PubMed · 8314710
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R Rice. Suicidal thoughts or ideation.. https://pubmed.ncbi.nlm.nih.gov/8314710/
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OBJECTIVE: To assess the effect of using different risk calculation tools on how general practitioners and practice nurses evaluate the risk of coronary heart disease with clinical data routinely available in patients' records. DESIGN: Subjective estimates of the risk of coronary heart disease and results of four different methods of calculation of risk were compared with each other and a reference standard that had been calculated with the Framingham equation; calculations were based on a sample of patients' records, randomly selected from groups at risk of coronary heart disease. SETTING: General practices in central England. PARTICIPANTS: 18 general practitioners and 18 practice nurses. MAIN OUTCOME MEASURES: Agreement of results of risk estimation and risk calculation with reference calculation; agreement of general practitioners with practice nurses; sensitivity and specificity of the different methods of risk calculation to detect patients at high or low risk of coronary heart disease. RESULTS: Only a minority of patients' records contained all of the risk factors required for the formal calculation of the risk of coronary heart disease (concentrations of high density lipoprotein (HDL) cholesterol were present in only 21%). Agreement of risk calculations with the reference standard was moderate (kappa=0.33-0.65 for practice nurses and 0.33 to 0.65 for general practitioners, depending on calculation tool), showing a trend for underestimation of risk. Moderate agreement was seen between the risks calculated by general practitioners and practice nurses for the same patients (kappa=0.47 to 0.58). The British charts gave the most sensitive results for risk of coronary heart disease (practice nurses 79%, general practitioners 80%), and it also gave the most specific results for practice nurses (100%), whereas the Sheffield table was the most specific method for general practitioners (89%). CONCLUSIONS: Routine calculation of the risk of coronary heart disease in primary care is hampered by poor availability of data on risk factors. General practitioners and practice nurses are able to evaluate the risk of coronary heart disease with only moderate accuracy. Data about risk factors need to be collected systematically, to allow the use of the most appropriate calculation tools.
The introduction of an internal market in the National Health Service (NHS) in the United Kingdom necessitated the use of contracts between purchasers and providers. Little thought was given to the nature of these contracts by policy makers, who appeared to assume that the contracts could conform to the classical, complete model. This paper uses socio-legal and economic theories of contract (which provide an alternative model of relational contracts, in contrast to classical contracts) to explore how realistic that assumption was. An analysis of the institutional context in which the contracts were made is provided, including a legal analysis of the relevant legislation. Contracting by health authorities and GP fundholders is examined, using the results of a recent case study of contracting for district nursing services carried out in a health authority in Greater London. The results show that classical contracting is an inappropriate model for NHS contracts, but that relational contracting is not an entirely appropriate model either. Contracting was found to have increased the accountability of providers in respect of some financial matters, but not in respect of the quality of district nursing services. There are negative implications for the use of contracting in publicly financed health services--hierarchies may be more efficient (as lower transaction costs can be incurred) and possibly more effective in improving quality of care.
AIMS: The aim of this paper is to provide an in-depth analysis of the concept of equity in the British health visiting service and thus facilitate understanding of the term. An attempt has been made to apply the analytical process to the context of health visiting. BACKGROUND: Equity has been discussed at some length in the health literature. Much of this including the health visiting literature discusses inequality and inequalities in health at the same time as discussing equity. Increasingly, poverty and inequalities have become accepted as determinants in poor health. It seemed appropriate therefore to analyse these topical and seemingly related concepts. METHODS: A well established method of concept analysis has been utilized to facilitate the process of analysis. RESULTS: Confusion between the meaning and application of the concepts of equity and equality was found. Much of the health visiting and health care literature related to addressing the needs of groups who experience inequality in terms of service provision, and access to services. Following an in-depth critical analysis of the literature three critical attributes of the concept were identified: equal opportunity of access to services; a high standard of service for everyone; and unequal distribution of services to meet unequal need. These relate to two distinct forms of equity: horizontal and vertical equity. A definition of equity has been proposed. Maxwell's (1992) framework is suggested as a means to evaluate equity in service provision and uptake. CONCLUSIONS: Most of the literature examines equity at a macro level, that is service level. Nurses and health visitors are urged to examine the services that they are involved in to determine the level of equity that is achieved or not attained. Suggestions have been offered as to how this task may be undertaken. A definition has been proposed to stimulate debate and discussion about the concept within nursing contexts.