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Biomedical subjects

S Farrar

Publications and source records attributed to S Farrar.

At least 19 recordsLinked to original sources
PubMed2001

Integrated model for mental health care. Are health care providers satisfied with it?

OBJECTIVE: To determine whether health care providers are satisfied with an integrated program of mental health care. DESIGN: Surveys using a mailed questionnaire. Surveys were developed for each of the three disciplines; each survey had 30 questions. SETTING: Thirty-six primary care practices in Hamilton, Ont, participating in the Hamilton-Wentworth Health Service Organization's Mental Health Program. PARTICIPANTS: Family physicians, psychiatrists, and mental health counselors providing mental health care in primary care settings. MAIN OUTCOME MEASURE: Satisfaction as shown on 5-point Likert scales. RESULTS: High levels of satisfaction with the model were recorded. Family physicians increased their skills, felt more comfortable with handling mental health problems, and were satisfied with the benefit to their patients. Psychiatrists and counselors were gratified that they were accepted by other members of the primary care team. Areas for improvement included finding space in primary care settings and better scheduling to allow for optimal communication. CONCLUSION: Family physicians, counselors, and psychiatrists expressed great satisfaction with a shared mental health care program based in primary care.

Adult↗
PubMed2000

Using discrete choice modelling in priority setting: an application to clinical service developments.

Limited resources for health care means that techniques are required to aid the process of priority setting. This paper represents one of the first attempts to use discrete choice modelling (DCM) within the area of priority setting. It is shown how the technique can be used to estimate cost per unit of benefit ratios for competing clinical service developments. Integer programming is proposed as a method to be used, alongside DCM, to help policy makers select the optimal combination of clinical service developments within a given budget. The technique is also shown to be internally valid and internally consistent. It is argued that DCM is a potentially useful technique to be used within the area of priority setting more generally. However, further work is required to address methodological issues around the technique.

Adult↗
PubMed2000

Sedative but not anxiolytic properties of benzodiazepines are mediated by the GABA(A) receptor alpha1 subtype.

Inhibitory neurotransmission in the brain is largely mediated by GABA(A) receptors. Potentiation of GABA receptor activation through an allosteric benzodiazepine (BZ) site produces the sedative, anxiolytic, muscle relaxant, anticonvulsant and cognition-impairing effects of clinically used BZs such as diazepam. We created genetically modified mice (alpha1 H101R) with a diazepam-insensitive alpha1 subtype and a selective BZ site ligand, L-838,417, to explore GABA(A) receptor subtypes mediating specific physiological effects. These two complimentary approaches revealed that the alpha1 subtype mediated the sedative, but not the anxiolytic effects of benzodiazepines. This finding suggests ways to improve anxiolytics and to develop drugs for other neurological disorders based on their specificity for GABA(A) receptor subtypes in distinct neuronal circuits.

Allosteric Site↗
PubMed1999

theta, a novel gamma-aminobutyric acid type A receptor subunit.

gamma-Aminobutyric acid type A (GABA-A) receptors are a major mediator of inhibitory neurotransmission in the mammalian central nervous system, and the site of action of a number of clinically important drugs. These receptors exist as a family of subtypes with distinct temporal and spatial patterns of expression and distinct properties that presumably underlie a precise role for each subtype. The newest member of this gene family is the theta subunit. The deduced polypeptide sequence is 627 amino acids long and has highest sequence identity (50.5%) with the beta1 subunit. Within the rat striatum, this subunit coassembles with alpha2, beta1, and gamma1, suggesting that gamma-aminobutyric acid type A receptors consisting of arrangements other than alpha beta + gamma, delta, or epsilon do exist. Expression of alpha2beta1gamma1theta in transfected mammalian cells leads to the formation of receptors with a 4-fold decrease in the affinity for gamma-aminobutyric acid compared with alpha2beta1gamma1. This subunit has a unique distribution, with studies so far suggesting significant expression within monoaminergic neurons of both human and monkey brain.

Amino Acid Sequence↗
PubMed1999

Molecular and functional diversity of the expanding GABA-A receptor gene family.

