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PubMed1998

Patient removals from general practitioner lists in Northern Ireland: 1987-1996.

BACKGROUND: Being struck off a general practitioner's list is a major event for patients and a subject for much media attention. However, it has not hitherto received much research attention. AIMS: To quantify the numbers of patients removed at doctors' request in Northern Ireland between 1987 and 1996. To describe the characteristics of those removed and to determine if the rate of removal has increased. METHODS: This is a descriptive epidemiological study involving a secondary data analysis of records held by the Central Services Agency. RESULTS: Six thousand five hundred and seventy-eight new patients were removed at general practitioner (GP) request between 1987 and 1996. This equated to 3920 removal decisions, a rate of 2.43 per 10,000 person-years. The very young and young adults had the highest rates of removal; most of the young being removed as part of a family. Ten point six per cent of removed patients had a repeat removal, and 16.3% of first removal decisions required an assignment to another practice. Family removals have decreased and individual removals have increased over the 10 years. Disadvantaged and densely populated areas with high population turnover were associated with higher rates of removal, though heterogeneity is evident between general practitioners serving similar areas. Compared to the period 1987 to 1991, removal rates for the years 1992 to 1993 were reduced by 20.0% (95% confidence interval (CI) for rate ratio (RR) 0.73-0.87), and those for the years 1994 to 1996 increased by 8% (95% CI = 1.01-1.16). The greatest increase was in the over-75 years age group (standardized RR = 1.60; 95% CI = 1.57-1.62). CONCLUSIONS: Removals are relatively rare events for both patients and practices, though they have been increasing in recent years. Further research is needed to understand the processes that culminate in a removal.

Adolescent↗

PubMed1999

[Patients with fatigue in family practice: prevalence and treatment].

OBJECTIVE: To gain insight into the prevalence and treatment of severe fatigue in general practice. DESIGN: Secondary data analysis. METHOD: By means of an episode-oriented morbidity registration by 54 GPs throughout the Netherlands over the period 1985-1994 it was established how often in the course of one year 'fatigue' was listed as the reason for consultation, what diagnoses were then made, how long episodes of care because of 'fatigue' lasted and what interventions took place (n = 93,297). Of the patients with a care episode because of 'fatigue' lasting at least 6 months, age, sex, comorbidity and consumption of care were established; for this purpose use was also made of a file containing data on 4 years in succession (n = 9630). RESULTS: Per annum, 92 per 1000 listed patients consulted the GP because of fatigue. Somatic or psychic diagnoses were made in 27.7 per 1000 patients listed. The episode of care lasted 4 weeks at most in 86% and at least 6 months in approximately 4%. The GPs' management of patients with 'fatigue' included physical examination in 63% and blood testing in 34%, conversation in 35%, prescription of medication in 24% and referral to a specialist in 3%. Of the 97 patients with fatigue lasting longer than 6 months, 61% had a chronic disease or psychic problems. CONCLUSION: Fatigue is frequently encountered in general practice, but the estimate that one per 1000 listed patients meets the criteria of the chronic fatigue syndrome looks a little high. It appears that GPs, in accordance with recommendations, mostly adopt a policy of wait and see.

Adult↗

PubMed1999

[Utilization of middle ear ventilatory tubes for children, ages 0-12 years, in the Netherlands during 1990-1994].

OBJECTIVE: To explore the incidence of treatment with ventilation tubes in the Netherlands in children from birth to 12 years of age in the period from 1990 to 1994. DESIGN: Secondary data analysis. METHODS: Data on bilateral treatment with ventilation tubes in 1990-1994 in the Netherlands were obtained from the National Medical Register of SIG Health Care Information. Incidence rates of the treatment in children aged 0-12 years were calculated using population estimates issued by the National Department of Statistics. RESULTS: Whereas from 1990 to 1992 the total number of bilateral inserted tubes increased from 39.923 to 51.615, a decrease to 48.635 was observed in 1994. The average incidence rate of treatment with ventilation tubes was 1.97% (range: 0.12%-5.08%) in children from birth to 12 years. Peak incidences were found around 2 years and 6 years of age. Prevalence rates of otitis media with effusion as found in the literature were higher, especially during infancy.

