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Biomedical subjects

Paul Roderick

Publications and source records attributed to Paul Roderick.

15 recordsLinked to original sources
PubMed2004

Modifiable risk factors for non-adherence to immunosuppressants in renal transplant recipients: a cross-sectional study.

BACKGROUND: Non-adherence to immunosuppressants is a major cause of renal transplant failure. Interventions to improve adherence need to target modifiable risk factors. METHODS: Adherence was measured using the 'gold standard' measure of electronic monitoring in 58 adult renal transplant recipients from a UK transplant unit. Subjects were identified from a stratified random sample of 153 recipients recruited to a larger cross-sectional study comparing different measures of adherence. Inclusion criteria included age over 18 years and a functioning renal transplant, transplanted 6-63 months previously. Exclusion criteria included residence outside the region served by the unit and inability to give informed consent. Health beliefs, depression and functional status were measured using standardized questionnaires (Beliefs about Medicines Questionnaire, Illness Perception Questionnaire, Revised Clinical Interview Schedule and SF-36) and semi-structured interview. Transplant and demographic details were collected from the notes. RESULTS: Seven [12%, 95% confidence interval (CI) 4-20%] subjects missed at least 20% of days medication and 15 (26%, 15-37%) missed at least 10% of days. Lower belief in the need for medication and having a transplant from a live donor were the major factors associated with non-adherence. Depression was common, although not strongly associated with non-adherence. CONCLUSIONS: Beliefs about medication are a promising target for interventions designed to improve adherence. The lower adherence in recipients of transplants from live donors needs confirming but may be clinically important in light of the drive to increase live donation.

Adult↗
PubMed2004

Distance, rurality and the need for care: access to health services in South West England.

BACKGROUND: This paper explores the geographical accessibility of health services in urban and rural areas of the South West of England, comparing two measures of geographical access and characterising the areas most remote from hospitals.Straight-line distance and drive-time to the nearest general practice (GP) and acute hospital (DGH) were calculated for postcodes and aggregated to 1991 Census wards. The correlation between the two measures was used to identify wards where straight-line distance was not an accurate predictor of drive-time. Wards over 25 km from a DGH were classified as 'remote', and characterised in terms of rurality, deprivation, age structure and health status of the population. RESULTS: The access measures were highly correlated (r2>0.93). The greatest differences were found in coastal and rural wards of the far South West. Median straight-line distance to GPs was 1 km (IQR = 0.6-2 km) and to DGHs, 12 km (IQR = 5-19 km). Deprivation and rates of premature limiting long term illness were raised in areas most distant from hospitals, but there was no evidence of higher premature mortality rates. Half of the wards remote from a DGH were not classed as rural by the Office for National Statistics. Almost a quarter of households in the wards furthest from hospitals had no car, and the proportion of households with access to two or more cars fell in the most remote areas. CONCLUSION: Drive-time is a more accurate measure of access for peripheral and rural areas. Geographical access to health services, especially GPs, is good, but remoteness affects both rural and urban areas: studies concentrating purely on rural areas may underestimate geographical barriers to accessing health care. A sizeable minority of households still had no car in 1991, and few had more than one car, particularly in areas very close to and very distant from hospitals. Better measures of geographical access, which integrate public and private transport availability with distance and travel time, are required if an accurate reflection of the experience those without their own transport is to be obtained.

Journal Article↗
PubMed2004

Frequency and impact of nonadherence to immunosuppressants after renal transplantation: a systematic review.

Nonadherence to immunosuppressants is recognized to occur after renal transplantation, but the size of its impact on transplant survival is not known. A systematic literature search identified 325 studies (in 324 articles) published from 1980 to 2001 reporting the frequency and impact of nonadherence in adult renal transplant recipients. Thirty-six studies meeting the inclusion criteria for further review were grouped into cross-sectional and cohort studies and case series. Meta-analysis was used to estimate the size of the impact of nonadherence on graft failure. Only two studies measured adherence using electronic monitoring, which is currently thought to be the most accurate measure. Cross-sectional studies (n=15) tended to rely on self-report questionnaires, but these were poorly described; a median (interquartile range) of 22% (18%-26%) of recipients were nonadherent. Cohort studies (n=10) indicated that nonadherence contributes substantially to graft loss; a median (interquartile range) of 36% (14%-65%) of graft losses were associated with prior nonadherence. Meta-analysis of these studies showed that the odds of graft failure increased sevenfold (95% confidence interval, 4%-12%) in nonadherent subjects compared with adherent subjects. Standardized methods of assessing adherence in clinical populations need to be developed, and future studies should attempt to identify the level of adherence that increases the risk of graft failure. However, this review shows nonadherence to be common and to have a large impact on transplant survival. Therefore, significant improvements in graft survival could be expected from effective interventions to improve adherence.