Fast inhibitory neurotransmission in the mammalian CNS is mediated primarily by the neurotransmitter gamma-aminobutyric acid (GABA), which, upon binding to its receptor, leads to opening of the intrinsic ion channel, allowing chloride to enter the cell. Over the past 10 years it has become clear that a family of GABA-A receptor subtypes exists, generated through the coassembly of polypeptides selected from alpha 1-alpha 6, beta 1-beta 3, gamma 1-gamma 3, delta, epsilon, and pie to form what is most likely a pentomeric macromolecule. The gene transcripts, and indeed the polypeptides, show distinct patterns of temporal and spatial expression, such that the GABA-A receptor subtypes have a defined localization that presumably reflects their physiological role. A picture is beginning to emerge of the properties conferred to receptor subtypes by the different subunits; these include different functional properties, differential modulation by protein kinases, and the targeting to different membrane compartments. These properties presumably underlie the different physiological roles of the various receptor subtypes. Recently we have identified a further member of the GABA-A receptor gene family, which we have termed theta, which appears to be most closely related to the beta subunits. The structure, function, and distribution of theta-containing receptors, and receptors containing the recently reported epsilon subunit, are described.

Benzodiazepines↗
PubMed1999

Response-ordering effects: a methodological issue in conjoint analysis.

Conjoint analysis is a technique relatively new to the evaluation of health care services in the UK. The technique uses data generated from questionnaires. This paper addresses the issue of response-ordering effects that may result from the ordering of dimensions of benefit within a question. Two questionnaires were given to 216 hospital consultants as part of a priority setting exercise. These were identical other than the ordering of the dimensions within each question. The regression analysis was segmented according to questionnaire type and the coefficients of the segmentation were tested for statistically significant differences. The results show no evidence of ordering effects.

Health Services Research↗
PubMed1998

Consumer health information services: preliminary findings about who is using them.

Focus groups and in-depth telephone interviews were used to develop a telephone questionnaire later completed by people 55 years and older about their use of a Health Information Support Telephone Service (HISTS). Preliminary findings identified an equal number of well educated male and female callers, who called for information for themselves. The confidentially of the service was very important to respondents and may have impacted the time to recruit people for the focus groups. The second study described is a pilot test completed by three Consumer Health Information/Resource Centres (CHIRC). An Info Script was used by health professionals to direct people to information centres. Preliminary results indicate that over half of the participants stated they visited the information centre because they were given an Info Script and that they would not have gone without the Info Script.

Adult↗
PubMed1998

Photoaffinity labeling of the benzodiazepine binding site of alpha1beta3gamma2 gamma-aminobutyric acidA receptors with flunitrazepam identifies a subset of ligands that interact directly with His102 of the alpha subunit and predicts orientation of these within the benzodiazepine pharmacophore.

Photoincorporation of ligands into the benzodiazepine site of native gamma-aminobutyric acidA (GABAA) receptors provides useful information about the nature of the benzodiazepine (BZ) binding site. Photoincorporation of flunitrazepam into a single population of GABAA receptors, recombinant human alpha1beta3gamma2, was investigated to probe further the mechanism and orientation of flunitrazepam and other ligands in the BZ binding site. It was concluded that the receptor is primarily derivatized with the entire, unfragmented, flunitrazepam molecule, which undergoes a conformational change during photolysis and largely vacates the benzodiazepine binding site. Investigation of the BZ site after photoincorporation of [3H]flunitrazepam confirmed that binding of other radioligands was unaffected by incorporation of flunitrazepam. This did not correlate with their efficacy but depended on the presence of particular structural features in the molecule. It was observed that affected compounds have a pendant phenyl moiety, analogous to the 5-phenyl group of flunitrazepam, which are proposed to overlap and interact with the same residue or residues in the BZ binding site. Because the major site of flunitrazepam photoincorporation has been shown to be His102, we propose that this group of compounds interacts directly with His 102, whereas compounds of other structural types have no direct interaction with this amino acid. The orientation of ligands within the BZ binding site and their specific interaction with identified amino acids are not well understood. The data in the current study indicate that His102 interacts directly with the pendant phenyl group of diazepam, and further implications for the pharmacophore of the BZ binding site are discussed.

