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Biomedical subjects

J L Botha

Publications and source records attributed to J L Botha.

At least 19 recordsLinked to original sources
PubMed2001

Characteristics of non-responders to diabetes service use questionnaires.

Postal surveys of service use are likely to overestimate health service use and may also underestimate health needs in the population. A historical cohort study, using postal questionnaires and medical records, showed that non-respondents are registered at addresses in more-deprived wards, they are less likely to have attended a hospital diabetes clinic (38% vs 45%) and much less likely to have had a diabetes review in general practice (11% vs 26%). An analysis based on questionnaire respondents would only therefore both underestimate the level of material deprivation and overestimate the proportion receiving routine reviews in general practice in a population with a chronic condition.

Bias↗
PubMed2001

Breast and cervical cancer survival: making sense of "league tables".

During 1998, the Department of Health proposed to use survival rates of cervical and breast cancer in the 1989/90 incidence cohort as indicators of care. Valid interpretation was of concern within Trent and the Trent Cancer Registry responded by performing additional analyses. Trent Cancer Registry registrations for 1989/90 were re-analysed and the stability of districts' ranks for that cohort was investigated using random simulation techniques. Stability of ranks across more recent cohorts was investigated and attempts made to use all available information. The Department of Health's analyses were confirmed by our re-analysis of the 1989/90 cohort: Rotherham residents appeared to have the "worst" survival for cervical cancer, and Sheffield residents for breast cancer, although not statistically significantly so. Random simulations indicated that ranks based on a single cohort are not stable: for example Sheffield (ranked tenth for 1-y breast cancer survival) was ranked third or better in 6% of randomisations. Ranks were also unstable across cohorts: for example Rotherham 1-y cervical cancer survival was ranked tenth for 1989/90, fifth for 1991/92 and tenth for 1993/94. Analysis of 3-y running averages provided better information than the league table approach. Most districts improved over time, to different degrees, and similar sized gaps remained between the "best" and the "worst" districts. This analysis illustrates the need to be circumspect when interpreting "league tables" based on a single year or cohort analysis. League tables are based on ranks: clearly a large difference in rank may reflect only trivial (ie medically unimportant) differences in actual outcome. Lack of a statistically significant difference in survival between two districts does not mean their survival is equivalent. Even for a common cancer, like breast cancer, rankings were unstable from cohort to cohort. At the Registry we propose to perform these trend analyses routinely in future, adjusting, when possible, for the effects of deprivation and stage at diagnosis.

Breast Neoplasms↗
PubMed2000

Inequalities in access to diabetes care: evidence from a historical cohort study.

OBJECTIVE: To establish which factors predict attendance at a hospital diabetes clinic and for diabetes review in general practice. DESIGN: A historical cohort study of individuals with diabetes identified from general practice records. Information on service contacts and other clinical, social, and demographic variables was collected from general practice records and postal questionnaires. SETTING: Seven Leicestershire general practices. SUBJECTS: Individuals registered with study practices who had a diagnosis of diabetes made before 1990. MAIN OUTCOME MEASUREMENTS: Attendance at a hospital diabetes clinic or for a documented diabetes review in general practice at least once between 1990 and 1995. RESULTS: 124 (20%) had at least one recorded diabetes review in general practice and 332 (54%) attended a hospital diabetes clinic at least once. The main predictors of attending a hospital clinic were younger age, longer duration of diabetes, and treatment with insulin. Access to a car (OR 1.34, 95% CI 1.06 to 1.71), home ownership (OR 1.48, 95% CI 1.14 to 1.58) and a non-manual occupation (OR 1.56, 95% CI 1.09 to 2.24) were all associated with an increased likelihood of attending, although living in a less deprived area was not. The main predictors of attending for review in general practice were older age, less co-morbidity, and being white. Living in a more deprived area was related to a reduced chance of review in general practice (OR 0.81, 95% CI 0.76 to 0.86) while individual socioeconomic indicators were not. CONCLUSIONS: Whilst an indicator of area deprivation predicts reduced likelihood of review in general practice, individual indicators predict reduced likelihood of attending outpatients. This suggests a need for different approaches to tackling inequalities in access to care in primary and secondary care settings.

