Does it matter whether patients take their antihypertensive medication as prescribed? The complex relationship between adherence and blood pressure control.
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Antihypertensive Agents↗
Biomedical subjects
J Mant
Publications and source records attributed to J Mant.
What do stroke patients and their carers want from community services?
BACKGROUND: Previous research has focused on the longer term needs of 'new' stroke patients at fixed time intervals after the event, but neglected those of stroke patients who may have had the event many years earlier. OBJECTIVE: To identify the long-term support needs of patients with prevalent stroke, and their carers identified from practice stroke registers. DESIGN OF STUDY: Patients and their carers were invited to attend focus groups at the university, a nursing home or in the community. SETTING: Seven practices in South Birmingham. Adults (18+) with a validated record of stroke. METHODS: Focus groups were audio-taped and data analysed using a constant comparison method. RESULTS: Twenty-seven patients and six carers participated in the study. Three major themes emerged: emotional and psychological problems; lack of information available for patients and their families; the importance of Primary Care as the first point of contact for information or problems, even if these were non medical. CONCLUSIONS: Better methods of providing information for long-term survivors of stroke, and for addressing their emotional and psychological needs are required. Primary care could be a key setting for helping to provide more inclusive services for both patient and carer.
Adult↗
Targets and self monitoring in hypertension: randomised controlled trial and cost effectiveness analysis.
OBJECTIVES: To assess whether blood pressure control in primary care could be improved with the use of patient held targets and self monitoring in a practice setting, and to assess the impact of these on health behaviours, anxiety, prescribed antihypertensive drugs, patients' preferences, and costs. DESIGN: Randomised controlled trial. SETTING: Eight general practices in south Birmingham. PARTICIPANTS: 441 people receiving treatment in primary care for hypertension but not controlled below the target of < 140/85 mm Hg. INTERVENTIONS: Patients in the intervention group received treatment targets along with facilities to measure their own blood pressure at their general practice; they were also asked to visit their general practitioner or practice nurse if their blood pressure was repeatedly above the target level. Patients in the control group received usual care (blood pressure monitoring by their practice). MAIN OUTCOME MEASURES PRIMARY OUTCOME: change in systolic blood pressure at six months and one year in both intervention and control groups. SECONDARY OUTCOMES: change in health behaviours, anxiety, prescribed antihypertensive drugs, patients' preferences of method of blood pressure monitoring, and costs. RESULTS: 400 (91%) patients attended follow up at one year. Systolic blood pressure in the intervention group had significantly reduced after six months (mean difference 4.3 mm Hg (95% confidence interval 0.8 mm Hg to 7.9 mm Hg)) but not after one year (mean difference 2.7 mm Hg (- 1.2 mm Hg to 6.6 mm Hg)). No overall difference was found in diastolic blood pressure, anxiety, health behaviours, or number of prescribed drugs. Patients who self monitored lost more weight than controls (as evidenced by a drop in body mass index), rated self monitoring above monitoring by a doctor or nurse, and consulted less often. Overall, self monitoring did not cost significantly more than usual care (251 pounds sterling (437 dollars; 364 euros) (95% confidence interval 233 pounds sterling to 275 pounds sterling) versus 240 pounds sterling (217 pounds sterling to 263 pounds sterling). CONCLUSIONS: Practice based self monitoring resulted in small but significant improvements of blood pressure at six months, which were not sustained after a year. Self monitoring was well received by patients, anxiety did not increase, and there was no appreciable additional cost. Practice based self monitoring is feasible and results in blood pressure control that is similar to that in usual care.
Adult↗
Phylogeography of pollinator-specific sexually deceptive Chiloglottis taxa (Orchidaceae): evidence for sympatric divergence?
