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At least 19 recordsLinked to original sources
PubMed1999

The scope for cardiovascular disease risk factor intervention among people with diabetes mellitus in England: a population-based analysis from the Health Surveys for England 1991-94.

AIMS: To examine the scope for cardiovascular disease risk factor intervention among diabetic patients in England was examined using data from the Health Surveys for England 1991-94. This evaluation included calculating the proportion who require lipid lowering therapy according to the Standing Medical Advisory Committee (SMAC) guidelines. METHODS: The Health Survey for England is an annual, nationwide household-based in which anthropomorphic data, blood pressure, lipids and details of cardiovascular risk factors are collected from households after random stratification for geographical and socio-economic factors within a population sample of 39639 adults, 970 (2.3%) diabetic subjects were identified. RESULTS: Overall, 51% of those with diabetes had hypertension (systolic blood pressure > or = 160 mmHg or a diastolic BP > or = 95 mmHg or being on antihypertensive therapy), 27% were obese (body mass index > or = 30 kg/m2) and 19% were current smokers. One-third of those with hypertension were untreated and less than one-half of those on treatment had their hypertension controlled to below 160/ 95 mmHg. More than one-quarter had poor glycaemic control (glycated Hb>11% or an HbA1c>7.5%). Of those aged <70 years, 29% required lipid lowering therapy according to the SMAC guidelines and almost all (94%) of these were not on treatment. An analysis showed that, because the SMAC guidelines do not require high density lipoprotein (HDL) cholesterol to be measured, their use is likely to result in substantial underestimation of the need for lipid lowering, particularly in diabetic women. CONCLUSION: In England, among those with diabetes there is considerable unmet need for cardiovascular risk factor intervention, particularly for hypertension and raised cholesterol. With this baseline established, future improvements can be monitored.

Adult↗
PubMed1982

Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway.

We examined the incidence of seven common surgical procedures in seven hospital service areas in southern Norway, in 21 districts in the West Midlands of the United Kingdom, and in the 18 most heavily populated hospital service areas in Vermont, Maine, and Rhode Island. Although surgical rates were higher in the New England states than in the United Kingdom or Norway, there was no greater degree of variability in the rates of surgery among the service areas within the three New England states. Hernia repair was more variable in England (P less than 0.05) and hysterectomy in Norway (P less than 0.05) than in the other countries. There was consistency among countries in the rank order of variability for most procedures: tonsillectomy, hemorrhoidectomy, hysterectomy, and prostatectomy varied more from area to area than did appendectomy, hernia repair, or cholecystectomy. The degree of variation generally appeared to be more characteristic of the procedure than of the country in which it was performed. Thus, differences among countries in the methods of organizing and financing care appear to have little relation to the intrinsic variability in the incidence of common surgical procedures among hospital service areas in these countries. Despite the differences in average rates of use, the degrees of controversy and uncertainty concerning the indications for these procedures seem to be similar among clinicians in all three countries.

Appendectomy↗
PubMed1996

Indications, practice, and procedural outcomes of percutaneous transluminal coronary angioplasty in northern New England in the early 1990s. The Northern New England Cardiovascular Disease Study Group.

We conducted a prospective cohort study from October 1, 1989 to December 31, 1993 of the current indications, practices and procedural outcomes of percutaneous transluminal coronary angioplasty (PTCA) in Northern New England to determine how it compared with reports from other regions and registries. Thirty-five cardiologists contributed data on 12,232 admissions for PTCA performed at all hospitals in New Hampshire and Maine, plus 1 in Massachusetts, supporting PTCA. Mean patient age was 61.1 years, 67.5% were men, and 38.5% had multivessel disease. Unstable (45.6%), stable (22.9%), and postinfarction angina (21.0%) were common indications for the procedure. Of all patients, 86.9% had 1-vessel PTCA, including 65.7% of those with multivessel disease. Angiographic success was 90.4%, and 88.1% of patients had > or = 1 lesion successfully dilated and no adverse clinical event. The risk of death, nonfatal acute myocardial infarction, or coronary artery bypass grafting was 5.7%. The practice and outcomes of PTCA in Northern New England were somewhat similar to reports from other regional registries but different from a registry of select institutions. We conclude that PTCA as performed in Northern New England is safe and effective.

Aged↗
PubMed1998

Blood pressure screening, management and control in England: results from the health survey for England 1994.

OBJECTIVE: To assess the current levels of awareness, treatment and control of hypertension in England and to determine the number and type of drugs prescribed. DESIGN: A cross-sectional household-based survey of English adults. SUBJECTS: A random sample from the adult English population of 12,116 adults who participated in the 1994 Health Survey for England. MAIN OUTCOME MEASURES: Prevalences of treatment hypertension, awareness and control. RESULTS: Using a definition of hypertension as a systolic blood pressure > or = 160 mmHg or a diastolic blood pressure > or = 95 mmHg, or a patient's being administered antihypertensive treatment, the prevalence of awareness of hypertension was 63%. Among hypertensives, 50% were receiving treatment and 30% had their hypertension controlled (< 160 mmHg/95 mmHg). Awareness, treatment and control rates are considerably lower than the most recently reported rates from the USA. Diuretics and beta-blockers remain the most common antihypertensive agents used in England. CONCLUSION: There is considerable scope for improving the treatment and control of hypertension in the English adult population.

