participants; 19.2% (610/3175) of respondents reported having hip pain. Internal reliability (Cronbach's alpha) was 0.84 (95% CI: 0.81-0.86) for all 11 items of the LISOH; however, factor analysis identified two factors (sub-scales): "function and mobility" and "pain and discomfort". Rasch analysis revealed that the two factors were only unidimensional when applied to sub-groups of respondents. Convergent validity of the LISOH was questionable, as the "function and mobility" factor was more highly correlated with SF-36 bodily pain score than was the "pain and discomfort" factor. The assessment of sensitivity over time was problematic due to changing patterns of symptomatic weight-bearing joints over time. CONCLUSIONS: The current study identifies major limitations with the LISOH--particularly if used as a single composite measure.

Aged↗

PubMed2004

Skin cancers in renal-transplant recipients occur more frequently than previously recognized in a temperate climate.

BACKGROUND: Renal-transplant recipients are at increased risk of developing skin cancers, especially squamous cell carcinoma. We have carried out a comprehensive epidemiologic review of skin cancers occurring in a population receiving transplants in Oxford over a 21-year period, where nearly all patients have remained under the care of the Oxford Transplant Centre. METHODS: Between 1975 and 1996, 1,360 renal transplants were performed in 1,115 patients. Skin cancer data were reviewed in 979 patients from this group who remained under the care of the Oxford Transplant Centre. The lesions included in the analysis were histologically confirmed basal cell carcinoma, Bowen's disease, squamous cell carcinoma, keratoacanthoma, malignant melanoma, Merkel cell tumor, and sebaceous carcinoma. RESULTS: One hundred eighty-seven (19.1%) transplant patients developed at least one skin malignancy. The rate of skin cancer was 141 per 1,000 person years at risk. Sixty-four percent of patients with skin cancer had multiple lesions (maximum 50). Squamous cell carcinoma was the most common skin cancer to develop and the most common first skin cancer to present. The mean time to presentation of the first skin cancer was 8 years. Six patients developed nodal metastases, and two patients died secondary to skin cancer. Risk factors identified were increasing age at transplantation, recipient sex, total time of exposure to immunosuppression, increased creatinine levels at 1 year, and graft relation. The cumulative incidence of skin cancer reached 61% at 20 years after transplantation. CONCLUSION: The data from this study suggest that more patients develop skin malignancies than previously reported from Europe. It is important to advise patients before transplantation in regard to skin complications, provide regular dermatological follow-up, and tailor immunosuppressive regimen to minimum doses to be compatible with good graft function.

Carcinoma, Squamous Cell↗

PubMed2003

The impact of screening for Type 2 diabetes in siblings of patients with established diabetes.

BACKGROUND: Targeted screening for Type 2 diabetes has been proposed as a method of identifying people with, or at risk of, the disease in order to implement preventive care. AIM: To assess the changes in anxiety, well-being, and cognitions associated with screening for Type 2 diabetes in people at increased risk of diabetes after 1 year; and to identify potential predictors of increased anxiety and lower well being over this period. DESIGN AND SETTING: One-year follow up of a cohort of non-diabetic siblings of those with Type 2 diabetes registered with general practitioners in Oxfordshire and Northamptonshire who were identified for participation in a programme to undertake sib-pair genetic analysis. METHODS: Potential families were selected through identification of people with Type 2 diabetes. Family members aged 35-74 years, who did not have diabetes and who were willing to participate in the study, completed measures before receiving the results of a fasting plasma glucose test, and 1 year later. Measures included the Spielberger State Anxiety Scale-short form (SSAI-SF), the Well-Being Questionnaire 12 item scale (WBQ-12), and measures of cognitions about developing diabetes. The Health Anxiety Inventory (HAI) was completed before receiving the results of the tests to assess its relationship with anxiety at 1 year. RESULTS: A cohort of 431 individuals was identified, of whom 328 (76%) returned fully completed WBQ scales both initially and at 1 year. State anxiety measured with the SSAI-SF fell from 34.5 (95% CI 33.4-35.6) to 32.3 (31.2-33.4) at 1 year (P < 0.0001). Mean WBQ-12 scores rose (i.e. improved) from 26.8 (26.0-27.4) to 27.4 (26.7-28.1) (P = 0.008). SSAI-SF and WBQ-12 mean scores over 1 year did not differ between participants receiving a normal or an at-risk test result. However, those receiving an at-risk test result were more likely, at 1 year, to consider themselves at increased likelihood of developing diabetes (P < 0.001) and to report thinking about what it would be like to develop diabetes (P = 0.006). A score in the upper tertile of the initial HAI was associated with an increased level of anxiety at 1 year (adjusted odds ratio 2.0, 95% CI 1.2-3.4, P = 0.006). CONCLUSIONS: There is no evidence that an 'at-risk' test result leads to sustained anxiety or reduced well being at 1 year compared with those receiving a normal test result. However, further studies are required to clarify levels of anxiety prior to screening to assess the overall impact of the process.

