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Biomedical subjects

Nick Black

Publications and source records attributed to Nick Black.

At least 19 recordsLinked to original sources
PubMed2004

Cross sectional survey of multicentre clinical databases in the United Kingdom.

OBJECTIVES: To describe the multicentre clinical databases that exist in the United Kingdom, to report on their quality, to explore which organisational and managerial features are associated with high quality, and to make recommendations for improvements. DESIGN: Cross sectional survey, with interviews with database custodians and search of electronic bibliographic database (PubMed). STUDIES REVIEWED: 105 clinical databases across the United Kingdom. RESULTS: Clinical databases existed in all areas of health care, but their distribution was uneven-cancer and surgery were better covered than mental health and obstetrics. They varied greatly in age, size, growth rate, and geographical areas covered. Their scope (and thus their potential uses) and the quality of the data collected also varied. The latter was not associated with any organisational characteristics. Despite impressive achievements, many faced substantial financial uncertainty. Considerable scope existed for improvements: greater use of nationally approved codes; more support from relevant professional organisations; greater involvement by nurses, allied health professionals, managers, and laypeople in database management teams; and more attention to data security and ensuring patient confidentiality. With some notable exceptions, the audit and research potential of most databases had not been realised: half the databases had each produced only four or fewer peer reviewed research articles. CONCLUSIONS: At least one clinical database support unit is needed in the United Kingdom to provide assistance in organisation and management, information technology, epidemiology, and statistics. Without such an initiative, the variable picture of databases reported here is likely to persist and their potential not be realised.

Clinical Medicine↗
PubMed2004

General practitioners' perceptions of chronic fatigue syndrome and beliefs about its management, compared with irritable bowel syndrome: qualitative study.

OBJECTIVES: To compare general practitioners' perceptions of chronic fatigue syndrome and irritable bowel syndrome and to consider the implications of their perceptions for treatment. DESIGN: Qualitative analysis of transcripts of group discussions. PARTICIPANTS AND SETTING: A randomly selected sample of 46 general practitioners in England. RESULTS: The participants tended to stereotype patients with chronic fatigue syndrome as having certain undesirable traits. This stereotyping was due to the lack of a precise bodily location; the reclassification of the syndrome over time; transgression of social roles, with patients seen as failing to conform to the work ethic and "sick role" and conflict between doctor and patient over causes and management. These factors led to difficulties for many general practitioners in managing patients with chronic fatigue syndrome. For both conditions many participants would not consider referral for mental health interventions, even though the doctors recognised social and psychological factors, because they were not familiar with the interventions or thought them unavailable or unnecessary. CONCLUSIONS: Barriers to the effective clinical management of patients with irritable bowel syndrome and chronic fatigue syndrome are partly due to doctors' beliefs, which result in negative stereotyping of patients with chronic fatigue syndrome and the use of management strategies for both syndromes that may not take into account the best available evidence.

Attitude of Health Personnel↗
PubMed2004

Improving care of the critically ill: institutional and health-care system approaches.

Institutional and health-care system approaches complement bedside strategies to improve care of the critically ill. Focusing on the USA and the UK, we discuss seven approaches: education (especially of non-clinical managers, policy-makers, and the public), organisational guidelines, performance reporting, financial and sociobehavioural incentives to health-care professionals and institutions, regulation, legal requirements, and health-care system reorganisation. No single action is likely to have sustained effect and we recommend a combination of approaches. Several recent initiatives that hold promise tie performance reporting to financial incentives. Though performance reporting has been hampered by concerns over cost and accuracy, it remains an essential component and we recommend continued effort in this area. We also recommend more public education and use of organisational guidelines, such as admission criteria and staffing levels in intensive care units. Even if these endeavours are successful, with rising demand for services and continuing pressure to control costs, optimum care of the critically ill will not be realised without a fundamental reorganisation of services. In both the USA and UK, we recommend exploration of regionalised care, akin to US state trauma systems, and greater use of physician-extenders, such as nurse practitioners, to provide enhanced access to specialist care for critical illness.

Critical Care↗
PubMed2004

Effects of training on quality of peer review: randomised controlled trial.

OBJECTIVE: To determine the effects of training on the quality of peer review. DESIGN: Single blind randomised controlled trial with two intervention groups receiving different types of training plus a control group. SETTING AND PARTICIPANTS: Reviewers at a general medical journal. Interventions Attendance at a training workshop or reception of a self taught training package focusing on what editors want from reviewers and how to critically appraise randomised controlled trials. MAIN OUTCOME MEASURES: Quality of reviews of three manuscripts sent to reviewers at four to six monthly intervals, evaluated using the validated review quality instrument; number of deliberate major errors identified; time taken to review the manuscripts; proportion recommending rejection of the manuscripts. RESULTS: Reviewers in the self taught group scored higher in review quality after training than did the control group (score 2.85 v 2.56; difference 0.29, 95% confidence interval 0.14 to 0.44; P = 0.001), but the difference was not of editorial significance and was not maintained in the long term. Both intervention groups identified significantly more major errors after training than did the control group (3.14 and 2.96 v 2.13; P < 0.001), and this remained significant after the reviewers' performance at baseline assessment was taken into account. The evidence for benefit of training was no longer apparent on further testing six months after the interventions. Training had no impact on the time taken to review the papers but was associated with an increased likelihood of recommending rejection (92% and 84% v 76%; P = 0.002). CONCLUSIONS: Short training packages have only a slight impact on the quality of peer review. The value of longer interventions needs to be assessed.