Age Factors↗

PubMedDate not supplied

Time since immigration and excess body weight.

OBJECTIVES: To examine the relationship between time since immigration and excess body weight. METHODS: Secondary data analysis of a cross-sectional survey of 19,600 Canadians. RESULTS: The prevalence of excess weight (BMI > 25) increases with time since immigration for both men and women. After controlling for birthplace, socio-demographic, lifestyle and health correlates, only female immigrants (less than five years) are significantly less likely to have BMI scores greater than 25 kg/m2 compared to those born in Canada. Stratified analyses, however, revealed similar findings for Asian men who had immigrated less than five years prior to the survey. DISCUSSION: Our results suggest that length of time since immigration is an important risk factor for excess weight. Further research with longitudinal data, more reliable measures of ethnicity and anthropometric measures of weight are required to confirm these initial findings.

Adult↗

PubMed1999

Sensitivity, specificity, reliability, and clinical validity of provider-reported symptoms: a comparison with self-reported symptoms. Outcomes Committee of the AIDS Clinical Trials Group.

BACKGROUND: If symptoms are to be recognized and effectively addressed in clinical research, they must be collected using sensitive, specific, reliable, and clinically meaningful methods. OBJECTIVE: To perform a comparison of self-administered symptom survey data with data from conventional provider-reports. DESIGN/METHODS: Secondary data analysis of AIDS Clinical Trials Group Study 081 (ACTG 081), a randomized trial taking place in 33 sites comparing three approaches to prophylaxis for Pneumocystis carinii-related pneumonia that found no difference among treatment arms. The study was performed on 842 subjects with advanced HIV infection. No intervention was undertaken as a result of this study. ACTG 081 included data on functional status, global quality of life and survival, and two methods of symptom measurement: an open-ended, provider-reported symptom assessment (provider-report) and a self-administered symptom survey (self-report). Agreement was measured using kappa scores. Sensitivity and specificity were calculated using self-report as the standard. Reliability was measured by intersite variation and test-retest reliability (8 weeks later). Clinical validity was evaluated by testing expected associations with functional status, global quality of life, and survival. RESULTS: Symptom data were available for 808 patients (96%). Patient and provider agreement was poor (mean kappa, 0.14; range, 0.07-0.25). Compared with self-report, providers underreported the presence and severity of symptoms (mean symptom count, 5.2 versus 1.3; mean severity score, 1.3 versus 0.74). provider-report demonstrated greater variability by site (R2 associated with site, 0.02 versus 0.16) and poorer test-retest reliability (mean kappa, 0.34 versus 0.25). Provider-report severity scores were less strongly associated than were self-report with functional status (chi2, 252 versus 80), global quality of life (R2 for model, 0.57 versus 0.15), and survival (chi2, 38 versus 24). Self-reported symptom severity was strongly correlated to patient-reported global quality of life (p, 0.75; p < .0001). CONCLUSIONS: Provider-reported symptoms as currently collected within the ACTG are less sensitive and reproducible than a self-administered symptom survey. Provider-reported severity scores are also more weakly associated with functional status, global quality of life, and survival. A self-reported symptom survey may provide a better method of symptom measurement for HIV research.

Acquired Immunodeficiency Syndrome↗

PubMed1999

Who has screening mammography? Results from the 1994-1995 National Population Health Survey.

OBJECTIVE: To determine the characteristics of Canadian women aged 35 to 49 who receive screening mammograms not recommended by the Canadian Task Force on the Periodic Health Examination. DESIGN: Secondary data analysis of the 1994-1995 National Population Health Survey. SETTING: Patients' homes. PARTICIPANTS: From a full national representative sample of 17,626 Canadian residents, we selected 2053 women aged 35 to 49 with no breast problems. MAIN OUTCOME MEASURES: Age, education, employment status, marital status, immigrant status, region of residence, self-reported health status, having a regular doctor, smoking status, alcohol consumption, and having a confidant. RESULTS: Of the 2053 women in the sample, 825 (40.2%) had had a screening mammogram as part of a regular medical checkup; 1228 (59.8%) had never had one. Logistic analysis showed that respondents who were approaching age 50, had higher incomes, lived in Quebec, and had regular medical doctors were more likely to have screening mammograms. Statistical trends indicated that heavy drinkers were less likely and immigrants more likely to have mammograms (not significant at P < .01: P = .012 and P = .02, respectively). CONCLUSIONS: Most of these findings are consistent with those of other studies of women 50 and younger. The findings suggest that the patient variables associated with having mammograms in those younger than 50 might be similar to those in women older than 50. An important next step is to determine whether this pattern of use has more to do with younger patients' demand for screening or with physicians' ordering of tests. Further research is also needed to understand the dynamics of the doctor-patient relationship in this situation.