Azides↗
PubMed1997

Assessing community values in health care: is the 'willingness to pay' method feasible?

In this paper an economics approach to assessing community values in health care priority setting is examined. The approach is based on the concept of 'willingness to pay' (WTP). Eighty two parents were interviewed with regard to three aspects of provision of child health services. For each aspect a choice of two courses of action was presented. Parents were asked which course of action they preferred and what was the maximum amount of money they would be prepared to pay for this rather than their less preferred option. WTP responses are acceptable to the majority of respondents and appear to 'behave' in accordance with a priori expectations. A method of assessing the influence of ability to pay on preferences and WTP is outlined. Preferences and WTP do not appear to have been unduly distorted by ability to pay. Use of WTP data does have the potential to provide health care purchasers and providers with information on intensity as well as direction of the preferences of members of the community.

Child↗
PubMed1997

Providing psychiatric backup to family physicians by telephone.

OBJECTIVE: To examine whether links between psychiatric services and family physicians can be strengthened and additional support provided for family physicians if a psychiatrist is available by phone to respond to clinical calls from family physicians. METHOD: A psychiatrist, who visited 18 family physicians in 5 practices on a regular basis to provide clinical consultations, was available to provide telephone backup concerning mental health problems the family physicians encountered. All calls received by the psychiatrist were documented and analysed at the end of a 12-month period. RESULTS: Over the course of one year, 128 calls were received from the 5 practices. Fifty were considered urgent, while 78 involved more routine management or medication issues. Telephone advice enabled the family physicians to handle these cases more effectively, often reducing utilization of other mental health services and providing support that was not otherwise available. The average time spent per call was 8 minutes, which meant the psychiatrist was only spending 20 minutes per week on the phone responding to family physicians' requests. CONCLUSION: Providing telephone backup to family physicians is a time-efficient and effective method of supporting family physicians and reducing utilization of mental health services. It is applicable to psychiatrists working in any clinical setting.

Cooperative Behavior↗
PubMed1997

Sharing care: the psychiatrist in the family physician's office.

OBJECTIVE: One way of strengthening ties between primary care providers and psychiatrists is for a psychiatrist to visit a primary care practice on a regular basis to see and discuss patients and to provide educational input and advice for family physicians. This paper reviews the experiences of a program in Hamilton, Ontario that brings psychiatrists and counsellors into the offices of 88 local family physicians in 36 practices. METHOD: Data are presented based on the activities of psychiatrists working in 13 practices over a 2-year period. Data were gathered from forms routinely completed by family physicians when making a referral and by psychiatrists whenever they saw a new case. An annual satisfaction questionnaire for all providers participating in the program was also used to gather information. RESULTS: Over a 2-year period, 1021 patients were seen in consultation by one full-time equivalent psychiatrist. The average duration of a consultation was 51 minutes, and a family member was present for 12% of the visits. Twenty-one percent of the patients were seen for at least one follow-up visit, 75% of which were prearranged. In addition, 1515 cases were discussed during these visits without the patient being seen. All participants had a high satisfaction rating for their involvement with the project. CONCLUSIONS: Benefits of this approach include increased accessibility to psychiatric consultation, enhanced continuity of care, support for family physicians, and improved communication between psychiatrists and family physicians. This model, which has great potential for innovative approaches to continuing education and resident placements, demands new skills of participating psychiatrists.

Consumer Behavior↗
PubMed1996

Using economics alongside medical audit. A case study of the management of endometriosis.

During 1993, the diagnosis and initial management of endometriosis in women was identified as an important topic to be addressed within the Gynaecology Audit Project in Scotland (GAPS). This paper documents the experience of using the medical audit data collected by this exercise to estimate the costs and outcomes associated with alternative treatments for endometriosis associated infertility. Its aim is not to draw firm policy conclusions but rather to demonstrate the economic methods and to highlight difficulties in the application of economics to audit. The average cost of medical management was found to be significantly higher than the average cost of expectant management because of the high costs of the drugs involved. There was little difference in clinical and health outcomes observed between those women managed expectantly and those women managed medically. The results of the economic assessment add cautious support to the growing volume of clinical evidence indicating expectant management as the first line treatment of choice although further research is required to substantiate these results in a larger sample of women presenting with this condition.