Divergence in sexually deceptive orchids is thought to occur through shifts in the attraction of specific pollinators, a process that is mediated by changes in the floral odours that lure sexually excited male insects. We investigated the origin of reproductive isolation in a sexually deceptive species complex of Chiloglottis R.Br. (Orchidaceae: Diurideae). Two geographically separated montane regions in eastern Australia were sampled, each containing sympatric pairs of orchid taxa presently found under the name, Chiloglottis pluricallata. Behavioural tests confirmed at least three distinct orchid taxa that specifically attract different pollinators. An artificial crossing experiment among two taxa from one region demonstrated their interfertility, and confirmed isolation to be a function of pollinator attraction. A phylogeographic analysis using amplified fragment length polymorphisms (AFLPs) indicated that samples from each geographical region are most closely related, a pattern consistent with in situ or sympatric divergence. However, an extensive population genetic study on two taxa from one region failed to entirely reject the possibility of intertaxon gene flow. Although clear genetic differentiation of the taxa is evident in two out of three sites where both grow in direct sympatry, overall, the two taxa are not strongly distinguished by AFLP markers. The reconstruction of a simple bifurcating pattern of divergence may be confounded by a combination of contemporary population-level processes operating within each taxon, the retention of ancestral polymorphism or intertaxon gene flow.
Alleles↗
Family support for stroke: one year follow up of a randomised controlled trial.
BACKGROUND: There is evidence that family support can benefit carers of stroke patients, but not the patients themselves. OBJECTIVE: To extend the follow up of a single blind randomised controlled trial of family support for stroke patients and carers to one year to ascertain whether there were any late effects of the intervention. METHODS: The study was a randomised controlled trial. Patients admitted to hospital with acute stroke who had a close carer were assigned to receive family support or normal care. Families were visited at home by a researcher 12 months after the stroke, and a series of questionnaires was administered to patient and carer. RESULTS: The benefits to carers mostly persisted, though they were no longer statistically significant because some patients were lost to follow up. There was no evidence of any effects on patients. CONCLUSION: Family support is effective for carers, but different approaches need to be considered to alleviate the psychosocial problems of stroke patients.
Adaptation, Psychological↗
A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study.
OBJECTIVES: To determine the most cost-effective method of screening for atrial fibrillation (AF) in the population aged 65 years and over, as well as its prevalence and incidence in this age group. Also to evaluate the relative cost-effectiveness of different methods of recording and interpreting the electrocardiogram (ECG) within a screening programme. DESIGN: Multicentred randomised controlled trial. Purposefully selected general practices were randomly allocated to 25 intervention practices and 25 control practices. SETTING: Fifty primary care centres across the West Midlands, UK. PARTICIPANTS: Patients aged 65 years and over. INTERVENTIONS: GPs and practice nurses in the intervention practices received education on the importance of AF detection and ECG interpretation. Patients in the intervention practices were randomly allocated to systematic (n = 5000) or opportunistic screening (n = 5000). Prospective identification of pre-existing risk factors for AF within the screened population enabled comparison between targeted screening of people at higher risk of AF and total population screening. MAIN OUTCOME MEASURES: AF detection rates in systematically screened and opportunistically screened populations in the intervention practices were compared with AF detection rate in 5000 patients in the control practices. The screening period was 12 months. RESULTS: Baseline prevalence of AF was 7.2%, with a higher prevalence in males (7.8%) and patients aged 75 years and over (10.3%). The control population demonstrated higher baseline prevalence (7.9%) than either the systematic (6.9%) or opportunistic (6.9%) intervention population. In the control population 47 new cases were detected (incidence 1.04% per year). In the opportunistic arm 243 patients without a baseline diagnosis of AF were found to have an irregular pulse, with 177 having an ECG, yielding 31 new cases (incidence 0.69% per year). A further 44 cases were detected outside the screening programme (overall incidence 1.64% per year). In the systematic arm 2357 patients had an ECG yielding 52 new cases (incidence 1.1% per year). Of these, 31 were detected by targeted screening and a further 21 by total population screening. A further 22 cases were detected outside the screening programme (overall incidence 1.62% per year). In terms of ECG interpretation, computerised decision support software (CDSS) gave a sensitivity of 87.3%, a specificity of 99.1% and a positive predictive value (PPV) of 89.5% compared with the gold standard (cardiologist reporting). GPs and practice nurses performed less well. The only difference in performance between intervention populations and controls was that practice nurses from the control arm performed less well than with intervention practice nurses on interpretation of limb-lead (PPV 38.8% versus 20.8%) and single-lead (PPV 37.7% versus 24.0%) ECGs. The within-trial economic