Adult↗

PubMed2002

The level of haemoglobin in anaemic cancer patients correlates positively with quality of life.

The aim of this study was to assess the relationship between haemoglobin level and quality-of-life in anaemic cancer patients. Patients, diagnosed with one of four cancers, were recruited if their haemoglobin level was <12 g dl(-1) (female) or <13 g dl(-1) (male). The condition-specific Functional Assessment of Cancer Therapy-Anaemia and the generic SF-36 were used to assess quality-of-life. Thirty-six per cent of the 179 recruited patients had breast cancer, 28% ovarian cancer, 25% lung cancer, and 11% multiple myeloma. Their mean (s.d.) haemoglobin level was 10.66 (1.04) g dl(-1). Partial correlations controlling for the potentially confounding effects of age, gender, and time since diagnosis found significant positive relationships between haemoglobin and all domains of the Functional Assessment of Cancer Therapy-Anaemia, and with all but two of the SF-36 domains. On linear regression controlling for the same factors, each unit haemoglobin rise equalled an average 8.19 Functional Assessment of Cancer Therapy-Anaemia, and an average 6.88 Functional Assessment of Cancer Therapy-Fatigue, increase. Haemoglobin accounted for a similar amount of variability (8%) in SF-36 scores. In conclusion, quality-of-life has been found to be significantly positively related to haemoglobin level in anaemic cancer patients. This suggests that normalisation of haemoglobin in cancer patients is likely to increase their quality-of-life. The greater sensitivity of the condition-specific Functional Assessment of Cancer Therapy-Anaemia compared with the generic SF-36 suggests that the Functional Assessment of Cancer Therapy-Anaemia can be used alone to assess quality-of life in this patient group.

Adult↗

PubMed2002

Characteristics and outcome of membranous nephropathy in older patients.

Many patients with idiopathic membranous nephropathy are elderly, but little is known about the natural or treated history of these patients. We have studied a cohort of 155 patients with membranous nephropathy who were recruited and followed-up over a 20 year period. We have compared the clinical features and outcome of the older (>60 years) and younger age groups. There was a higher incidence of an identifiable cause for the nephropathy in older patients. At presentation with idiopathic disease, older patients were more often hypertensive and had worse renal impairment than the younger cohort, but had a similar levels of proteinuria, hypoalbuminemia and hematuria. Thrombotic complications and minor rheumatological complaints were more common in the older patients. Prognosis for life and renal survival was worse in the older onset patients. Treatment was well tolerated in selected older patients and was associated with a better outcome in those selected for treatment.

Adrenal Cortex Hormones↗

PubMed2002

Quality of life in acute exacerbation of chronic bronchitis: results from a German population study.

This study reports on data from a study conducted in the Federal Republic of Germany examining the quality of life (QoL) of patients with chronic bronchitis (CB) and its acute exacerbations (AECB). Data from 320 patients were collected at AECB and subsequently during a stable phase (non-AECB) utilizing the St George's Respiratory Questionnaire (SGRQ) and the Nottingham Health Profile (NHP). As expected, the QoL of CB patients was poor, even at non-AECB, with patients reporting lower scores than patients with other chronic conditions. Patients reported significantly poorer QoL at AECB than at non-AECB. After adjusting for the severity of the underlying condition, poorer QoL at AECB was significantly and independently associated with older age, unemployment, increasing BMI, increasing number of prior AECBs, and Anthonisen AECB grade. While younger subjects reported significantly greater deterioration in QoL at AECB, the factors most consistently and independently associated with relative QoL deterioration at AECB were the number of prior AECBs and exposure to air pollution at home. In conclusion, this study highlights the detrimental effect of CB, and in particular AECB, on QoL. The association between QoL and patient reports of previous AECB number and air pollution are consistent with reports from other studies.