Adult↗

PubMed1999

Physician use of diagnostic codes for child and adult abuse.

OBJECTIVE: To report on physician use of diagnostic codes for child and adult abuse according to national medical care utilization data. METHODS: Secondary data analysis was performed on the National Ambulatory Medical Care Survey (NAMCS) of office-based physician visits and the National Hospital Ambulatory Medical Care Survey (NHAMCS) of visits to hospital emergency and outpatient departments for 1993 to 1996. Both databases describe physician, patient, and visit characteristics, and variables include up to three diagnoses per visit. RESULTS: Only 93 diagnoses of child or adult abuse were coded for 351,359 patient visits during the four years. As we would expect, child abuse was diagnosed more often than adult abuse (67 v 26), and the majority of cases (n = 57) were visits to emergency departments. CONCLUSION: Diagnostic codes for abuse are not often used. Because these codes represent an important tool for reporting the prevalence and incidence of abuse, such documentation could lead to greater support for health care policies and resource allocation for victims of abuse. Lack of awareness about the diagnostic codes for abuse may be one explanation for underuse, but other barriers are also discussed.

Adult↗

PubMed1999

A comparison of nursing and medical diagnoses in predicting hospital outcomes.

UNLABELLED: The main premise of the Nursing Minimum Data Set (NMDS) is that nursing data should be included in the hospital discharge abstract. Yet to date, little empirical evidence has been published to measure the efficacy or usefulness of these nursing data elements. We report the results of a comparison between a daily collection of nursing assessments using nursing diagnoses (NDX) to the Diagnostic Related Group (DRG) and the All Payer Refined DRG (APR-DRG) in their ability to predict three common outcome variables: hospital days, ICU day, and total charges. A secondary data analysis was performed from a large existing data set of four years patient data from a Midwest University hospital. FINDINGS: NDX is significantly associated with hospital length of stay, ICU length of stay, and total charges. NDX also improves explanatory power when added to models with DRG or APR-DRG. This suggests that nursing data compliments existing data and is not redundant with the DRG or APR-DRG. The findings also suggest that NDX explains a different portion of the variance of the three outcome variables in this series. The results of this study support the argument that nursing data should be included in the hospital discharge abstract.

Diagnosis-Related Groups↗

PubMed2000

Serum 6-beta-naltrexol levels are related to alcohol responses in heavy drinkers.

BACKGROUND: There is strong evidence for the role of the endogenous opioid system in alcohol reinforcement and consumption; however, recent human laboratory studies and clinical trials have reported mixed effects of naltrexone (a nonselective opioid antagonist) on alcohol-related behaviors. This paper reports a secondary data analysis of a human laboratory study that examines the relationship between serum levels of 6-beta-naltrexol, the major, biologically active metabolite of naltrexone, and subjective effects of alcohol. METHODS: The study used a within-subjects design to examine the effects of naltrexone (0, 50, and 100 mg/day) on subjective responses to alcohol (none, moderate, and high dose) in heavy drinkers (n = 23). Each subject received three doses of naltrexone in random order; each naltrexone dose was administered over an 8 day period on an inpatient unit, with a 1 week outpatient washout between doses. After stabilization at each of the naltrexone doses, subjects participated in three alcohol challenge sessions (none, moderate, and high dose) in random order; thus, each subject participated in a total of nine alcohol administration sessions. RESULTS: Doubling the naltrexone dose (50 vs. 100 mg/day) doubled the mean serum 6-beta-naltrexol levels. At each naltrexone dose, there was a 4-fold range in 6-beta-naltrexol levels across subjects. Before alcohol administration, higher 6-beta-naltrexol levels were associated with higher ratings of sedation. After high-dose alcohol administration, higher 6-beta-naltrexol levels were associated with significantly lower ratings of liking and best effects. CONCLUSIONS: These findings provide further evidence of the involvement of the opioid system in the modulation of alcohol effects and suggest that serum 6-beta-naltrexol concentrations may be important in predicting therapeutic response to naltrexone.

