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Biomedical subjects

N R Hicks

Publications and source records attributed to N R Hicks.

16 recordsLinked to original sources
PubMed2003

Autopsy after termination of pregnancy for fetal anomaly: retrospective cohort study.

OBJECTIVE: To study trends in termination of pregnancy for fetal anomaly over 10 years and to assess the contribution of autopsy to the final diagnosis and counselling after termination. DESIGN: Retrospective study with cases from a congenital anomaly register and a defined unselected population. DATA SOURCES: Pregnancies resulting in termination for fetal anomaly identified from the Oxford congenital anomaly register. Details about the prenatal diagnosis and autopsy findings were retrieved from case notes. RESULTS: Of the 57 258 deliveries, 309 (0.5%) were terminated because of prenatally diagnosed abnormality. There were 129/29 086 (0.4%) terminations for fetal anomaly carried out in 1991-5 and 180/28 172 (0.6%) in 1996-2000. The percentage of fetuses that underwent autopsy fell from 84% to 67%. Autopsy was performed in 132 cases identified by ultrasound scan, with no evidence for abnormal karyotype. In 95 (72%) the autopsy confirmed the suspected diagnosis and did not add important further information, two cases were not classified, and in 35 (27%) the autopsy added information that led to a refinement of the risk of recurrence (reduced in 17, increased in 18); in 11 of these 18 cases it was increased to a one in four risk. CONCLUSIONS: Though there has been an increase in the rate of terminations of pregnancy for fetal anomaly, there has been a decline in the autopsy rate. When a prenatal diagnosis was based on the results of a scan only, the addition of information from an autopsy by a specialist paediatric pathologist provided important information that changed the estimated risk of recurrence in 27% of cases and in 8% this was to a higher (one in four) risk.

Abortion, Induced↗
PubMed1998

6-year experience of prenatal diagnosis in an unselected population in Oxford, UK.

BACKGROUND: The benefits and harm associated with prenatal diagnosis are open to debate. We give a 6-year overview of the experience of one prenatal-diagnosis unit using a defined, unselected population. METHODS: All congenital malformations suspected prenatally and all congenital malformations, including chromosome anomalies, confirmed at birth were identified from the local Congenital Malformation Register. All fetuses or infants of women booked for delivery at the Oxford Women's Centre who had an OX postcode and date of delivery between 1991 and 1996 were eligible for the study. FINDINGS: 725 (2%) of 33,376 babies, were judged abnormal at delivery. 396 (55%) malformed fetuses and infants had been correctly identified prenatally. 174 fetuses had a suspected abnormality identified on scan and subsequently proved to be normal. 160 (92%) of these false-positive results were attributable to the reporting of so called ultrasound soft markers. Accuracy of ultrasound diagnosis was good for structural malformations. Ultrasound soft markers were responsible for a 4% increase in detection of malformations (from 51% to 55%) and a 12-fold increase in false-positive rate (one in 2332 to one in 188). 171 pregnancies (43% of prenatally diagnosed malformed babies) were terminated because of suspected abnormality. Suspicion of abnormality in these cases was first aroused after ultrasound scan in 136 (79%); chromosome analysis because of advanced maternal age, family history, or higher risk in biochemical screening test in 25 (15%); and molecular analysis of single gene defect because of family history in ten (6%). There was a 20% reduction in prevalence of conditions compatible with survival beyond the neonatal period because of termination of such pregnancies. INTERPRETATION: More than half of all malformed fetuses can be identified prenatally in routine practice, mostly following initial suspicion from ultrasound examination. Ultrasound soft markers lead to a small increase in detection of malformations but a large increase in false positives. Further research on the impact, including psychological, and value of markers is required to determine whether the benefits of reporting them exceeds the harm. Because methods and techniques continually change, ongoing surveillance of prenatal diagnostic services is vital.

Adult↗
PubMed1998

Coronary event and case fatality rates in an English population: results of the Oxford myocardial infarction incidence study. The Oxford Myocardial Infarction Incidence Study Group.