Adolescent↗
PubMed1995

Thinking of England and taking care: family building strategies and infant mortality in England and Wales, 1891-1911.

"Debates concerning the origins and development of the late nineteenth- to early twentieth-century declines in marital fertility and infant mortality in England and Wales have been centred largely on the material provided by answers to the ¿special' questions in the 1911 census. In their published form these figures have restricted researchers to an examination of large scale geographic and social class differences in the levels and rates of decline of the two phenomena. This paper outlines research conducted on a sample of individual census returns from the 1911 census. From this data it becomes clear that for Victorian and Edwardian England ¿where one lived' was rather more important than ¿who one was' in determining both family building strategies and the survival of those children born."

Birth Rate↗
PubMed2000

Decreasing mortality for aortic and mitral valve surgery in Northern New England. Northern New England Cardiovascular Disease Study Group.

BACKGROUND: Although numerous reports have documented declining mortality rates associated with coronary artery bypass surgery in recent years, it is unknown whether similar trends have occurred with valve surgery during this time. METHODS: We conducted a regional, prospective study to assess trends in patient casemix and in-hospital mortality rates over time with aortic valve replacement (AVR), mitral valve replacement (MVR), and mitral valve repair. Data were collected from all patients undergoing AVR (n = 2,596), MVR (n = 759), or mitral valve repair (n = 522) in Northern New England between January 1992 and December 1997. Logistic regression was used to identify significant predictors of in-hospital mortality and to calculate risk-adjusted mortality rates. RESULTS: For AVR, the trend in patient casemix was toward increased risk with increases in patient age and in the proportion of patients with: body surface area less than 1.7, diabetes, coronary artery disease, and prior valve surgery. A decrease was noted in the proportion of patients undergoing additional surgical procedures. For MVR, patient risk improved over the time period with fewer female patients and fewer patients with coronary artery disease. For mitral valve repair patient risk increased over the time period with increases in the proportion of patients with coronary artery disease, diabetes, and whose surgical priority was classified as urgent. In addition, there was a borderline significant increase in the proportion of mitral valve repair patients in New York Heart Association class IV preoperatively. Risk-adjusted mortality decreased 44% from 9.3% in 1992 through 1993 to 5.3% in 1996 through 1997 for patients undergoing AVR (p = 0.01) and decreased 53% from 13.6% in 1992 through 1993 to 8.2% in 1996 through 1997 for patients undergoing MVR (p = 0.01). We observed a statistically insignificant increase in risk-adjusted mortality over the time period for patients undergoing mitral valve repair (from 3.6% in 1992 through 1993 to 5.0% in 1996 through 1997; p = 0.34). CONCLUSIONS: Significant improvement in mortality rates with valve replacement was observed in northern New England during this time period. This improvement persisted following adjustment for changes in patient casemix over this time. These trends mirror improvements in mortality with other cardiac surgical interventions that have been observed in recent years in our region and nationally.

Aged↗
PubMed1996

Comparison of cancer deaths in England and Wales and the developed world by age and gender 1973-92, and, new malignancies in England and Wales 1971-88.

Cancer deaths in England and Wales and the developed world were examined by age and gender between 1973-1992. Whilst over-all mortality levels increased, this was mainly linked to extended longevity, as the rate fell substantially for people under 55 in the majority of countries, possibly as a result of improved treatment and prevention outcomes. Whilst England and Wales had above average reductions in cancer deaths, especially for children, there were considerable rises in new malignancies, 1971-88, particularly amongst women under 35 years, and in certain selected sites. These over-all changes do not appear to be the result of improved diagnosis, thus, despite evidence of more effective therapeutic and preventative measures the incidence of new malignancies is increasing. The possible implications are briefly discussed, in the context of "medical audit', which increasing uses mortality rates as "indicators of effectiveness'.

Adolescent↗
PubMed1998

Gender differences in accessing cardiac surgery across England: a cross-sectional analysis of the health survey for England.