Adult↗

PubMed2000

Structured writing about stressful events: exploring potential psychological mediators of positive health effects.

In a previous study, the authors found that structured writing about stressful events improved symptomatology in 112 patients with rheumatoid arthritis and asthma relative to patients who did not write (J. Smyth, A. Stone, A. Hurewitz, & A. Kaell, 1999). However, little is currently known about the pathways from the intervention to alterations in outcomes. In addition to measuring symptom outcomes after the intervention in the previous study, the authors monitored perceived stress, quality of sleep, affect, substance use, and medication use on a momentary basis for the 7 days prior to writing, during the 3 intervention days, and for the 14 days following the intervention (N = 105). These variables were tested in a secondary data analysis to determine whether they mediated the effects observed in the J. Smyth, A. Stone, et al. study. No evidence was found supporting mediation, and the mechanism underlying structured writing about stressful events remains unknown.

Adaptation, Psychological↗

PubMed2001

Canadians without regular medical doctors. Who are they?

OBJECTIVE: Because having a regular medical doctor is associated with positive outcomes, this study attempted to determine the characteristics of Canadians without regular doctors so that alternative methods of delivering care to people with those characteristics can be studied. DESIGN: Secondary data analysis of the National Population Health Survey using bivariate analyses and logistic regression. PARTICIPANTS: A total of 15,777 respondents older than 20 years. MAIN OUTCOME MEASURES: Responses to the question "Do you have a regular medical doctor?" and analysis of 11 variables covering demographics, health status, and lifestyle factors. RESULTS: One in seven respondents did not have a regular doctor. Younger respondents, men, single people, poorer respondents, respondents who perceived themselves in better health, recent immigrants, those without confidants, and smokers were more likely not to have regular doctors. Comparing provinces, participants from Quebec were least likely to have regular doctors. CONCLUSION: Primary care reform might need to consider alternative ways of providing care to certain people. Future primary care programs could be targeted to improve coverage of relatively underserviced people, particularly men, people on low incomes, those without confidants, and recent immigrants.

Adult↗

PubMed2001

[Lung cancer in the Netherlands in the period 1989-1997: the epidemic is not over yet].

OBJECTIVE: To describe and interpret changes in incidence, mortality and survival of lung cancer in the Netherlands in the period 1989-1997. DESIGN: Secondary data analysis. METHODS: Data on the incidence of lung cancer were collected from the Dutch Cancer Registration (1989-1997), on mortality from Statistics Netherlands (CBS; 1989-1994), on the incidence of lung cancer in other European countries from EUROCIM (1990-1994), on survival of Dutch lung cancer patients from the Comprehensive Cancer Centre Amsterdam (1988-1997) and the Comprehensive Cancer Centre South (1988-1992) and on survival of other European lung cancer patients from EUROCARE (1985-1989). Incidence rates were calculated per 100,000 person years and standardized by age according to the European population structure. Survival was calculated as the ratio of observed survival among the lung cancer patients and the expected survival of the general population. RESULTS: The incidence of lung cancer among men decreased from 109 to 93, whereas that among women increased from 18 to 23. The incidence of lung cancer among Dutch men was high in comparison to other European countries, whereas that among women was average. The trends in lung cancer incidence were probably related to the trends in past smoking behaviour. Mortality decreased among men from 106 to 91 and increased among women from 15 to 20. Survival was better for younger patients, a localised tumour, and better for squamous cell carcinoma or adenocarcinoma than for large-cell undifferentiated or small-cell carcinoma. The relative 5-year survival was 12%, the relative 1-year survival 39%; these were good in comparison with other European countries. CONCLUSION: The incidence and mortality of lung cancer among Dutch men decreased, but still in 1997 almost 20 men in the Netherlands died each day of lung cancer. Among women the end of the increase is not in sight and in 1997 over 5 women died each day of lung cancer.