Acute Disease↗

PubMed2001

Public awareness and health education: findings from an evaluation of health services for incontinence in England.

Improving the health and well being of local populations is a feature of international and national health policy and initiatives. Promotion of health has been attempted traditionally via health education and public awareness campaigns. More recently, attention has been drawn to inter-agency collaboration and alliances in formalised health improvement programmes. This study has evaluated health services for incontinence in two health authorities in England in relation to health education and public awareness. One health authority had an established continence service and the other did not. A convenience sample of self selecting respondents from an earlier postal survey were interviewed via the telephone (n=376). Significantly, more people in the health authority with a continence service than the one without received information on incontinence from within formal health services (p<0.001) and read about services in health centres and clinics (p<0.001), whereas people in the health authority without a continence service were more likely to obtain information on incontinence from local newspapers (p<0.01) and local chemist shops (p<0.01). People in the health authority without a continence service were significantly more likely to feel that services could be improved than those where there was a service (p<0.0001). Only a minority of people with incontinence had received information about their condition or related health care and services. The availability of a continence service significantly influenced the information received. More information on incontinence had been obtained from informal sources than formal health sources. Local initiatives on the availability of services and how to access them, as well as health education information on incontinence may be more effective in raising public awareness and should supplement national campaigns.

Adult↗

PubMed2001

Recognition of environmental and genetic effects on barley phenolic fingerprints by neural networks.

Through computational analysis of high-performance liquid chromatography (HPLC) traces we find correlations between secondary metabolites and growth conditions of six varieties of barley. Using artificial neural networks, it was possible to classify chromatograms for which the varieties were fertilized by nitrogen and treated by fungicide. For each variety of barley we could also differentiate it from the others. Surprisingly, all these classification tasks could be solved successfully by a simple network with no hidden units. When adding to the methodology pruning of the network weights, we were able to reduce the set of peaks in the chromatograms and obtain a necessary subset from which the growth conditions and differentiation may be decided. In some instances, more complex networks with hidden units could lead to a further reduction of the number of peaks used. In most cases, far more than half of the peaks are redundant. We find that it requires fewer information-rich peaks to perform the variety differentiation tasks than to recognize any of the growth conditions. Analysis of the network weights reveals correlations between weighted combinations of peaks.

Chromatography↗

PubMed2001

Domestic violence: a comparative survey of levels of detection, knowledge, and attitudes in healthcare workers.

The objective of this study was to compare the knowledge, attitudes, responses and levels of detection of domestic violence among a variety of healthcare workers in different specialities.Self-administered questionnaires were sent to community and hospital based healthcare workers in Oxfordshire working in primary care, obstetrics and gynaecology, mental health and accident and emergency. These comprised all principal general practitioners and general practitioner registrars, 50% of practice/district nurses and health visitors in each practice, and all healthcare workers in obstetrics and gynaecology, community mental health teams and accident and emergency in one trust. The amount of domestic violence detected in different healthcare settings was far less than indicated by anonymous surveys and crime figures. Knowledge about many of the issues surrounding domestic violence was inconsistent and there were fundamental deficiencies. The attitudes of healthcare workers to domestic violence were generally sympathetic and supportive. Women, nurses and community mental health workers reported significantly better knowledge and more positive attitudes than other respondents. Gender, role and speciality were independently associated with more positive attitudes and the latter two were independently associated with good knowledge. The response that healthcare workers make when they uncover domestic violence is confused and often inappropriate. In conclusion, most healthcare workers accept that domestic violence is a healthcare issue but lack fundamental knowledge about the issues surrounding domestic violence itself and appropriate agencies that can offer help. They also lack skills in identifying and discussing this issue with patients/clients. A large, unfulfilled training need has been identified.

Attitude of Health Personnel↗

PubMed2001

Return of fertility in nulliparous women after discontinuation of the intrauterine device: comparison with women discontinuing other methods of contraception.