evaluation results showed the lowest incremental cost to be for the opportunistic arm, with an incremental cost-effectiveness ratio of 337 pounds Sterling for each additional case detected compared to the control arm. Opportunistic screening dominated both more intensive screening strategies. Model-based analyses showed small differences in cost and quality-adjusted life-years for different methods and intensities of screening, but annual opportunistic screening resulted in the lowest number of ischaemic strokes and greatest proportion of cases of AF diagnosed. Probabilistic sensitivity results indicated that there was a probability of approximately 60% that screening from the age of 65 years was cost-effective in both men and women. CONCLUSIONS: The results of the study indicated that in terms of a screening programme for atrial fibrillation in patients 65 and over, the only strategy that improved on routine practice was opportunistic screening, model-based analyses indicated that there was a probability of approximately 60% of annual opportunistic screening being cost effective. It is suggested that the following topics are worthy of further investigation: the effect of the implementation of a screening programme for AF on the uptake and maintenance of anticoagulation in patients aged 65 years and over; an evaluation of the role of CDSS in the diagnosis of cardiac arrythmias; the best method for routinely detecting paroxysmal AF; ways of improving healthcare professionals' performance in ECG interpretation; development of a robust economic model to incorporate data on new therapeutic agents for use as thromboprophylactic agents for patients with AF, and an evaluation of the relative risk of stroke for patients with incident as opposed to prevalent AF.
Aged↗
Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care.
OBJECTIVES: To ascertain the value of a range of methods - including clinical features, resting and exercise electrocardiography, and rapid access chest pain clinics (RACPCs) - used in the diagnosis and early management of acute coronary syndrome (ACS), suspected acute myocardial infarction (MI), and exertional angina. DATA SOURCES: MEDLINE, EMBASE, CINAHL, the Cochrane Library and electronic abstracts of recent cardiological conferences. REVIEW METHODS: Searches identified studies that considered patients with acute chest pain with data on the diagnostic value of clinical features or an electrocardiogram (ECG); patients with chronic chest pain with data on the diagnostic value of resting or exercise ECG or the effect of a RACPC. Likelihood ratios (LRs) were calculated for each study, and pooled LRs were generated with 95% confidence intervals. A Monte Carlo simulation was performed evaluating different assessment strategies for suspected ACS, and a discrete event simulation evaluated models for the assessment of suspected exertional angina. RESULTS: For acute chest pain, no clinical features in isolation were useful in ruling in or excluding an ACS, although the most helpful clinical features were pleuritic pain (LR+ 0.19) and pain on palpation (LR+ 0.23). ST elevation was the most effective ECG feature for determining MI (with LR+ 13.1) and a completely normal ECG was reasonably useful at ruling this out (LR+ 0.14). Results from 'black box' studies of clinical interpretation of ECGs found very high specificity, but low sensitivity. In the simulation exercise of management strategies for suspected ACS, the point of care testing with troponins was cost-effective. Pre-hospital thrombolysis on the basis of ambulance telemetry was more effective but more costly than if performed in hospital. In cases of chronic chest pain, resting ECG features were not found to be very useful (presence of Q-waves had LR+ 2.56). For an exercise ECG, ST depression performed only moderately well (LR+ 2.79 for a 1 mm cutoff), although this did improve for a 2 mm cutoff (LR+ 3.85). Other methods of interpreting the exercise ECG did not result in dramatic improvements in these results. Weak evidence was found to suggest that RACPCs may be associated with reduced admission to hospital of patients with non-cardiac pain, better recognition of ACS, earlier specialist assessment of exertional angina and earlier diagnosis of non-cardiac chest pain. In a simulation exercise of models of care for investigation of suspected exertional angina, RACPCs were predicted to result in earlier diagnosis of both confirmed coronary heart disease (CHD) and non-cardiac chest pain than models of care based around open access exercise tests or routine cardiology outpatients, but they were more expensive. The benefits of RACPCs disappeared if waiting times for further investigation (e.g. angiography) were long (6 months). CONCLUSIONS: Where an ACS is suspected, emergency referral is justified. ECG interpretation in acute chest pain can be highly specific for diagnosing MI. Point of care testing with troponins is cost-effective in the triaging of patients with suspected ACS. Resting ECG and exercise ECG are of only limited value in the diagnosis of CHD. The potential advantages of RACPCs are lost if there are long waiting times for further investigation. Recommendations for further research include the following: determining the most appropriate model of care to ensure accurate triaging of patients with suspected ACS; establishing the cost-effectiveness of pre-hospital thrombolysis in rural areas; determining the relative cost-effectiveness of rapid access chest pain clinics compared with other innovative models of care; investigating how rapid access chest pain clinics should be managed; and establishing the long-term outcome of patients discharged from RACPCs.