Adult↗

PubMed2001

Post-traumatic stress disorder in extremely poor women: implications for health care clinicians.

OBJECTIVES: To identify childhood antecedents for lifetime post-traumatic stress disorder (PTSD) and to determine how this diagnosis relates to health and service use among extremely poor women. METHODS: We conducted a secondary data analysis of 425 women in the Worcester Family Research Project, a case-control longitudinal study of 220 sheltered homeless and 216 extremely poor housed (never homeless) women in Worcester, Massachusetts. RESULTS: We found that extremely poor women with lifetime PTSD were more likely to have grown up in family environments of violence, threat, and anger than those without PTSD. The strongest risk factor for PTSD was childhood sexual abuse with threat. Low-income women with lifetime PTSD had more bodily pain, even when controlling for other health and demographic factors. Women with PTSD experienced more chronic health conditions and had more problematic relationships with their health care providers and perceived more barriers to care. CONCLUSION: Many low-income women have difficulty using medical care appropriately because of childhood histories of physical and sexual abuse, the subsequent development of post-trauma responses, and structural barriers to care. Given these factors, it is critical that health care clinicians routinely screen for histories of violence and PTSD and develop treatment plans that ensure safety, link current symptoms with prior experiences, and provide support as necessary. A team approach coordinated by a case manager may be the best strategy. Without routine screening for PTSD and sensitive treatment, many extremely poor women will receive compromised health care and may even be retraumatized.

Adult↗

PubMed2001

General practice out-of-hours service, variations in use and equality in access to a doctor: a cross-sectional study.

BACKGROUND: There is increasing dissatisfaction among general practitioners (GPs) with their 24 hour commitment despite the demand for GP services outside ordinary working hours. The creation of out-of-hours co-operatives has been welcomed by participating GPs and their families and patient satisfaction is generally high. However, there have been concerns about the lack of patient consultation in their development and on the quality of care provided. OBJECTIVES: To examine geographical variation in the rates of out-of-hours calls and to see if there is any systematic variation in how the co-operative that covers the area responds to calls. DESIGN OF STUDY: A secondary data analysis of 110,357 calls received by the co-operative during the second year of its operation. SETTING: A co-operative with four centres providing out-of-hours care for one mostly rural Health Board in Northern Ireland. METHOD: Deprivation score and mortality and long-term illness ratios provided indicators of need at an area level. Proximity to the four co-operative centres was measured as the distance in kilometres and estimated travel time (in minutes) along the road network. RESULTS: Out-of-hours call ratios were proportional to the area deprivation score and proximity to the co-operative centres, though not to area indicators of ill health. Older patients were more likely to be seen by the GP and females over the age of 15 years were more likely to receive telephone advice only (adjusted odds ratio [OR] = 0.785, 95% confidence intervals [CI] 0.756-0.816, P < 0.001). Each kilometre from the centres reduced the likelihood of seeing the GP (OR = 0.978, 95% CI = 0.976-0.979, P < 0.001). Even after controlling for potential confounders a large difference remained in how centres responded to calls. CONCLUSIONS: It is not certain whether these inequalities in services delivery represent inequity as the apposite level or type of response cannot be determined until more is known about the appropriateness of the demand for out-of-hours medical care.

Adolescent↗

PubMed2001

[Eliminating iodine deficiency disorders in Nepal through precede-proceed].