OBJECTIVE: To clarify the effect of the using the intrauterine device on fertility in nulliparous women. DESIGN: Prospective cohort study of two groups of nulliparous women, one recruited while using an intrauterine device and the other while using an oral contraceptive. SETTING: Seventeen family planning clinics in England and Scotland. SAMPLE: 1,071 nulliparous, married women, aged 18-40 years, 558 of whom contributed information to the main objective of the study. METHODS: The women were recruited between 1982 and 1985 and followed up annually to 1994. Dates and reasons for any contraceptive method changes (which were most frequently to barrier methods) were recorded, together with the outcome of any pregnancies, at each follow up. MAIN OUTCOME MEASURES: The number of nulliparous women giving birth at term after stopping contraception (oral contraceptive, intrauterine device or barrier method) in order to conceive. RESULTS: Women who stopped using a barrier method to achieve a planned pregnancy conceived most quickly: 54% were delivered after one year vs 39% of intrauterine device and 32% of oral contraceptive users (log rank P = 0.002). There was no association between fertility and duration of oral contraceptive use: However, short term intrauterine device users (< 42 months) showed a fertility pattern more favourable than seen in those discontinuing oral contraceptives, with increasing duration of intrauterine device use being associated with decreasing fertility (linear trend P = 0.005); the fertility of women who had used the intrauterine device for 78 + months was the most impaired (28% were delivered by 12 months vs 46% of short term users; at 36 months the corresponding figures were 79% vs 91%). This association remained after adjusting for potential confounding factors, including maternal age, husband's social class, and history of gynaecological illnesses, factors which themselves had independent associations with fertility. CONCLUSIONS: Long term intrauterine device use in nulliparous women appears to be associated with an increased risk of fertility impairment.

Adolescent↗

PubMed2000

Prevalence of urinary incontinence and its relationship with health status.

A postal survey of two random samples of adult populations within two health authorities in the UK was undertaken during 1994. One health authority had an established continence advisory service (HA1) and the other one did not have a continence advisory service (HA2). A total of 12,529 patients (HA1, 6319; HA2, 6210) were mailed a structured questionnaire and 53% (n = 6139) returned completed questionnaires. A point prevalence of current urinary incontinence of 9% (n = 519, 95% CI, or confidence interval, from 7.9% to 9.3%) was found. A large number of people within the populations had experienced urinary incontinence at some time during their adult years (23%, n = 1427, 95% CI from 22.2% to 24.3%). People who were incontinent had a significantly lower health status than people who were continent (mean scores across all eight domains of the Short Form 36, SF36, P < 0.0001), indicative of greater health and social care needs. The prevalence of urinary incontinence in the adult populations of two communities indicates that it is a sizeable public health and primary healthcare issue.

Activities of Daily Living↗

PubMed2000

The health of students in institutes of higher education: an important and neglected public health problem?

BACKGROUND: A survey of students in three UK higher education establishments was undertaken to obtain information about students' physical and emotional well-being, their attitudes to, and beliefs about health, and the prevalence of risk factors for future ill health. METHODS: Health was measured by the prevalence of longstanding illness and by the SF-36 health status measurement tool. Survey results were compared with equivalent data for 18- to 34-year-olds in the local population. The prevalence of long-standing illness was also compared with two national surveys. RESULTS: The survey achieved a 49 per cent response rate. More than one-third of respondents reported a long-standing illness, a higher prevalence than in all comparison surveys. Students scored significantly worse than their peers in the local population on all eight SF-36 dimensions. The greatest difference was for role limitations as a result of emotional problems. The main sources of emotional distress were study or work problems and money. CONCLUSION: The poor response rate in this survey dictates the need for caution in interpretation of the results. However, they suggest that the health of students is poor relative to that of their peers, and that their emotional health is more of a problem than their physical health. Public health practitioners might want to pay more attention to the health of this important and relatively neglected group. Worries about studies and money appear to be affecting students' academic work, and this should be of concern to higher education establishments.

Adolescent↗

PubMed1999

Help seeking behaviour and health and social services utilisation by people suffering from urinary incontinence.