Aged↗
PubMed1999

The British Diabetic Association Cohort Study, I: all-cause mortality in patients with insulin-treated diabetes mellitus.

AIMS: To assess mortality in patients with diabetes incident under the age of 30 years. METHODS: A cohort of 23 752 diabetic patients diagnosed under the age of 30 years from throughout the United Kingdom was identified during 1972-93 and followed up to February 1997. Following notification of deaths during this period, age- and sex-specific mortality rates, attributable risks and standardized mortality rates were calculated. RESULTS: The 23 752 patients contributed a total of 317 522 person-years of follow-up, an average of 13.4 years per subject. During follow-up 949 deaths occurred in patients between the ages of 1 and 84 years, 566 in males and 383 in females. All-cause mortality rates in the patients with diabetes exceeded those in the general population at all ages and within the cohort were higher for males than females at all ages except between 5 and 15 years. The relative risk of death (standardized mortality ratio, SMR), was higher for females than males at all ages, being 4.0 (95% CI 3.6-4.4) for females and 2.7 (2.5-2.9) for males overall, but reaching a peak of 5.7 (4.7-7.0) in females aged 20-29, and of 4.0 (3.1-5.0) in males aged 40-49. Attributable risks, or the excess deaths in persons with diabetes compared with the general population, increased with age in both sexes. CONCLUSIONS: This is the first study from the UK of young patients diagnosed with diabetes that is large enough to calculate detailed age-specific mortality rates. This study provides a baseline for further studies of mortality and change in mortality within the United Kingdom.

Adolescent↗
PubMed1999

The British Diabetic Association Cohort Study, II: cause-specific mortality in patients with insulin-treated diabetes mellitus.

AIMS: To measure cause-specific mortality, by age, in patients with insulin-treated diabetes incident at a young age. METHODS: A cohort of 23 752 patients with insulin-treated diabetes diagnosed under the age of 30 years, from throughout the United Kingdom, was identified during 1972-93 and followed to February 1997. Death certificates have been obtained for deaths during the follow-up period and cause-specific mortality rates and standardized mortality ratios by age and sex are reported. RESULTS: During the follow-up period 949 deaths occurred and at all ages mortality rates were considerably higher than in the general population. Acute metabolic complications of diabetes were the greatest single cause of excess death under the age of 30 years. Cardiovascular disease was responsible for the greatest proportion of the deaths from the age of 30 years onwards. CONCLUSIONS: Deaths in patients with diabetes diagnosed under the age of 30 have been reported and comparisons drawn with mortality in the general population. To reduce these deaths attention must be paid both to the prevention of acute metabolic deaths and the early detection and treatment of cardiovascular disease and associated risk factors.

Adolescent↗
PubMed1999

Do diabetes clinic attendees stay out of hospital? A matched case-control study.

AIMS: To examine whether routine care for diabetes mellitus influences the risk of hospital admission. METHODS: All people with diabetes in five randomly selected general practices in the city of Leicester were identified from medical records and prescribing information. Cases with a hospital admission between 1992 and 1995 but no admission in the preceding 2 years were compared with age-matched controls in a nested study. RESULTS: The variables significantly associated with an increased risk of admission were duration of diabetes in years (OR 1.07, 95% confidence interval (CI) 1.03-1.11) and number of non-diabetic drugs prescribed (OR 1.51, 95% CI 1.27-1.79). Having attended a hospital clinic in the previous 2 years was associated with reduced risk of admission (OR 0.30, 95% CI 0.14-0.65), whilst having been seen for a diabetes review in general practice was not (OR 0.91, 95% CI 0.41-1.99). Similar results were found for both diabetes-related and unrelated admissions. CONCLUSIONS: Although general practice-based review was not associated with a change in the risk of admission, attendance at a hospital clinic was associated with a decreased risk of admission. These results may be explained by the characteristics of those who attend hospital clinics, as well as by the possible effectiveness of access to specialist services in reducing admissions.