OBJECTIVES: To determine coronary event and case fatality rates in an English population aged less than 80 years in Oxfordshire, and to compare these rates with those reported by the UK monitoring trends and determinants of cardiovascular disease (MONICA) centres in Scotland and Northern Ireland and those ascertained in Oxfordshire in 1966-67. DESIGN: A population wide surveillance study conducted in 1994-95 using prospective and retrospective case ascertainment. SETTING: A resident population in Oxfordshire of 568,800. SUBJECTS: Patients with suspected myocardial infarction or coronary death. OUTCOME MEASURES: A diagnosis of definite or possible myocardial infarction or coronary death using WHO MONICA diagnostic criteria based on symptoms, electrocardiograms, cardiac enzymes, necropsy findings, and past medical history. RESULTS: The annual rate for a first or recurrent coronary event per 100,000 population aged less than 65 years in 1994-95 was 273 for men and 66 for women after age adjustment to a standard world population. Rates in the age group 65-79 years were 1350 for men and 677 for women. Between 1966-67 and 1994-95, the age standardised event rate in the age group 30-69 years decreased significantly by 33% (95% confidence interval (CI) 44 to 21) in men, and there was a non-significant reduction of 8% (95% CI -33 to 17) in women. The age standardised 28 day case fatality rates also decreased significantly by 28% (95% CI 41 to 15) in men and by 32% (95% CI 55 to 9) in women. CONCLUSIONS: The coronary event rate in Oxfordshire was much lower than rates reported by MONICA centres in Glasgow and Belfast, and similar to rates reported by MONICA centres in France and northern Italy. The substantially lower event rate accounts for lower coronary heart disease mortality in Oxfordshire than in Scotland and Northern Ireland. The reduced coronary mortality in this region is attributable to declines in coronary event and case fatality rates.

Adult↗
PubMed1996

Assessing quality of care: what are the implications of the potential lack of sensitivity of outcome measures to differences in quality?

Measuring outcome can be an insensitive way to detect differences in the quality of health care. This paper captures the implications of this poor sensitivity for the interpretation of studies of outcome that compare provider performance, and considers in what circumstances monitoring outcome might be useful. When interpreting studies, it is important to consider the size of the effect that a difference in the quality of care might be expected to have on outcome and whether it is likely that important differences in quality might not have been detected. It is argued that outcome measures may be of value when how you do something is as important as what you do, when process measures are invalid or impractical, and when the overall effectiveness of an intervention is critically dependent upon its complication rate.

Health Services Research↗
PubMed1995

Using decision analysis to compare policies for antenatal screening for Down's syndrome.

OBJECTIVE: To compare different screening policies for Down's syndrome across a broad range of outcomes, using decision analysis, with particular reference to the role of maternal serum testing. DESIGN: A decision tree was used to combine data from local sources and the medical literature to predict the likely frequency of several outcomes. Sensitivity analyses were used to test the robustness of the conclusions drawn. SETTING: Oxfordshire Health Authority. MAIN OUTCOME MEASURES: Live births with and without Down's syndrome; miscarriages with Down's syndrome; cases of Down's syndrome detected antenatally; amniocenteses performed (and associated miscarriages); direct NHS screening costs; number of women offered screening. RESULTS: Screening policies for Down's syndrome that include serum testing can produce better population outcomes than programmes that do not. Each option for screening for Down's syndrome that we considered had significant drawbacks. In Oxfordshire, offering serum testing to women of all ages would prevent the birth of approximately one more baby with Down's syndrome per year than would a policy of screening for women aged 30 years or more. The cost of preventing this one extra Down's birth would be one or two normal babies lost after amniocentesis, 4500 blood tests for young women (with the associated anxiety and counselling), approximately 200 false positive serum test results and amniocenteses (with the associated anxiety and distress), and 90,000 pounds for the extra tests, counselling, and amniocenteses. Opinions are divided as to which policy is the better option for the population. CONCLUSIONS: Decision analysis is a useful tool for determining the likely consequences of different policy options across a broad range of outcomes. This focuses debate and decision making on outcomes of care, which in turn makes it clear that the choice of screening programme for Down's syndrome depends on the relative importance ascribed to the different outcomes. If individuals' values vary widely it may be impossible to find one screening policy that meets the needs of all pregnant women.

Adult↗
PubMed1994

Some observations on attempts to measure appropriateness of care.

There are a growing number of published studies that suggest that much health care is delivered inappropriately. There are calls for measures of appropriateness to be used by purchasers and others to regulate or influence the delivery of health care. This paper explores assumptions inherent in results generated by a leading measure of appropriateness and concludes that there are considerable uncertainties about the measure's meaning, the magnitude of bias that it contains, and the degree to which its application can be generalised. Some of these uncertainties could be resolved if the tacit assumptions inherent in the generation of the criteria could be made explicit. Existing measures of appropriateness are not yet sufficiently robust to be used with confidence to influence or control the delivery of health care. They may have a use as an aid rather than as a constraint in clinical decision making. A randomised controlled trial could resolve whether patients achieve better outcomes if their care is influenced by appropriateness criteria.

Bias↗
PubMed1993

The appropriateness of hysterectomy. A comparison of care in seven health plans. Health Maintenance Organization Quality of Care Consortium.