Acute Disease↗
Mortality study of 18 000 patients treated with omeprazole.
BACKGROUND: The long term safety of potent gastric acid suppressive therapy has yet to be established. METHOD: General practice record review at a median interval of 26 months followed by retrieval of details of all deaths within four years using the UK National Health Service Central Registers in 17 936 patients prescribed omeprazole in 1993-1995. Death rates were compared with general population rates. RESULTS: Records of 17 489 patients (97.5%) were examined. A total of 12 703 patients received further scripts for antisecretory drugs, 8097 for omeprazole only (65.6%): 3097 patients have died. All cause mortality was higher in the first year (observed/expected (O/E) 1.44 (95% confidence intervals (CI) 1.34-1.55); p<0.0001) but had fallen to population expectation by the fourth year. There were significant mortality increases in the first year, falling to or below population expectation by the fourth year, for deaths ascribed to neoplasms (1.82 (95% CI 1.58-2.08); p<0.0001), circulatory diseases (1.27 (95% CI 1.13-1.43); p<0.0001), and respiratory diseases (1.37 (95% CI 1.12-1.64); p<0.001). Increased mortality ascribed to digestive diseases (2.56 (95% CI 1.87-3.43); p<0.0001) persisted, although reduced. Increased mortality rates for cancers of the stomach (4.06 (95% CI 2.60-6.04); p<0.0001), colon and rectum (1.40 (95% CI 0.84-2.18); p=0.075), and trachea, bronchus, and lung (1.64 (95% CI 1.19-2.19); p<0.01) seen in the first year had disappeared by the fourth year but that for cancer of the oesophagus had not (O/E 7.35 (95% CI 5.20-10.09) (p<0.0001) in year 1; 2.88 (95% CI 1.62-4.79) (p<0.001) in year 4). Forty of 78 patients dying of oesophageal cancer had the disease present at registration. Twenty seven of those remaining cases had clinical evidence of Barrett's disease, stricture, ulcer, or oesophagitis at registration (O/E 3.30 (95% CI 2.17-4.80)). Six deaths occurred in patients with hiatal hernia or reflux only (O/E 1.02 (95% CI 0.37-2.22)) and five in patients without oesophageal disease (O/E 0.77 (95% CI 0.25-1.80)). No relationships were detected with numbers of omeprazole scripts received. CONCLUSIONS: Increases in mortality associated with treatment are due to pre- existing illness, including pre-existing severe oesophageal disease. There was no evidence of an increased risk of oesophageal adenocarcinoma in those without oesophageal mucosal damage recorded at registration.
Adolescent↗
Identification of stroke in the community: a comparison of three methods.