OBJECTIVES: Assess the PRECEDE-PROCEED model's suitability for developing countries. Analyze the Iodine Deficiency Disorders (IDD) control program in Nepal according to PRECEDE-PROCEED. METHODS: Primary and secondary data analysis within the framework of PRECEDE-PROCEED's first five steps. Key informant interviews. Qualitative data from Nepal's IDD control program participants were assessed according to PRECEDE-PROCEED's third through fifth steps. RESULTS: According to the first and second steps of PRECEDE-PROCEED for social and epidemiological assessment, Nepal's IDD control program needs improvement. Limited data were available for the assessment, making it difficult to execute the first two steps with certainty. Social and epidemiological assessments can be problematic in any developing country since the necessary data are typically not available. Behavioral and environmental assessments (step three) showed that: Most people are unaware of IDD and manage iodized salt poorly. The environment within which iodized salt is managed is insufficient for maintaining proper salt iodination at the consumer level. Educational and ecological assessments (step four) pointed out several problems, including: Inadequate understanding of IDD Incorrect beliefs about refined salt Poor supply of refined salt in markets Weak regulation of non-iodized salt importation and sales Finally, administrative and policy assessments (step five) emphasized the need for an active role of the Salt Trading Corporation in Nepal, with a significant manpower and budget, in improving the IDD program. Data for completing PRECEDE-PROCEED steps three through five were readily available. In addition to providing a framework within which to assess Nepal's IDD control program, the model helped highlight specific action goals for behavioral and environmental objectives (consume more iodized salt, improve quality of salt warehouses and increase iodized salt's market availability). DISCUSSION: Though it was difficult to obtain data for social and epidemiological assessments, the PRECEDE-PROCEED model proved useful in analyzing IDD control in Nepal. The model can comprehensively analyze ongoing interventions and assess the status of various nation-wide health programs, highlighting areas of modification needed to help programs achieve their goals.

Developing Countries↗

PubMed2001

The role of contextual, child and parent factors in predicting criminal outcomes in adolescence.

This study examined predictor variables that would contribute toward an explanatory model linking child maltreatment and the outcome of crime seriousness. A secondary data analysis was completed on a random sample of youth committed and detained by a juvenile justice system in the northeast United States. Although existing data indicate a predisposition to crime and violence among youth that are maltreated, more research is needed to determine the exact nature of the link, as well as the need to determine the relationship of associated factors. The aim of this analysis was to identify key contextual, child, and parental factors related to maladaptive behavior in abused and neglected adolescent offenders. Logistic regression was used to predict serious criminal outcomes. Overall, 73% of the cases were correctly classified. Ten variables remained in the model to predict serious juvenile criminal behavior. Youth who had been exposed to community violence or who had a mother with mental illness were four times as likely to commit serious criminal behaviors.

Adolescent↗

PubMed2001

Self-esteem matters: racial & gender differences among rural southern adolescents.

Self-esteem does matter! It matters so much that Oprah dedicated an entire issue of "O" magazine to address the subject. "It's a woman's most treasured possession" (Winfrey, 2000a). Self-esteem has a profound influence on adolescent health promotion behaviors. This study contributes to understanding the role self-esteem plays in the behavior of adolescents. Utilizing a secondary data analysis, race and gender self-esteem differences among adolescents were investigated. The sample of 1,237 students (46% African-American and 52% White) from rural southern areas consisted of 744 females and 493 males. Self-esteem was assessed using the Miller Self-esteem Questionnaire (SEQ). The Hendricks Perceptual Health Promoting Determinants Model (HPHD) provided the theoretical framework for the study. The results of the study revealed a statistically significant difference in various aspects of self-esteem according to race and gender. African-Americans and males had a higher self-esteem which is consistent with many prior studies.

Adolescent↗

PubMed2002

Decomposing the relationships between pretreatment social network characteristics and alcohol treatment outcome.

OBJECTIVE: In Project MATCH a summary measure of network support for drinking identified matching and prognostic effects. The goals of the present analyses were (1) to determine which of the 11 component indexes are most predictive of treatment outcome regardless of treatment type and (2) to determine which of the indexes are most influential in the already demonstrated network support by treatment interaction effect. METHOD: This is a secondary data analysis of the outpatient arm of Project MATCH (N = 952), focusing primarily on the Important People and Activities instrument administered pretreatment. RESULTS: Patients with larger daily networks and patients with more abstainers/recovering alcoholics in their networks had a better prognosis. Patients with a higher network drinking frequency did better in Twelve Step Facilitation than in Motivational Enhancement Therapy. CONCLUSIONS: Three of the 11 indexes can be used to replicate the prognostic and matching effects found for an overall index of network support. These may be measured by a short form of the Important People and Activities instrument.

Adult↗