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Biomedical subjects

P Littlejohns

Publications and source records attributed to P Littlejohns.

At least 37 records · Page 2Linked to original sources
PubMed1997

Continuing medical education: the question of evaluation.

This paper examines the question of evaluation which has been largely neglected in the credit-based systems of continuing medical education adopted by the Medical Royal Colleges. These systems are seen to encourage a training model of continuing education and a scientific model of evaluation as measurement. By contrast, humanistic evaluation is interpretative and differs not only in its criteria and methods, but also in its underpinning curricular ideologies and values. This model has closer links with concepts of education and professional practice associated with continuing professional development. Decisions about who should conduct the evaluation, what is to be evaluated, how it should be carried out, and about the goals and purposes of evaluation are outlined, noting that they presuppose an ideological view of the relationship of professional knowledge, values and practice. In a concluding discussion of evaluation and the control of professional knowledge, it is argued that the narrow, professional control of evaluation, buttressed by the quality assurance and monitoring mechanisms of the Colleges, is inappropriate, given the increasingly diverse accountabilities which affect medical professionals.

Education, Medical, Continuing↗
PubMed1997

Continuing education for medical professionals: a reflective model.

The Royal Colleges and their Faculties have moved continuing professional development up the agenda of doctors in the UK. The low educational value and failure to change professional practice of much continuing medical education has led to criticism of its emphasis on formal, didactic teaching and academic knowledge. The ubiquitous scientific or technical bias in medical education makes questionable assumptions about the nature of professional knowledge, how professionals learn, and the linkage of theory and practice in professional work. Given its narrow conception of professional knowledge, it is hardly surprising that the effectiveness of continuing medical education has proven difficult to evaluate. These points of criticism suggest that a more systematic and coherent approach to continuing education is required. The adoption of the concept of continuing professional development, which draws on learning by reflective practice, marks an important step in this direction. Continuing professional development emphasises self-directed learning, professional self-awareness, learning developed in context, multidisciplinary and multilevel collaboration, the learning needs of individuals and their organisations, and an inquiry-based concept of professionalism. It also involves a widening of accountability to patients, the community, managers and policymakers, and a form of evaluation which is internal, participatory and collaborative rather than external and scientific in character.

Clinical Competence↗
PubMed1997

Newborn screening for inborn errors of metabolism: a systematic review.

OBJECTIVES. To establish a database of literature and other evidence on neonatal screening programmes and technologies for inborn errors of metabolism. To undertake a systematic review of the data as a basis for evaluation of newborn screening for inborn errors of metabolism. To prepare an objective summary of the evidence on the appropriateness and need for various existing and possible neonatal screening programmes for inborn errors of metabolism in relation to the natural history of these diseases. To identify gaps in existing knowledge and make recommendations for required primary research. To make recommendations for the future development and organisation of neonatal screening for inborn errors of metabolism in the UK. HOW THE RESEARCH WAS CONDUCTED. There were three parts to the research. A systematic review of the literature on inborn errors of metabolism, neonatal screening programmes, new technologies for screening and economic factors. Inclusion and exclusion criteria were applied, and a working database of relevant papers was established. All selected papers were read by two or three experts and were critically appraised using a standard format. Seven criteria for a screening programme, based on the principles formulated by Wilson and Jungner (WHO, 1968), were used to summarise the evidence. These were as follows. Clinically and biochemically well-defined disorder. Known incidence in populations relevant to the UK. Disorder associated with significant morbidity or mortality. Effective treatment available. Period before onset during which intervention improves outcome. Ethical, safe, simple and robust screening test. Cost-effectiveness of screening. A questionnaire which was sent to all newborn screening laboratories in the UK. Site visits to assess new methodologies for newborn screening. The classical definition of an inborn error of metabolism was used (i.e., a monogenic disease resulting in deficient activity in a single enzyme in a pathway of intermediary metabolism). RESEARCH FINDINGS. INBORN ERRORS OF METABOLISM. Phenylketonuria (PKU) (incidence 1:12,000) fulfilled all the screening criteria and could be used as the 'gold standard' against which to review other disorders despite significant variation in methodologies, sample collection and timing of screening and inadequacies in the infrastructure for notification and continued care of identified patients. Of the many disorders of organic acid and fatty acid metabolism, a case can only be made for the introduction of newborn screening for glutaric aciduria type 1 (GA1; estimated incidence 1:40,000) and medium-chain acyl CoA dehydrogenase (MCAD) deficiency (estimated incidence 1:8000-1:15,000). Therapeutic advances for GA1 offer prevention of neurological damage but further investigation is required into the costs and benefits of screening for this disorder. MCAD deficiency is simply and cheaply treatable, preventing possible early death and neurological handicap. Neonatal screening for these diseases is dependent upon the introduction of tandem mass spectrometry (tandem MS). This screening could however also simultaneously detect some other commonly-encountered disorders of organic acid metabolism with a collective incidence of 1:15,000.(ABSTRACT TRUNCATED)

Cost-Benefit Analysis↗
PubMed1996

Continuing education for public health medicine--is it just another paper exercise?