BACKGROUND: Evidence concerning secondary prevention of cerebrovascular disease is not optimally used in clinical practice. A necessary first step is to identify those eligible for treatment. In primary care, this equates to setting up a register of prevalent stroke. AIM: To compare three different methods for identifying prevalent cases of cerebrovascular disease in the community: general practice-based computer systems; population surveys; and hospital-based routine information systems. DESIGN OF STUDY: Comparison of results of each method applied to a defined population and then assessed against reference criteria for cerebrovascular disease. SETTING: A total of 5801 people aged 65 years or over, resident in seven practices situated within the South Birmingham Primary Care Trust area. METHOD: The sensitivity, specificity, and predictive value of each method of identification were calculated against reference criteria applied by two investigators independently of each other. RESULTS: The prevalence of reference criteria-validated cerebrovascular disease in patients aged 65 years or over was 8.2%. Overall, general practice-based computer systems had a sensitivity of 81.0%, a specificity of 97.2% and a positive predictive value (PPV) of 71.8%, but there was a wide range of sensitivity (33% to 90%) and PPV (42% to 92%) between practices. Patient survey and hospital information systems were less sensitive (75.7% and 28.4%, respectively) but had higher PPVs (77.5% and 89.2%, respectively). Thirty-nine per cent of patients with a history of cerebrovascular disease had not been admitted to hospital. CONCLUSION: General practice-based computer systems can produce reasonably accurate prevalent stroke registers. In areas where these are poorly developed, patient survey is an alternative.
Aged↗
Comparison of estimates and calculations of risk of coronary heart disease by doctors and nurses using different calculation tools in general practice: cross sectional study.
OBJECTIVE: To assess the effect of using different risk calculation tools on how general practitioners and practice nurses evaluate the risk of coronary heart disease with clinical data routinely available in patients' records. DESIGN: Subjective estimates of the risk of coronary heart disease and results of four different methods of calculation of risk were compared with each other and a reference standard that had been calculated with the Framingham equation; calculations were based on a sample of patients' records, randomly selected from groups at risk of coronary heart disease. SETTING: General practices in central England. PARTICIPANTS: 18 general practitioners and 18 practice nurses. MAIN OUTCOME MEASURES: Agreement of results of risk estimation and risk calculation with reference calculation; agreement of general practitioners with practice nurses; sensitivity and specificity of the different methods of risk calculation to detect patients at high or low risk of coronary heart disease. RESULTS: Only a minority of patients' records contained all of the risk factors required for the formal calculation of the risk of coronary heart disease (concentrations of high density lipoprotein (HDL) cholesterol were present in only 21%). Agreement of risk calculations with the reference standard was moderate (kappa=0.33-0.65 for practice nurses and 0.33 to 0.65 for general practitioners, depending on calculation tool), showing a trend for underestimation of risk. Moderate agreement was seen between the risks calculated by general practitioners and practice nurses for the same patients (kappa=0.47 to 0.58). The British charts gave the most sensitive results for risk of coronary heart disease (practice nurses 79%, general practitioners 80%), and it also gave the most specific results for practice nurses (100%), whereas the Sheffield table was the most specific method for general practitioners (89%). CONCLUSIONS: Routine calculation of the risk of coronary heart disease in primary care is hampered by poor availability of data on risk factors. General practitioners and practice nurses are able to evaluate the risk of coronary heart disease with only moderate accuracy. Data about risk factors need to be collected systematically, to allow the use of the most appropriate calculation tools.
Community Health Nursing↗
Using case-control studies for prescribing research.
In this review, the principles of design, analysis and interpretation of case-control studies are illustrated by considering the evidence from case-control studies that link hormone replacement therapy to venous thromboembolism.
Case-Control Studies↗
Long term anticoagulation or antiplatelet treatment. Inclusion criteria determine results of review.
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Aged↗
Community pharmacies for detection and control of hypertension.
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Antihypertensive Agents↗
Process versus outcome indicators in the assessment of quality of health care.