Adolescent↗
PubMed1999

The 1996 Leicestershire Community Stroke & Ethnicity Study: differences and similarities between South Asian and white strokes.

OBJECTIVE: To estimate the number of strokes in Leicestershire and investigate possible differences between South Asian and white patients. DESIGN: Prospective incidence sample survey. SETTING: Leicestershire. PARTICIPANTS: Acute stroke cases occurring in registered populations of 12 'high Asian' and 11 'low Asian' general practices. RESULTS: The age-specific incidence rates of stroke in Leicestershire were similar to those of the Oxford Community Stroke Project. South Asian patients were less likely to be living alone at home before their stroke and they tended to be younger than whites. However, only 12% of South Asian patients with a stroke were not admitted to hospital within 7 days of their stroke compared to 23% of white patients (chi2 = 3.24, d.f. = 1, P = 0.07). Only 21% of South Asian patients died within 28 days of their stroke compared to 33% of white patients (age-adjusted odds ratio = 0.37; 95% CI: 0.14-0.97). CONCLUSIONS: Overlapping case-finding was crucial to finding all 'possible' strokes and this required close collaborative working between general practices, community health services, hospitals and the health authority. Relatively fewer South Asian patients were managed in the community in the first 7 days. Interestingly, South Asian patients were less likely than white patients to die within 28 days. This is an area worthy of further research.

Adolescent↗
PubMed1999

Partial remission phase of diabetes in children younger than age 10 years.

There is renewed interest in the phase of partial remission in recently diagnosed diabetes because of the potential for pharmacological and immune intervention to preserve beta cell function. 95 children younger than 10 years were investigated to assess the influence of age, sex, diabetic ketoacidosis (DKA), admission at diagnosis, and ethnicity on the frequency of remission and insulin requirements during the first two years after diagnosis. Partial remission was defined as a requirement of insulin < 0.5 U/kg body weight/day. There was partial remission in 41 patients, with no differences for children aged 2-4 years and those aged 5-9 years. None of the five children aged < 2 years remitted. Forty five of 95 children were admitted to hospital at diagnosis, of whom 26 of 45 had DKA (blood pH < 7.25). In this number of children we were unable to show a statistical difference in the rate of remission with respect to DKA, admission to hospital at diagnosis, sex, or South Asian ethnic background. There were no differences in insulin requirements between the different groups by the end of two years and at that time seven of the children required insulin < 0.5 U/kg/day. The results suggest that even in preschool children there is potential for attempting to preserve beta cell function.

Age Factors↗
PubMed1997

A Survey of the Dietary Management of Children's Diabetes.

A cross-sectional survey of dietitians using a structured postal questionnaire was sent to 148 dietitians who provided a service to children with diabetes. One hundred and twenty-two (82%) replied, of whom 50 were paediatric dietitians (4 paediatric diabetes dietitians) and 72 were other grades. One hundred and eighteen (97%) dietitians reviewed newly diagnosed children within 24-48 hours of diagnosis but only 81 (66%) used literature specifically designed for children. The majority 116 (95%) felt they worked within a multidisciplinary team. Only 15 (12%) dietitians used purely qualitative carbohydrate dietary education; the remainder used quantitative methods, e.g. 10 g exchange system. Ninety-one (75%) used carbohydrate exchange lists. High fibre foods were suggested but dietitians felt only a moderate intake was achievable. One hundred and twelve (92%) recommended a reduced fat intake but guidance was not as unanimous on reducing specific fatty acids. Objective assessment of dietary outcomes was limited. Paediatric dietitians compared with other grades were more likely to use innovative methods of education but no other differences in dietary practice existed. A minority of dietitians 17 (18%) felt families would find implementing the diet easy. The survey confirmed national inconsistencies in dietary messages and poor evaluation of patient compliance. Research is required into effective dietary counselling to support evidence-based practice.