It is estimated that urinary incontinence can effect up to 23% of the population at some time during their adult years, with 9% currently experiencing symptoms. This study found that the majority of sufferers had spoken to or had contacted their GP about their incontinence, and that people currently suffering from incontinence were significantly more likely to have seen their GP within the last month than those who were continent. Help seeking behaviour was also influenced by the severity of incontinence, with people suffering from severe incontinence significantly more likely to have sought help than those with light to moderate incontinence. Two thirds of sufferers who did not seek help were too embarrassed to do so. Significantly more people who were incontinent that did not seek help in a health authority without an established continence service did not know that health services were available, compared with those in a health authority having an established continence service. It is important for health care providers to ensure that the public knows what services are on offer and how to access them. Significantly more incontinence sufferers in the health authority with an established continence service chose not to seek help from a health professional compared with those in the health authority without service, which could indicate there was an element of informed choice in not accessing the services available. Significantly more people who were incontinent than continent required help with their activities of daily living and personal self care. They were also significantly more likely than those who were continent to require formal and informal contacts provided by health services, local authority, the church or voluntary sector. It is important that people suffering from incontinence have their health and social needs assessed so that services can be effectively targeted.

Activities of Daily Living↗

PubMed1999

Lifestyle factors and continence status: comparison of self-report data from a postal survey in England.

OBJECTIVE: To compare health and lifestyle factors of people with and without urinary incontinence (UI). DESIGN: A postal survey was undertaken that represents the first of a 3-stage project designed to evaluate the health interventions of primary health care teams and continence advisory services on patient outcomes related to UI. SETTING AND SUBJECTS: Two random samples of adult populations (N = 12,529) were included, generated from the family physician patient registers within 2 health authorities in England. INSTRUMENTS: Data were collected using a structured questionnaire that queried demography, perceived health status, activities of daily living, self-care, and use of local health and social services. Information was also collected on past and present continence status. METHODS: Structured questionnaires and a cover letter were mailed to the target population. Two reminders were sent to nonresponders to maximize the response rate. MAIN OUTCOME MEASURES: The main measures relate to factors associated with UI: mobility, sleep, childbirth, smoking, diet, body mass index, and accommodation. RESULTS: Significantly more women than men had UI (P < .0001). Respondents with UI were older than those who were continent (P < .0001). Women with UI were significantly more likely to have a greater number of pregnancies (P < .0001), were more likely to have given birth to a baby weighing more than 9 lb (P < .01), and to have had more than 4 children (P = .01) compared with women who were continent. People with UI were less likely to be single and more likely to be widowed than those who were continent (P < .0001). People who lived alone and who had UI were also significantly less likely to have a relative or friend that they could depend on for help than those who were continent (P < .001). UI was also found to be significantly associated with impaired mobility (P < .0001) and sleeping difficulties (P < .0001). No meaningful differences were found between diet and UI, although significantly more people with UI had higher mean body mass index, were obese, or reported that they felt too heavy for their height when compared with people who were continent (P < .0001). No association was found in the present study with smoking or ethnicity and UI. CONCLUSIONS: Key health and lifestyle factors associated with UI included age, gender, childbirth, mobility, sleep patterns, obesity, living alone, and access to help. These factors should be assessed when planning and implementing health care for persons with UI. Attention to these associated factors may prove useful in identifying new cases or people at risk of developing UI when screening people as part of routine health checks. This, in turn, could assist with targeting effective and efficient health care but may also contribute to prevention for some people.

Activities of Daily Living↗

PubMed1998

Leg extensor power and quadriceps strength: an assessment of repeatability in patients with osteoarthritic knees.

OBJECTIVE: To assess the repeatability of two muscle function measures -- leg extensor power (LEP) and isometric quadriceps force (IQF) -- in a population of patients with osteoarthritis of the knee. DESIGN: Repeat measures of LEP and IQF at 25 degrees and 50 degrees knee flexion were taken within seven days. Both legs were measured and a numerical rating scale was used to assess pain on the two occasions. SUBJECTS: Patients who were on a waiting list for a primary unilateral knee replacement for osteoarthritis were invited to take part in the study. SETTING: The physiotherapy department of a National Health Service Orthopaedic Hospital in Oxford, UK. INTERVENTION: Subjects were measured using a Kin-Com dynamometer to assess maximum isometric force and a leg extensor power rig to assess maximum single leg explosive power. RESULTS: Twenty-six patients (mean age: 72 years; SD: 8 years; range: 50-87 years) were included in the study following informed consent. A weak relationship was found between LEP, IQF and pain scores which reached the 5% significance level for the LEP measures only. The level of repeatability for both measures was found to be acceptable. CONCLUSION: Both LEP and IQF are recommended as repeatable measures for assessment of muscle function in patients with osteoarthitis of the knee. However, the LEP rig has the added advantage of being quicker, cheaper and simpler to use in the clinical setting.