OBJECTIVE: To develop and test a method for comparing the appropriateness of hysterectomy use in different health plans. DESIGN: Retrospective cohort study. SETTING: Seven managed care organizations. PATIENTS: Random sample of all nonemergency, non-oncological hysterectomies performed in the seven managed care organizations over a 1-year period. Patients who were not continuously enrolled in a plan for 2 years prior to their hysterectomy were excluded. MAIN OUTCOME MEASURES: Proportion of women undergoing hysterectomy in each plan for inappropriate clinical reasons according to ratings derived from a panel of managed care physicians. RESULTS: Overall, about 16% of women underwent hysterectomy for reasons judged to be clinically inappropriate. Only one plan had significantly more hysterectomies rated inappropriate compared with the group mean (27%, unadjusted). Adjusting for age and race did not affect the rankings of the plans and had little effect on the numeric results. CONCLUSION: The rates of inappropriate use of hysterectomies are similar to those for other procedures and vary to a small degree among health plans. This information may be useful to purchasers when they consider which health plans to offer their employees.

Adult↗
PubMed1992

Policy and practice--an audit of neonatal BCG immunization in Avon.

Two surveys were carried out to audit the Avon Neonatal BCG Immunization Policy. The aim of the audit was to determine whether children with indications for neonatal BCG immunization had received the vaccine before attendance at routine six-week postnatal examination. In the first survey, 15 of 359 (4.2 per cent) infants were identified as eligible for BCG, of whom only two (13.3 per cent) had received it. These findings were discussed with the medical and nursing staff involved in the care of the infants in Avon, and action was taken to improve compliance with the policy. The survey was then repeated to complete the loop of the audit cycle and to observe whether the action taken had the desired effect. Forty of 644 (6.2 per cent) infants were identified as being eligible for BCG immunization in the repeat survey, of whom 32 (80 per cent) had received it. There was a statistically significant difference in results between the first and the second survey (p < 0.0001). It is concluded that completion of the audit cycle can markedly improve clinical practice.

BCG Vaccine↗
PubMed1991

General practitioners' opinions of health services available to their patients.

OBJECTIVES: To establish a means for general practitioners to express their views about health services available to their patients, to identify services that general practitioners perceive as most in need of improvement, and to establish good working relations between the health authority's purchasing team and local general practitioners. DESIGN: Postal questionnaire survey of general practitioners. SETTING: Bristol and Weston health district. SUBJECTS: 226 general practitioners, of whom 171 replied. MAIN OUTCOME MEASURES: Scores of quality and quantity of hospital and community services, frequency that services were identified as priorities for improvement, and the nature of written comments received about services. RESULTS: There was considerable agreement among respondents about which services were adequate and which were inadequate. Most services were perceived as at least adequate in both quality and quantity, but seven services were perceived by more than 60% (102) of doctors as inadequate or worse in quantity and eight by 10% (17) of doctors as poor in quality. Orthopaedics, ophthalmology, care of elderly people, and physiotherapy were the services doctors most wanted improved. CONCLUSIONS: A postal questionnaire is an acceptable and accurate method of obtaining general practitioners' views about services available to their patients. General practitioners' priorities differ from those obtained from hospital medical advisory mechanisms.

Attitude of Health Personnel↗
PubMed1991

Carriage and community treatment of methicillin-resistant Staphylococcus aureus: what happens to colonized patients after discharge?

During a maternity hospital outbreak of colonization/infection due to methicillin-resistant Staphylococcus aureus (MRSA), mothers and babies from 35 families were known to have been discharged colonized with MRSA. Thirty-two of these families were followed up by screening in the community. After 4 weeks, carriage was still detectable in 22 families. The ten families in which carriage was no longer detectable had MRSA isolated at discharge from enrichment culture only. All of the 11 families who had MRSA isolated on direct culture at discharge continued to carry MRSA. Mothers and babies from the 22 families still carrying MRSA at 4 weeks were offered topical treatment. Carriage persisted in ten of these families despite treatment. The most common site of persistent carriage was the perineum in mothers and the throat in infants.

Carrier State↗
PubMed1989

Misplaced loss of confidence in measles vaccination: an investigation in a primary school.

Doubts were expressed about the effectiveness of measles vaccination during a measles outbreak in a Bristol primary school. Investigation of this outbreak showed that the vaccine uptake rate was 89%, vaccine effectiveness was 84% and that 57% of children developing measles had a history of previous measles vaccination. This apparent paradox arises because, for any vaccine that is not 100% effective, as the vaccine uptake rate rises so the percentage of cases previously vaccinated also rises. An understanding of this relationship may avoid unjustified loss of confidence in vaccine effectiveness as vaccine uptake increases.

Child↗