Child↗
PubMed1997

Effectiveness of influenza vaccine in reducing hospital admissions in people with diabetes.

The effectiveness of influenza vaccination in reducing hospitalization of people with diabetes for influenza, pneumonia, or diabetic events during influenza epidemics was assessed in a case control study in Leicestershire, England. Cases were 80 patients on the Leicestershire Diabetes Register who were admitted and discharged from hospital with International Classification of Disease codes for pneumonia, bronchitis, influenza, diabetic ketoacidosis, coma and diabetes, without mention of complications, during the influenza epidemics of 1989-90 and 1993. One hundred and sixty-controls, who were not admitted to hospital during this period, were randomly selected from the Register. Immunization against influenza was assessed in 37 cases and 77 controls for whom consent was obtained to access their clinical notes and for whom notes were available. Significant association was detected between reduction in hospitalization and influenza vaccination during the period immediately preceding an epidemic. Multiple logistic regression analysis estimated that influenza vaccination reduced hospital admissions by 79% (95% CI 19-95%) during the two epidemics, after adjustment for potential confounders.

Adolescent↗
PubMed1997

How do individuals with diabetes use the accident and emergency department?

OBJECTIVE: To determine whether the frequency and pattern of use of the accident and emergency (A&E) department by individuals with diabetes is different from that of the general population. METHODS: A historical cohort of 696 individuals with diabetes from six randomly selected general practices and a non-diabetic comparison cohort matched on age, sex, and general practice were identified. The use of an urban A&E department by the two cohorts was compared for number of visits between 1984 and 1996 for injuries, diabetes related and non-diabetes related illness, proportion referred by a general practitioner, proportion arriving by ambulance, and proportion admitted. RESULTS: More visits were made by the diabetic cohort (1002 v 706, P = 0.0001); 121 visits were directly related to diabetes, including 52 for hypoglycaemia. The diabetic cohort also had more visits for medical illness unrelated to diabetes (357 v 231, P = 0.0001). The number of visits for injuries was similar (524 v 475, P = 0.3). Individuals with diabetes who attended A&E were not significantly more likely to be referred by a general practitioner (14% v 16%) or admitted (20% v 17%). CONCLUSIONS: Individuals with diabetes made more frequent visits than the general population to the A&E department. Since there was no excess of visits for injuries and the proportion requiring admission was similar, the hypothesis that they have a different threshold for attending is not supported.

Adolescent↗
PubMed1996

Why don't all general practices offer structured diabetes care? A comparison of practices that do not with those that do.

The aim of the study was to examine whether the minority of practices not qualifying for payment for structured diabetes care programmes differ systematically from those that do. Information was collected for all Leicestershire general practices on practice size, population structure, deprivation indices, diabetes related admissions over two years and number of insulin treated patients on the district register. The 21 practices not offering structured diabetes care had a median list size of 3204, compared to 6340 for the other 124 practices (P < 0.001). Jarman and Townsend scores were higher for these practices and estimated prevalence of diabetes was 29% higher (95% CI: 26-32%). Crude admission rates were significantly higher in those practices not offering structured care. However rates adjusted for diabetes prevalence were similar (39.3 vs 39.2 per 100 insulin treated diabetics per year, P = 0.9). These results suggest that some practices face specific problems related both to small practice size and higher prevalence. If these issues are not addressed, inequalities in access to diabetes care between practice populations will persist. There is no evidence that the provision of structured care is associated with lower admission rates in this district. However more information, particularly in relation to prevalence of diabetes, is needed in order to accurately quantify this relationship. Variations in prevalence between practices should be adjusted for in any comparison of admission rates or spurious conclusions may be drawn.

Diabetes Mellitus↗
PubMed1996

Death certification: production and evaluation of a training video.