Aged↗

PubMed1997

Evaluation of index and profile measures of health status in a randomized controlled trial. Comparison of the Medical Outcomes Study 36-Item Short Form Health Survey, EuroQol, and disease specific measures.

OBJECTIVES: The authors compare two generic measures of health status with disease-specific measures in a randomized controlled trial of transurethral resection of the prostate with laser vaporization prostatectomy for benign prostatic hypertrophy. METHODS: Patients entered into the trial completed the following questionnaires prior to treatment and at follow-up at 3 months and 1 year. The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) is a generic measure that produces an eight-dimension profile as well as two summary measures of health status (the physical component score and the mental component score). The EuroQol provides two single index measures of health status; one intended to convey the utility (or lack of) that an individual derives from his or her own health state compared with alternative states and a second simple visual analog scale "thermometer" of health status. The American Urological Association symptom score and the Bothersome index are disease-specific indices of health status for use specifically with benign prostatic hypertrophy patients. RESULTS: The EuroQol indicates no statistically significant improvements with time for either arm of the trial. The SF-36 physical and general health perceptions domains indicates statistically significant improvements for the transurethral resection of the prostate arm alone at 3 months and 1 year, as do the physical summary score at the 3-month follow-up visit. The effect sizes of these improvements, however, are small, using standard criteria. In contrast, statistically significant differences are found with time for both transurethral resection of the prostate and laser prostatectomy on both disease-specific measures, which also indicate statistically significant superior outcome for the transurethral resection of the prostate arm compared with the laser arm. CONCLUSIONS: The results indicate that the disease-specific measures are more sensitive to change than the generic measures of outcome. Possible explanations for this are discussed.

Follow-Up Studies↗

PubMed1996

Relationship between health status and postoperative return to work.

BACKGROUND: Time back to work or normal activity is often regarded as an outcome measure of interest after surgery. It has recently been used as a way of quantifying the benefits of minimal access surgery. However, the extent to which variation in time back to normal reflects differences in health status is unclear. METHODS: The relationship was examined in 140 patients recovering from inguinal hernia repair. A multi-dimensional measure of health status, the Short Form 36 (SF-36), was administered preoperatively, and at ten days and six weeks postoperatively. The relationship between scores on the SF-36 dimensions and return to normal activity was examined using correlation statistics and stepwise regression. RESULTS: Health status dimensions measuring role limitation owing to physical restriction at 10 days and 6 weeks, and role limitation owing to mental problems at ten days were associated with time to return to normal on univariate analysis. Social class was also strongly associated. Using stepwise regression these two dimensions of health status together explained 33 per cent of the variance in time to normal. Other factors unrelated to health status clearly contributed to this outcome. CONCLUSION: Time back to normal activity postoperatively is influenced by a number of factors unrelated to health status and is an unreliable proxy for it. Time to normal is therefore, not a good outcome measure for quantifying the benefits of surgical interventions. Claims currently being made to justify investment in some minimal access interventions should be interpreted in the light of this.

Activities of Daily Living↗

PubMed1995

The effects of fundholding in general practice on prescribing habits three years after introduction of the scheme.

OBJECTIVES: To observe changes in prescribing practice that occurred after the introduction of fundholding in first wave practices and to contrast these with changes occurring in similar non-fundholding practices. DESIGN: Prospective observational study. SETTING: Oxford region fundholding study. SUBJECTS: Eight first wave fundholding practices and five practices that were not interested in fundholding in 1990-1, which were similar in terms of practice size, training status, locality, and urban rural mix. Three of the fundholding and none of the non-fundholding practices were dispensing practices. MAIN OUTCOME MEASURES: Changes in prescribing practice as measured by net cost per prescribing unit, cost per item, number of items prescribed, and substitution rates for generic drugs three years after the introduction of fundholding. Data for fundholding practices were analysed separately according to whether they were dispensing or non-dispensing practices. RESULTS: Prescribing costs rose by a third or more in all types of practice. The patterns of change observed in this cohort after one year of fundholding were reversed. No evidence existed that fundholding had controlled prescribing costs among non-dispensing fundholders; costs among dispensing fundholders rose least, but the differences were small compared with the overall increase in costs. CONCLUSIONS: Early reports of the effectiveness of fundholding in curbing prescribing costs have not been confirmed in this longer term study.

Drug Costs↗