In 1993 the Conference of Royal Colleges and their Faculties called for its members to develop formalized continuing medical education (CME) programmes. Most colleges have adopted a narrow definition of CME and a mechanistic approach to monitoring participation. The Faculty of Public Health Medicine has responded differently by initiating a broader model of continuing professional development (CPD) which emphasizes the individual nature of continuing education. This paper explores the rationale behind this decision. Recent systematic reviews of the effectiveness of CME have demonstrated the need for relevance in any continuing education activity. This means relevance not only to learning needs but also to current work and the applicability of the knowledge. However, the effectiveness of traditional CME for all doctors and particularly public health physicians remains to be established. Thus the Faculty has moved towards a wider context of learning in the form of CPD incorporating an evaluative approach and aspects of adult learning theory. There remains a need for the links between audit and continuing education to be strengthened.

Adult↗
PubMed1996

An evaluation of the prevalent round of the breast screening programme in south east Thames, 1988-1993: achievement of quality standards and population impact.

OBJECTIVE: To evaluate the impact of the prevalent round of the NHS breast screening programme on the whole population of women aged 50-64 during the period 1988-92, by comparing the numbers of cancers detected at screening with those diagnosed symptomatically, in one United Kingdom health region (population 3.5 million). To relate this impact to the achievement of national quality standards and the observed sensitivity and specificity of the programme. METHOD: The breast screening programme computer systems and the Thames Cancer Registry database were used to diagnose cancers in women aged 50-64 during the period 1988-1992, who were classified into screen detected, interval cases, eligible but not yet invited, non-attenders, and those not registered with the programme. RESULTS: The programme met all national quality assurance targets for uptake, diagnostic process, and detection, but screen detected cases comprised only 48% of those diagnosed during 1991 and 1992 when the breast screening programme was fully operational. As fewer than 40% of breast cancers registered occur in the eligible age range, this limits the impact of the programme to the possible early diagnosis of only 20% of all cases. A surprisingly high proportion occurred in women unknown to the programme, especially in inner London. The high number of interval cancers led to a programme sensitivity of only 73%, but 99.7% of women screening negative were correctly reassured as a result of screening- and for them the breast screening programme is a success. CONCLUSION: Despite achievement of quality standards, the breast screening programme is apparently having a low impact on the overall diagnosis of breast cancer in South East Thames, so a large mortality reduction due to screening alone is unlikely. Population coverage will need to be improved, and it may be necessary to reduce the screening interval, or extend the age range, or both.

Adult↗
PubMed1996

Knowledge based commissioning: can a national clinical effectiveness policy be compatible with seeking local professional advice?

OBJECTIVES: To help develop a means, based on the views of purchasers and providers of health care, of incorporating national research on clinical effectiveness into local professional advisory mechanisms in order to inform health care purchasing and contracting. METHODS: Three geographically based multidisciplinary workshops attended by National Health Service (NHS) staff drawn from the principal purchaser and provider groups in one English region were organized around the discussion of three health care purchasing case studies: coronary artery disease, diabetes and management of clinical depression in general practice. The proceedings were transcribed and analyzed using content analysis methods. RESULTS: 95 people took part. There were major differences between the purchasers' and health care providers' views on the right balance between local and national information and advisory sources for purchasing. In general, providers wanted the provision of advice to purchasers to be local, in which their opinion was sought, either individually or collectively, acted on and the results fed back to them. In contrast, health authority purchasers considered that local professionals were only one source of professional advice, albeit an important one, to be utilized in coming to decisions. General practitioner fundholders as purchasers, however, preferred to rely on their own experiences and contacts with local providers in making purchasing decisions. CONCLUSIONS: Professional specialist advisory groups are necessary to inform the purchasing of health care, but should extend beyond advising on the placement of individual contracts. Involving health care providers in all short-term contracting is unlikely to be cost-effective given the time commitment required. The emphasis at purchaser/provider meetings should be on education: providing an opportunity for purchasers and providers to develop closer relationships to discuss political imperatives and financial constraints; increasing communication and understanding of providers' and purchasers' roles; and providing an environment for professionals and purchasers to share their views on purchasing. As currently presented, elements of the national policies in the NHS advocating the use of both national evidence on clinical effectiveness and local professional advice are contradictory and should be clarified.

Community Health Planning↗
PubMed1995

Neural networks.

Explore the source record for details and available documents.

Adult↗
PubMed1995

Links between clinical audit and contracting systems.

In 1989, a programme of clinical audit was introduced throughout the UK National Health Service (NHS), in an attempt to improve care through the application of quality methodology to clinical issues. However, the role of clinical audit in the new NHS "internal market" is unclear. Reviews evidence on the development of audit and concludes that it has operated largely in isolation, under professional control. Central policy is now advocating greater purchaser and provider management involvement in audit, enabling feedback from and to service provision and management decisions. Where there are constructive local relationships the opening up of audit should be beneficial, but these do not always exist. Discusses a range of models for the interaction of clinical audit with wider NHS management systems. Recommends a split system of professionally controlled background audit and collaborative shared audits to balance conflicting goals.