The purpose of this study was to produce an effective training video on death certification suitable for use by medical students and postgraduates. A 15-minute video was commissioned from a video production unit and two authors (PA and CP) provided advice and support in the process of script writing and production. An evaluation by means of a randomized controlled trial took place among 185 first year medical students at the University of Leicester. The video was shown as an addition to the usual lecture on death certification. Performance in a test of knowledge, skill and motivation was recorded in each of the two groups. Students assigned to see the video scored slightly better overall in a test of knowledge and skill (difference in medians = 3, in a test marked out of 68, P = 0.046). The intervention group also gave a significantly higher priority to avoiding distress caused to relatives as a reason for certifying death accurately (60% vs. 35%, difference in proportions = 24%, P = 0.002). There was no evidence that enjoyment or views about the nature or content of the video had an impact on performance in the test. It is concluded that adding the video to the usual lecture had a limited effect on the overall knowledge and skills of undergraduate students but was highly effective in conveying the message that inaccurate death certification can cause distress to relatives. The randomized controlled trial is a practical and simple means of evaluating teaching methods for medical undergraduates.

Death Certificates↗
PubMed1995

Trends in mortality of childhood-onset insulin-dependent diabetes mellitus in Leicestershire: 1940-1991.

The relative risk of death by calendar date of diagnosis was investigated in a population-based incident cohort of 845 (463 males:382 females) IDDM diagnosed in Leicestershire before the age of 17 years between 1940 and 1989. The mortality status of 844 (99.9%) patients was determined as of the 31 December 1991, representing 14,346 person-years of risk. Trends in relative risk of death were investigated using Cox proportional hazards modelling for within cohort comparisons and age/sex and calendar time adjusted standardized mortality ratios (SMR) using generalized linear modelling for external comparisons. Median age at diagnosis was 10 years (range 3 months to 16 years); median duration of diabetes 15 years (range 1-51 years). Forty-four patients had died (5.2%; median age at death 31 years, range 11-51 years). A further four patients died at presentation (within 24 h) from ketoacidosis and are excluded from all analyses. Calendar date of diagnosis was found to be an important predictor of mortality. Adjusting for attained age there was evidence of a decline in relative risk of death with calendar date of diagnosis of 3.4% (95% CI, 0.005-6.9%) per annum, equivalent to a 32% fall per decade (95% CI, 5-51%), or 84% (95% CI, 21-97) from 1940 to 1989. The data are consistent with a large fall in mortality between the 1940s and 1950s representing over 50% of the total reduction in mortality between 1940 and 1991. Neither sex nor age at diagnosis were significant predictors of mortality. Over the study period 1940-89 the SMR (male and female combined) fell from 981 (541-1556) to 238 (60-953) relative to the general population. This population-based study shows that the prognosis for Type 1 (insulin-dependent) diabetes mellitus has improved markedly over the period 1940-1991.

Adolescent↗
PubMed1995

Insulin treated diabetes mellitus: causes of death determined from record linkage of population based registers in Leicestershire, UK.