Graft Rejection↗
PubMed2004

Measuring compliance with drug regimens after renal transplantation: comparison of self-report and clinician rating with electronic monitoring.

Nonadherence to immunosuppressants in renal transplant recipients is a major factor affecting graft survival, but it is difficult to detect accurately in clinical practice. Adherence was measured in 153 adult renal transplant recipients using self-report questionnaires and interview, clinician rating, and cyclosporine levels. The sensitivity and specificity of these measures were determined by comparison with electronic monitoring in a randomly selected subsample of 58 subjects. Measures of adherence in current clinical use do not perform well when tested against electronic monitoring. Self-report at a confidential interview was the best measure of adherence for the detection of both missed doses and erratic timing of medication. However, the use of a confidential interview is not directly applicable to a clinical setting. Further research on how best to facilitate disclosure in clinical settings may be the best way to develop adherence measures for use in routine practice.

Adult↗
PubMed2004

A clinical and cost evaluation of hemodialysis in renal satellite units in England and Wales.

BACKGROUND: The prevalence rate of renal replacement therapy in the United Kingdom has increased significantly, particularly by long-term hemodialysis (HD) therapy in renal satellite units (RSUs). These are largely nurse-run units linked to main renal units (MRUs). We compared outcomes, processes of care, and costs in RSUs with those in MRUs. METHODS: A cross-sectional comparison was performed of HD patients from a representative sample of 12 RSUs in England and Wales and HD patients in the linked MRUs deemed suitable by the senior nurse for RSU care. Data for patient characteristics, clinical process and outcome measures, health-related quality of life (HRQoL), and patient satisfaction were collected. A partial analysis of National Health Service and social care costs was undertaken. Geographic access was assessed by road time and distance traveled to dialysis sessions. RESULTS: Seven hundred thirty-six of 895 eligible patients (82%) participated. RSU patients were older (mean age, 63 versus 57 years), but had comorbidity similar to that of MRU patients. There were no significant differences in most processes of care or clinical outcomes; achievement of standards for adequacy of dialysis (urea reduction ratio) was significantly greater in RSU patients and hospitalization in the last year was less frequent. Patient HRQoL was similar, but patient satisfaction was greater in RSU patients. RSU patients potentially saved 19 minutes traveling for each dialysis session. Costs for routine dialysis and health/social care were similar. CONCLUSION: RSUs appear to be as effective as main HD units for a wide spectrum of patients, improve geographic access, and are more acceptable to patients. There is evidence that they are as cost-effective as main units.

Adolescent↗
PubMed2004

Simulation model of renal replacement therapy: predicting future demand in England.

BACKGROUND: The demand for renal replacement therapy (RRT) in England has risen steadily, although from a lower base than many other developed countries. Predicting the future demand for RRT and the impact of factors such as the acceptance rate, transplant supply and patient survival, is required in order to inform the planning of such services. METHODS: A discrete event simulation model estimates the future demand for RRT in England in 2010 for a range of scenarios. The model uses current prevalence and current and projected future acceptance rates, survival rates and the transitions between modalities to predict future patient numbers. National population and mortality data, published literature and data from the UK Renal Registry and UK Transplant, are used to estimate unmet need for RRT, the impact of changing demography and incidence of Type 2 diabetes, patient haemodialysis (HD) survival and transplant supply. RESULTS: By 2010 the predicted prevalence will have increased from about 30,000 in 2000 to between 42 and 51,000 (900-1000 p.m.p.), an average annual growth of 4.5-6%. Changing transplant supply has a small effect on overall numbers but changes the proportion of patients with functioning graft by up to 8%. Even with an optimistic increase in transplant supply (11% p.a. for 5 years), numbers on HD will continue to rise substantially, especially in the elderly. The factors most influencing future patient numbers are the acceptance rate and dialysis survival. CONCLUSION: This model predicts a substantial growth in the RRT population to 2010 to a rate approaching 1000 p.m.p., particularly in the elderly and those on HD, with a steady state not being reached for at least 25 years.

Adolescent↗
PubMed2004

Community hospitals: an under-recognized resource for palliative care.