Clinical Competence↗
PubMed1994

Comparison of asthmatic patients admitted to hospital from health districts experiencing high and low asthma mortality rates.

Geographical variation in asthma mortality rates within the United Kingdom could be a reflection of variability in effectiveness of medical care services, or epidemiological variation. In order to ascertain whether differing hospital admission processes could contribute to this variation, asthmatic patients admitted from two districts, experiencing above and below average mortality rates were compared. The present study was part of a cohort study of 1,200 consecutive acute adult admissions in 1987/88. In the main study, social data and information on referral were collected by interview for all patients. The admitting doctors' perception of the patient's severity was assessed on the basis of the severity of symptoms, and likelihood of morbidity or mortality if the patient was not admitted. Further information on asthmatic patients (treatment and physiological measurements) was retrieved from the notes. Sixty-six asthmatic patients resident in Wandsworth (a district with high asthma mortality rates) were admitted to St George's Hospital or St James' Hospital (WW) and 31 patients resident in East Surrey (ES) (a district with low asthma mortality rates) were admitted to the East Surrey Hospital (ESH). Notes were obtained on 55 (83%) and 27 (87%) of patients in the two districts, respectively. WW received significantly more patients by self-referral: 68% of patients called an ambulance or came directly to casualty compared with 30% in ES (chi-squared = 13.7, d.f. = 2, P = < 0.001). There was a tendency for more admissions to ESH to be taking oral steroids (chi-squared = 3.2, d.f. = 1, P = 0.07). Patients admitted in WW tended to have more severe disease: 39 (85%) of patients admitted to WW had peak expiratory flow less than 200 1/minute on admission compared to 14 (58%) in ES (chi-squared = 6, d.f. = 1, P = 0.01). In WW the mean first recorded peak expiratory flow on admission was 154 1/minute compared to 172 1/minute in ES; their mean peak flow on discharge was 318 1/minute compared with 377 1/minute in ES. Twenty-one (38%) of admissions in WW were considered to be very urgent by the admitting hospital doctor compared to four (15%) in ESH (chi-squared = 4.67, d.f. = 1, P = 0.03). This opportunistic study found that, in an area experiencing high mortality rates, more patients with severe disease were admitted to hospital compared to a low mortality area. This does not appear to be due to differing hospital practices but rather to increased levels of morbidity in the community. As patients with more severe asthma are at a greater risk of dying, these finding reinforce the need to standardize asthma treatment in the community.

Acute Disease↗
PubMed1993

The relationship between severe asthma and social class.

Asthma is one of the few diseases which has been reported to be common in the higher social classes. In order to assess the relationship between severe asthma and social class we analysed a national study of disabled adults undertaken by the Office of Population Censuses and Surveys (OPCS). The study estimated that there were 5.8 million people over 16 years with some degree of disability living in private households in England and Wales. Thirteen percent of disabilities were due to respiratory disease: 6% chronic bronchitis and emphysema, 3% asthma and allergy, and 4% other respiratory diseases. Among 10,000 individuals interviewed, 338 disabled adults reported asthma as a contributing cause of their disability. Of 291 cases with social class recorded, 41 (14%) were in social classes 1 and 2, 128 (44%) in social class 3, and 122 (42%) in social classes 4 and 5. An estimate of the relationship between social class and adult asthma in the general population was derived by calculating a morbidity ratio for the different social classes. The morbidity ratio for all social classes combined equals 100: for social classes 1 and 2 it was 63 (95% confidence intervals 48, 91); 93 (95% confidence intervals 77, 109) for social class 3; and 131 (95% confidence intervals 108, 153) for social classes 4 and 5. Adults in social classes 4 and 5 were approximately twice as likely to have severe asthma as those in social classes 1 and 2. This could be as a result of differences in the prevalence or treatment of asthma among the social classes.

Adolescent↗
PubMed1992

Trial of intensive compared with weekly speech therapy in preschool children.

Forty two preschool children referred to a speech therapy department were randomly allocated to receive intensive individual speech therapy or the more traditional once weekly approach. Boys and minority ethnic groups were referred most frequently. Speech therapy improved expression more than comprehension, as measured on Reynell scales. The mean improvements were 0.5 SDs (95% confidence intervals (CI) 0.3 to 0.7) and 0.3 (95% CI 0.1 to 0.5) respectively. There was a greater improvement in children receiving intensive compared with weekly therapy in the expression scores (0.8 SDs (95% CI 0.5 to 1.1) v 0.2 SDs (95% CI -0.1 to 0.5]. White and non-white children had similar improvements in comprehension scores but white children had greater improvement in expression scores (1.1 SDs v 0.3 SDs). This difference was seen in both therapy groups. Randomised trials are useful in the evaluation of speech therapy in children.

Child, Preschool↗