STUDY OBJECTIVE: Analyses of causes of mortality in people with diabetes using data form death certificates mentioning diabetes provide unreliable estimates of mortality. Under-recording of diabetes as a cause on death certificates has been widely reported, ranging from 15-60%. Using a population based register on people with diabetes and linking data from another source is a viable alternative. Data from the Office of Population Censuses and Surveys (OPCS) are the most acceptable mortality data available for such an exercise, as direct comparison with other published mortality rates is then possible. DESIGN: A locally maintained population-based mortality register and all insulin-treated diabetes mellitus cases notified to the Leicestershire diabetes register (n = 4680) were linked using record linkage software developed in-house (Lynx). This software has been extensively used in a maintenance and update cycle designed to maximise accuracy and minimise duplication and false registration on the diabetes register. Deaths identified were initially coded locally to the International Classification of Diseases, 9th revision (ICD9), and later a linkage was performed to use official OPCS coding. Mortality data identified by the linkage was indirectly standardised using population data for Leicestershire for 1991. Standardised mortality ratios (SMR) were estimated, with 95% confidence intervals. Insulin dependent diabetes (IDDM) was defined as diabetes diagnosed before age 30 years with insulin therapy begun within one year of diagnosis. All other types were considered non-insulin dependent diabetes (NIDDM). Analyses were performed for the whole sample and then for the NIDDM subgroup. Results from these analyses were similar and therefore only whole group analyses are presented. MAIN RESULTS: A total of 370 deaths were identified for the period of 1990-92 inclusive - 56% were in men and 44% in women, median age (range) 71 years (12-94). Approximately 90% of deaths were subjects with NIDDM. Diabetes was mentioned on 215 (58%) death certificates. The all causes SMRs were significantly raised for men and women for all ages less than 75 years. Ischaemic heart disease (ICD9) rubrics 410-414) accounted for 146 (40%) deaths - 41% of male and 38% of female deaths. Male and female SMRs were significantly raised for the age groups 45-64, 65-74, and 75-84 years. Cerebrovascular disease (ICD9 rubrics 430-438) accounted for 39 (10%) deaths and the SMR for women the external causes of death (ICD9 rubrics E800-E999) were also significantly raised overall and in age groups 15-44 and 45-64 years. This was not true for men, although numbers of deaths in this category were small for both men (4) and women (9). CONCLUSION: Record linkage has been used successfully to link two local, population based registers. This has enabled an analysis of mortality in people with diabetes to be performed which overcomes the problems associated with using as a sample, death certificates where diabetes is mentioned. The mortality rates and SMRs estimated should more accurately reflect the true rates than would be possible using other methods. The persisting excess mortality identified for people with diabetes is of a similar magnitude and attributable to similar causes as has been reported elsewhere in population based studies.

Adolescent↗
PubMed1995

Use of general practitioner beds in Leicestershire community hospitals.

BACKGROUND: The shift in care from secondary to primary services is likely to place greater demands on community hospitals. Before changes in the provision of community hospitals can occur, baseline data are needed, outlining their current use. AIM: A study was undertaken to obtain baseline data describing the use of general practitioner beds in Leicestershire community hospitals. METHOD: A three-month prospective, observational study was carried out between February and May 1992 using data from a questionnaire completed by nurses and general practitioners and from patient hospital records. Study patients comprised all patients admitted to general practitioner beds in all eight Leicestershire community hospitals. RESULTS: A 100% questionnaire response rate was obtained giving data on 685 hospital admissions. Around 70% of admissions were of patients aged 75 years and over. Of admissions, 35% were for acute care, 31% for respite care, 22% for rehabilitation, 7% for terminal/palliative care and 5% for other reasons. Fifteen per cent of patients had been transferred from a consultant bed. Of those not transferred, 91% were admitted by their usual general practitioner or practice partner and for 96% of these patients this was the general practitioner's first choice for care. There was significant variation in both the age mix and care category mix of patients between individual hospitals. Medical deterioration in an underlying condition and family pressure on the general practitioner or carers' inability to cope each contributed to around half of all admissions. Of all admissions, 38% lived alone, and 18% of carers were disabled. Incontinence was reported for 35% of patients, and 26% of all patients were of a high nursing dependency. There was low utilization of community services before admission and 33% received none. There was variation between individual hospitals in use of local and district general hospital investigations, specialist referral and types of therapy. Of 685 admissions 11% died during their stay. Of those discharged, 76% went to their own or a relative's home, 10% to a residential or nursing home and 9% were transferred to an acute bed. Nine percent of discharges were postponed and 10% were brought forward. On discharge to non-residential care, 26% of patients received no community services. CONCLUSION: Shifting resources from secondary to primary care is a priority for purchasers. Both the introduction of the National Health Service and community care act 1990, and acute units having increasing incentives for earlier discharge, are likely to place greater demands on community hospital beds. Not all general practitioners have the option of community hospital beds. Before access to general practitioner beds can be broadened, existing beds should be used appropriately and shown to be cost-effective. Purchasers therefore require criteria for the appropriateness of admissions to general practitioner beds, and the results of a general practitioner bed cost-benefit analysis.

Bed Conversion↗