In the UK there are concerns that, in certain groups of dying patients such as the old, those with non-cancer diagnoses and those in rural areas, the quality of care is unacceptably variable. There has been no systematic survey of the extent to which community hospitals provide general palliative care for such patients. Therefore, by means of a structured questionnaire we asked senior nurses/managers at all 478 community hospitals in the UK for information on staff expertise, facilities and specialist equipment, liaison arrangements with specialist palliative care providers, priorities, practice and policy in end-of-life care. Of the 346 hospitals (72%) that responded, only 28 were in urban areas. 73% of hospitals employed at least one nurse with additional training in palliative care, 72% had access to 24-hour specialist palliative care advice and 51% had separate overnight accommodation for relatives, but only 22% had designated palliative care beds. Most hospitals did not have written policies or guidelines for patient assessment or symptom control. These findings add to evidence that community hospitals represent an important resource to improve access to palliative care for groups that are currently under-served.

Health Facility Size↗
PubMed2003

A population-based study of the incidence and outcomes of diagnosed chronic kidney disease.

BACKGROUND: This study aims to determine the incidence rate and prognosis of detected chronic kidney disease (CKD) in a defined population. METHODS: This is a retrospective cohort study of all new cases of CKD from Southampton and South-West Hampshire Health Authority (population base, 405,000) determined by a persistently increased serum creatinine (SCr) level (>or=1.7 mg/dL [>or=150 micromol/L] for 6 months) identified from chemical pathology records. Follow-up was for a mean of 5.5 years for survival, cause of death, and acceptance to renal replacement therapy (RRT). RESULTS: The annual incidence rate of detected CKD was 1,701 per million population (pmp; 95% confidence interval [CI], 1,613 to 1,793) and 1,071 pmp (95% CI, 1,001 to 1,147) in those younger than 80 years. There was a steep age gradient; median age was 77 years. The man-woman rate ratio was 1.6 (95% CI, 1.4 to 1.8), with a male excess in all age groups older than 40 years. Incidence increased in areas with greater socioeconomic deprivation. Median survival was 35 months. Age, SCr level, and deprivation index were all significantly associated with survival. Standardized mortality ratios were 36-fold in those aged 16 to 49 years, 12-fold in those aged 50 to 64 years, and more than 2-fold in those older than 65 years. Cardiovascular disease (CVD) was the most common cause of death (46%). Only 4% of patients were accepted to RRT. CONCLUSION: The incidence of diagnosed CKD is common, especially in the elderly, and is greater in more deprived areas. Prognosis is poor, with CVD prominent. More research is needed to assess the effectiveness and costs of increasing referral to nephrologists of patients with CKD.

Adolescent↗
PubMed2003

Comparison of apparent efficiency of haemodialysis satellite units in England and Wales using data envelopment analysis.

OBJECTIVES: To expand care for chronic haemodialysis (HD) patients throughout England and Wales by studying two aspects of service delivery that are important: to identify relative performance of haemodialysis satellite units (HDSUs), and understand the factors that influence the performance. As a first step toward these aspects, this work reports a study of apparent comparative efficiency in the delivery of HDSUs and demonstrates the potential of data envelopment analysis (DEA). METHODS: DEA was applied to data obtained from a national survey of the organizational structures and processes of delivering care at HDSUs in England and Wales. RESULTS: DEA was found to be a judicious approach for performance assessment of HDSUs, although valid results depend on appropriate model specification and quality of data available. The available data were not of sufficient comprehensiveness or quality to produce definitive results but suggested that overall efficiency could improve; these data suggested by as much as 10% overall (mean efficiency score 90%) and variably within the sample (46 [65%] that HDSUs were potentially inefficient, the lowest unit scoring 38%). CONCLUSIONS: Addressing questions raised by comparative inefficiency could help plans to improve capacity to deal with the growing demand for HD delivered in HDSUs. The application was an important start and needs to be followed by further research to establish model validity and obtain authoritative results.

Ambulatory Care Facilities↗
PubMed2002

A simulation to evaluate screening for Helicobacter pylori infection in the prevention of peptic ulcers and gastric cancers.

A discrete event simulation model has evaluated a screening programme for Helicobacter pylori infection (H. pylori) in which individuals under the age of 50 years would be screened once. Eradication of H. pylori would reduce the peptic ulcer risk immediately and the gastric cancer risk after a fixed delay. The data were derived from published databases and peer reviewed papers. The simulation model, using variance reduction techniques, predicted that a screening programme would reduce morbidity and deaths but could cost around 19 million pounds for England and Wales in the first year of screening. A factorial design analysis showed the sensitivity of key variables. An increase in the opportunistic testing was found significantly to reduce the impact of screening.