Education, Professional↗
PubMed2004

Is publicly funded health care really distributed according to need? The example of cardiac rehabilitation in the UK.

OBJECTIVES: To demonstrate the importance of measuring both the horizontal and vertical components of equity in order to examine whether patients are receiving the health care that they need. METHODS DESIGN: A theoretical demonstration followed by analysis of a prospectively collected national random sample of acute cardiac admissions to 94 hospitals in the UK. PATIENTS: 1064 patients under 70 years old. ANALYSIS: The association between use of cardiac rehabilitation and gender (after adjusting for clinical need) was measured using multivariable analysis with effect modification. RESULTS: Hypertensive males were nearly twice as likely to undergo rehabilitation compared to hypertensive females (OR 1.76, 95% CI 1.03-3.02). Hyertensive patients were less likely to undergo rehabilitation than normotensive patients (OR 0.67, 95% CI 0.50-0.89) but this treatment difference did not apply in the same way to both men and women. Hypertensive women were half as likely to undergo rehabilitation compared with normotensive women (OR 0.48, 95% CI 0.30-0.78), whereas hypertensive men were as likely as normotensive men to receive rehabilitation (OR 1.00. 95% CI 0.63-1.60). CONCLUSIONS: Horizontal inequity was demonstrated because male and female hypertensive patients with equal needs were not treated equally. There was also vertical inequity because although patients with hypertension were treated differently to normotensive patients, this treatment difference was not the same for men and women.

Coronary Artery Disease↗
PubMed2004

Health care workforce research: identifying the agenda.

Research can contribute to resolving some of the workforce challenges that all heath care systems face. In an attempt to identify the research agenda, key stakeholders in the UK were brought together and background papers were presented by academics with expertise in seven related but distinct areas: global issues; professional boundaries; education; regulation; workplaces; professional-patient interaction; and organisation and management. The research questions identified in each area are described along with some methodological challenges. It is hoped that this will encourage research in this crucial area of health services by facilitating a coherent approach to the diverse needs identified.

Delivery of Health Care↗
PubMed2003

Is publicly funded health care really distributed according to need? The example of cardiac rehabilitation in the UK.

OBJECTIVES: To demonstrate the importance of measuring both the horizontal and vertical components of equity in order to examine whether patients are receiving the health care that they need. METHODS DESIGN: A theoretical demonstration followed by analysis of a prospectively collected national random sample of acute cardiac admissions to 94 hospitals in the UK. PATIENTS: One thousand and sixty-four patients under 70 years old. ANALYSIS: The association between use of cardiac rehabilitation and gender (after adjusting for clinical need) was measured using multivariable analysis with effect modification. RESULTS: Hypertensive males were nearly twice as likely to undergo rehabilitation compared with hypertensive females (OR 1.76, 95%CI 1.03-3.02). Hyertensive patients were less likely to undergo rehabilitation than normotensive patients (OR 0.67, 95% CI 0.50-0.89) but this treatment difference did not apply in the same way to both men and women. Hypertensive women were half as likely to undergo rehabilitation compared with normotensive women (OR 0.48, 95% CI 0.30-0.78), whereas hypertensive men were as likely as normotensive men to receive rehabilitation (OR 1.00. 95%CI 0.63-1.60). CONCLUSIONS: Horizontal inequity was demonstrated because male and female hypertensive patients with equal needs were not treated equally. There was also vertical inequity because although patients with hypertension were treated differently to normotensive patients, this treatment difference was not the same for men and women.

Acute Disease↗
PubMed2003

From health technology assessment to research on the organisation and delivery of health services: addressing the balance.

This paper argues that the focus of research to improve health services has, until recently, been on health technology assessment. The authors make the case for a greater emphasis on research on how health services are managed, organised and delivered, and refer to initiatives in a number of countries which are seeking to address this balance. The way two such initiatives in England and Canada have set priorities for this type of research, involving a wide range of stakeholders is described. The authors argue that a wide range of disciplines needs to be applied to research on the organisation and delivery of health services. Important theoretical differences between and within disciplines, and their implications for research methods, are discussed. An example of an issue in the delivery of organisation of health services (how best to deliver orthopaedic care) is used to illustrate how a number of different disciplines can be applied. The challenge for researchers from these disciplines is to see how far they can work together to carry out research in this important field. The challenge for this research is that the findings are valued and used by health service professionals, managers and users.