This paper reviews the relative strengths and weaknesses of outcome and process measures as performance indicators in health care. Differences in outcome may be due to case mix, how the data were collected, chance, or quality of care. Health care is only one determinant of health and other factors have important effects on health outcomes, such as nutrition, environment, lifestyle and poverty. The advantages of process measures are that they are more sensitive to differences in the quality of care and they are direct measures of quality. However, outcome measures are of greater intrinsic interest and can reflect all aspects of care, including those that are otherwise difficult to measure such as technical expertise and operator skill. Outcome indicators can be improved if efforts are made to standardize data collection and case mix adjustment systems are developed and validated. It is argued that this is worth doing only where it is likely that variations in health care might lead to significant variations in health outcome and where the occurrence of the outcome is sufficiently common that the outcome indicator will have the power to detect real differences in quality. If these conditions are not met, then alternative strategies such as process measurement and risk management techniques may be more effective at protecting the public from poor quality care.
Clinical Competence↗
Anticoagulation to prevent stroke in atrial fibrillation. It's still not clear whether results in secondary care translate to primary care.
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Anticoagulants↗
Family support for stroke: a randomised controlled trial.
BACKGROUND: Attention is currently focused on family care of stroke survivors, but the effectiveness of support services is unclear. We did a single-blind, randomised, controlled trial to assess the impact of family support on stroke patients and their carers. METHODS: Patients with acute stroke admitted to hospitals in Oxford, UK, were assigned family support or normal care within 6 weeks of stroke. After 6 months, we assessed, for carers, knowledge about stroke, Frenchay activities index, general health questionnaire-28 scores, caregiver strain index, Dartmouth co-op charts, short form 36 (SF-36), and satisfaction scores, and, for patients, knowledge about stroke and use of services, Barthel index, Rivermead mobility index, Frenchay activities index, London handicap scale, hospital anxiety and depression scales, Dartmouth co-op charts, and satisfaction. FINDINGS: 323 patients and 267 carers were followed up. Carers in the intervention group had significantly better Frenchay activities indices (p=0.03), SF-36 scores (energy p=0.02, mental health p=0.004, pain p=0.03, physical function p=0.025, and general health perception p=0.02), quality of life on the Dartmouth co-op chart (p=0.01), and satisfaction with understanding of stroke (82 vs 71%, p=0.04) than those in the control group. Patients' knowledge about stroke, disability, handicap, quality of life, and satisfaction with services and understanding of stroke did not differ between groups. Fewer patients in the intervention group than in the control group saw a physiotherapist after discharge (44 vs 56%, p=0.04), but use of other services was similar. INTERPRETATION: Family support significantly increased social activities and improved quality of life for carers, with no significant effects on patients.
Aged↗
Using anticoagulation or aspirin to prevent stroke. Study does not have the power to show that aspirin is as good as anticoagulation.
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Anticoagulants↗
The accuracy of general practitioner records of smoking and alcohol use: comparison with patient questionnaires.
BACKGROUND: General practitioner (GP) records are increasingly being used as sources of information on potential confounders such as smoking use and alcohol intake in epidemiological studies. The aim of this study was to assess the accuracy of GP records on smoking use and alcohol intake compared with data from patient questionnaires. METHODS: Patients registered with 42 practices in Oxfordshire that agreed to take part in a post-marketing surveillance study of omeprazole were sent a postal questionnaire that included questions about alcohol and tobacco use. Two years later, data on these aspects of lifestyle were abstracted from the GP records. RESULTS: A total of 892 patients agreed to take part in the study; 804 (90 per cent) completed the postal questionnaire, and the records of 856 (96 per cent) were reviewed. Information on smoking and alcohol use was present in 74 per cent and 63 per cent of GP records, respectively. Agreement between the two data sources was moderate for both smoking (kappa = 0.50) and alcohol use (kappa = 0.52). With regard to smoking, the main discrepancy between the two data sources was that 46 per cent (94/206) of patients who reported themselves as exsmokers were recorded as being never smokers in the GP record. With regard to alcohol, there were no systematic differences between the two data sources. CONCLUSION: Data from GP records on smoking status and alcohol use are incomplete and subject to some misclassification. This is a source of potential failed adjustment for confounding, which should be considered in epidemiological studies that make use of these records.
Alcohol Drinking↗