Endometriosis↗
PubMed1993

Prostitution and risk of HIV: female prostitutes in London.

OBJECTIVE: To measure the prevalence of HIV and to describe established risk factors in female prostitutes. DESIGN: A cross sectional survey. SETTING: A genitourinary medicine clinic, streets, and magistrates' courts in London. SUBJECTS: 280 female prostitutes recruited between April 1989 and August 1991. MAIN OUTCOME MEASURES: Infection with HIV-1, reported risk behaviours, and prevalence of sexually transmitted infections. RESULTS: 228 of the women had HIV tests, and two (0.9% (95% confidence interval 0% to 2.1%)) were infected with HIV-1. Reported use of condoms was high for commercial clients and low for non-paying partners: 98% (251/255) of women used condoms with all clients and 12% (25/207) with non-paying partners for vaginal intercourse. Twenty two women were current or past injecting drug users. Of the 193 women examined for sexually transmitted infections, 27 had an acute infection (gonorrhoea, chlamydia, trichomonas, or primary genital herpes) at the time of interview. Infection was associated with younger age and increasing numbers of non-paying sexual partners, but not with duration of prostitution, numbers of clients, or reports of condom failures. When age and numbers of non-paying partners were analysed by logistic regression they remained significantly associated with sexually transmitted infections. CONCLUSIONS: A large and diverse sample of prostitutes had a low prevalence of infection with HIV and high levels of use of condoms in commercial sex. There was a significant risk of other sexually transmitted infections associated with prostitutes' non-commercial sexual relationships, in which unprotected sex is common. Interventions to reduce the risk of sexually transmitted infections in prostitutes should address both commercial and non-commercial sexual partnerships.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Needs assessment: developing an economic approach.

Health authorities and health boards in the UK are required under the provisions of the NHS Act, 1990, to assess the needs of their resident populations for health care and, through contracting, to act as purchasers of services informed by those needs. This paper presents an economic approach to informing the purchaser on priority setting for contracting. For illustrative purposes, the technique is applied to services for elderly people with dementia. The paper demonstrates that an economic approach to needs assessment is both desirable and practicable.

Aged↗
PubMed1993

Teaching and research in hospitals: implications for the NHS reforms.

In this paper the implications of the support of undergraduate medical education and research for the new NHS market are examined. Inaccuracies in current methods of distribution of the Service Increment for Teaching and Research (SIFTR) and Additional Cost of Teaching and Research (ACTR) monies will have adverse effects. Receipt of too much money results in providers' care being unfairly subsidised while receipt of too little results in providers bearing an unfair burden of the cost of teaching and research. Results are reported from a study in the north east of Scotland with regard to the feasibility of obtaining more accurate estimates of the costs to the NHS of supporting teaching and research. The choice is between potentially accurate, but cumbersome and costly, systems of data collection or the continuation of the current, more arbitrary, approach of allocating monies. A combination of the two is recommended.

Attitude of Health Personnel↗
PubMed1993

NHS reforms and resource management: whither the hospital?

This paper considers whether resource management (RM) as currently constituted in the National Health Service (NHS) is likely to fulfil its aim of efficiency. For the individual hospital RM has two key features: changes in managerial structure and changes in information systems. The paper assesses the extent to which the hospital behavioural model that implicitly underlies RM can be judged to reflect well the actual behaviour of hospitals. It is noteworthy that in the RM literature there is no explicit statement about the assumed underlying behaviour of the NHS hospital. Here the author selects the Harris model of hospital behaviour as providing the best explanation of internal hospital organisation. Harris represents the two lines of authority, physicians and administrators (managers in the present-day NHS), as two firms within the hospital structure, each with its own managers, objectives and constraints, making this model particularly appealing as a basis for analysing RM. Using this model the paper concludes that RM alone and as currently constituted will not be successful in promoting efficiency, because the structural and cultural mechanisms put in place by RM will not sufficiently affect physician behaviour.

Economic Competition↗