Canada↗
PubMed2003

Epidemiology of severe sepsis occurring in the first 24 hrs in intensive care units in England, Wales, and Northern Ireland.

OBJECTIVE: To investigate the numbers, clinical characteristics, resource use, and outcomes of admissions who met precise clinical and physiologic criteria for severe sepsis (as defined in the PROWESS trial) in the first 24 hrs in the intensive care unit. DESIGN: Observational cohort study, with retrospective analysis of prospectively collected data. SETTING: Ninety-one adult general intensive care units in England, Wales, and Northern Ireland between 1995 and 2000. PATIENTS: Patients were 56,673 adult admissions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We found that 27.1% of adult intensive care unit admissions met severe sepsis criteria in the first 24 hrs in the intensive care unit. Most were nonsurgical (67%), and the most common organ system dysfunctions were seen in the cardiovascular (88%) and respiratory (81%) systems. Modeling the data for England and Wales for 1997 suggested that 51 (95% confidence interval, 46-58) per 100,000 population per year were admitted to intensive care units and met severe sepsis criteria in the first 24 hrs.Of the intensive care unit admissions who met severe sepsis criteria in the first 24 hrs, 35% died before intensive care unit discharge and 47% died during their hospital stay. Hospital mortality rate ranged from 17% in the 16-19 age group to 64% in those >85 yrs. In England and Wales in 1997, an estimated 24 (95% confidence interval, 21-28) per 100,000 population per year died after intensive care unit admissions with severe sepsis in the first 24 hrs. For intensive care unit admissions who met severe sepsis criteria in the first 24 hrs, median intensive care unit length of stay was 3.56 days (interquartile range, 1.50-9.32) and median hospital length of stay was 18 days (interquartile range, 8-36 days). These admissions used 45% of the intensive care unit and 33% of the hospital bed days used by all intensive care unit admissions. CONCLUSIONS: Severe sepsis is common and presents a major challenge for clinicians, managers, and healthcare policymakers. Intensive care unit admissions meeting severe sepsis criteria have a high mortality rate and high resource use.

Adolescent↗
PubMed2003

Secondary use of personal data for health and health services research: why identifiable data are essential.

Databases provide a powerful and essential resource for health and health services research. There are seven reasons why the identification of individuals may be needed: linkage within a database; linkage between databases; ensuring comparisons are meaningful; ensuring completeness of recruitment; investigation of social factors; analysis of trends over time; and assessing the applicability of primary research findings. Examples of recent British research studies for which identifiable data were essential are described to illustrate six research applications: to understand the natural history and development of disease; to identify causes of disease; to evaluate health care interventions; to assess equity of care; to describe trends in health care utilisation; and to ensure the methodological rigour of research. Given the benefits to the public of such research activities, methods need to be found to ensure the continuation of such research while meeting legitimate concerns about individual privacy and confidentiality.

Access to Information↗
PubMed2002

Systematic review of mental health interventions for patients with common somatic symptoms: can research evidence from secondary care be extrapolated to primary care?

OBJECTIVES: To determine the strength of evidence for the effectiveness of mental health interventions for patients with three common somatic conditions (chronic fatigue syndrome, irritable bowel syndrome, and chronic back pain). To assess whether results obtained in secondary care can be extrapolated to primary care and suggest how future trials should be designed to provide more rigorous evidence. DESIGN: Systematic review. DATA SOURCES: Five electronic databases, key texts, references in the articles identified, and citations from expert clinicians. STUDY SELECTION: Randomised controlled trials including participants with one of the three conditions for which no physical cause could be found. Two reviewers screened sources and independently extracted data and assessed quality. RESULTS: Sixty one studies were identified; 20 were classified as primary care and 41 as secondary care. For some interventions, such as brief psychodynamic interpersonal therapy, little research was identified. However, results of meta-analyses and of randomised controlled trials suggest that cognitive behaviour therapy and behaviour therapy are effective for chronic back pain and chronic fatigue syndrome and that antidepressants are effective for irritable bowel syndrome. Cognitive behaviour therapy and behaviour therapy were effective in both primary and secondary care in patients with back pain, although the evidence is more consistent and the effect size larger for secondary care. Antidepressants seem effective in irritable bowel syndrome in both settings but ineffective in chronic fatigue syndrome. CONCLUSIONS: Treatment seems to be more effective in patients in secondary care than in primary care. This may be because secondary care patients have more severe disease, they receive a different treatment regimen, or the intervention is more closely supervised. However, conclusions of effectiveness should be considered in the light of the methodological weaknesses of the studies. Large pragmatic trials are needed of interventions delivered in primary care by appropriately trained primary care staff.

Antidepressive Agents↗