Adult↗
PubMed2002

The development of a simulation model of the treatment of coronary heart disease.

A discrete event simulation models the progress of patients who have had a coronary event, through their treatment pathways and subsequent coronary events. The main risk factors in the model are age, sex, history of previous events and the extent of the coronary vessel disease. The model parameters are based on data collected from epidemiological studies of incidence and prognosis, efficacy studies. national surveys and treatment audits. The simulation results were validated against different sources of data. The initial results show that increasing revascularisation has considerable implications for resource use but has little impact on patient mortality.

Aged↗
PubMed2002

Late referral for end-stage renal disease: a region-wide survey in the south west of England.

BACKGROUND: The proportion of patients referred for renal replacement therapy (RRT) at a late stage of disease appears to be similar to that first described nearly 20 years ago. This study investigated the current scale of the problem in a large region in England, identifying the prior health care, patient characteristics, referral pattern, and outcomes of those accepted onto RRT. METHODS: Three hundred and sixty-one (88%) out of 411 patients accepted for RRT in six renal units in the South and West Region of the UK between 1 June 1996 and 31 May 1997 were studied retrospectively. We examined the history of chronic renal failure, referral path to nephrologist, management of chronic renal failure (CRF) and patient outcomes. Patients were categorized as 'late' if they were referred to the renal unit either within 4 months or within 1 month of requiring RRT. RESULTS: One hundred and twenty-four (35%) patients were referred within 4 months of RRT, and 84 (23%) within 1 month. The main differences between patients referred later and other patients was seen for those referred within 1 month. These patients were older and had more co-morbidity, significantly worse laboratory parameters at the start of RRT, were less likely to have received standard treatments for CRF, had less permanent dialysis access in place at the start of RRT (18% vs 47%, P=0.001), and had a significantly longer hospital stay (18 vs 10 days, P=0.001). Seventy-four (19%) patients died in the first 6 months: 27 (32%) in the 1-month group, 46 (16%) in all others (P=0.002). We found no evidence that patients referred late had defaulted from nephrology follow-up or had an excess of rapidly progressive disease. Though data were incomplete, there was evidence of prior CRF of over 1 year in all late referral groups. CONCLUSION: Nearly a quarter of patients are referred for specialist nephrology treatment at a very late stage, within 1 month of RRT. They are less likely to receive interventions that could alter the progression of CRF or reduce its associated co-morbidity, have a worse clinical state at the start of RRT, longer hospitalization and poorer survival. These differences were much less marked for those referred within 1-4 months of starting RRT, although this is an insufficient time to prepare for RRT. Further research is needed to determine the missed opportunities for more proactive diagnosis and management of CRF.

Aged↗
PubMed2002

How many patients with haematological malignancy need the facilities offered by a district general hospital?

BACKGROUND: The objective of the study was to study the utilization of specialist clinical services for haematological malignancy in a defined patient population. Patients with haematological malignancy are mostly aged over 65 years. Demographic projections for the United Kingdom suggest that the incidence of haematological malignancy will increase by 20 per cent in the next 20 years, mostly as a result of demographic change. METHODS: A prevalence survey was carried out of out-patients with haematological malignancy resident in the New Forest area and their utilization of haematology clinical services at two sites. RESULTS: One hundred and ten patients (60 male, 50 female) were identified over three months: 87 (79 per cent) were aged over 65 years. Follow-up and therapy were carried out at a community hospital at Lymington, 19 miles from Southampton, in 83 patients (79 per cent, 45 male, 38 female, median age 74.9 years), and at one of two large hospitals in Southampton in 27 patients (21 per cent, 15 male, 12 female, median age 73.8 years). Attendance for more complex treatment at Southampton was necessary for 10 patients (9 per cent) in the Lymington group. Most interventions in both groups (356/379; 94 per cent) were basic, and were available and undertaken at either study site. Only 23/379 (6 per cent) of interventions required by the patient sample were more complex. CONCLUSIONS: Most haematological malignancies are chronic disorders with a simple clinical management plan, requiring periodic clinical monitoring. A consultant-led haematology clinic supported by access to multipurpose day treatment facilities in the community hospital allowed 75 per cent of patients to receive their care at a more geographically convenient location, important for conditions in which 79 per cent of patients are aged over 65 years, and in which this proportion will increase. Only a minority of cases require care in specialist hospital haematology units; the majority can be managed using community-based haematological follow-up care. Future studies are needed to assess cost-effectiveness and the impact on primary care of increasing the use of community-based treatment facilities.

Aged↗