OBJECTIVE: To examine gender differences in access to cardiac surgery in a nationally representative sample. DESIGN: Nationwide cross sectional household based survey (Health Survey for England). SETTING: Private households in England around 1993 and 1994. SUBJECTS: 1708 subjects reporting a history of either doctor diagnosed angina or heart attack from a stratified random sample of 32 378 people aged 16 and above. OUTCOME MEASURE: The proportion reporting having had cardiac surgery or on a waiting list. RESULTS: 13.5% reported previous (n = 206) or pending (n = 25) cardiac surgery. Men were more likely than women to have had or to be waiting for cardiac surgery (19.1% of men versus 6.8% of women, chi2 54.7, P<0.001). This finding was consistent regardless of age group and across three regional areas. The unadjusted odds ratio for cardiac surgery for men versus women was 3.3 (95% Cl 2.3, 4.5, P<0.001) and was only slightly attenuated to 2.8 (95% CI 1.9, 4.0. P<0.001), after adjustment for other factors. The gender difference remained even when analysis was restricted to subjects reporting a previous heart attack, and after statistical adjustment for disease severity. CONCLUSION: Women are less likely than men to receive cardiac surgery across all age groups and regional areas. These results include private operations and adjust for individual behavioural data. Neither disease severity or co-morbidity explains these discrepancies. Further studies are required to determine why this inequality occurs and how it can be addressed.

Adolescent↗
PubMed1998

Evaluation of total purchasing pilots in England and Scotland and implications for primary care groups in England: personal interviews and analysis of routine data. The Total Purchasing National Evaluation Team.

OBJECTIVES: To evaluate the reported achievements of the 52 first wave total purchasing pilot schemes in 1996-7 and the factors associated with these; and to consider the implications of these findings for the development of the proposed primary care groups. DESIGN: Face to face interviews with lead general practitioners, project managers, and health authority representatives responsible for each pilot; and analysis of hospital episode statistics. SETTING: England and Scotland for evaluation of pilots; England only for consideration of implications for primary care groups. MAIN OUTCOME MEASURES: The ability of total purchasers to achieve their own objectives and their ability specifically to achieve objectives in the service areas beyond fundholding included in total purchasing. RESULTS: The level of achievement between pilots varied widely. Achievement was more likely to be reported in primary than in secondary care. Reported achievements in reducing length of stay and emergency admissions were corroborated by analysis of hospital episode statistics. Single practice and small multipractice pilots were more likely than large multipractice projects to report achieving their objectives. Achievements were also associated with higher direct management costs per head and the ability to undertake independent contracting. Large multipractice pilots required considerable organisational development before progress could be made. CONCLUSION: The ability to create effective commissioning organisations the size of the proposed primary care groups should not be underestimated. To be effective commissioners, these care groups will need to invest heavily in their organisational development and in the short term are likely to need an additional development budget rather than the reduction in spending on NHS management that is planned by the government.

Budgets↗
PubMed1996

Occurrence of anthelmintic resistant nematodes on sheep farms in England and goat farms in England and Wales.

A survey in 1992 showed that 44 per cent of the sheep farms tested in the south west and 15 per cent of those in the north east of England had parasitic nematode worm burdens which were resistant to benzimidazole anthelmintics, and that 65 per cent of the non-dairy goat farms tested in England and Wales had resistant worms. Ostertagia circumcincta was the main species in sheep and Haemonchus contortus in goats. The resistance to benzimidazoles was diagnosed by a combination of an egg hatch assay and a larval development test. A simplified faecal egg count reduction test was used to investigate sheep and goat farms for signs of ivermectin resistance but no positive cases were detected. The initial identification of levamisole resistance on one farm, both from a faecal egg count reduction test and a positive larval development test, was confirmed by a 'dose and slaughter' trial.

Animals↗
PubMed1994

Laparoscopic cholecystectomy in England and Wales: results of an audit by the Royal College of Surgeons of England.

The results of an audit of open and laparoscopic cholecystectomy conducted by the Comparative Audit Service of The Royal College of Surgeons of England are presented. Data were submitted by 124 consultant surgeons on 3319 attempted laparoscopic and by 227 consultant surgeons on 8035 open cholecystectomies performed in England and Wales during the 2 years 1990 and 1991. These were contrasted with 9322 attempted laparoscopic cholecystectomies reported in 21 series reported in the world literature between 1991 and 1992, and with five other nations' audit studies. Among attempted laparoscopic cases, conversion to an open procedure was necessary in 175/3319 (5.2%) of cases and overall mortality was 0.15% (5/3319). Major complications were reported in 2.1% and minor complications in 5.9% of cases. Bile duct injury was reported to be significantly more common after attempted laparoscopic cholecystectomy (11/3319, 0.33%) than after open cholecystectomy (4/8035, 0.06%) (95% confidence intervals -0.48 to 0.08), but it was not significantly different from that reported for laparoscopic cholecystectomy in the combined world literature (28/9322, 0.3%) (95% confidence intervals -0.19 to 0.25). Most systemic complications were significantly more common after open cholecystectomy. For open cholecystectomy, the mortality was 55/8035 (0.76%), with major complications reported in 3.2% and minor complications in 9.8% of patients. Adoption of the laparoscopic approach was associated with a four-fifths reduction in the mortality of cholecystectomy, and a 40% reduction in the overall complication rate when compared with the open operation. While laparoscopic cholecystectomy has an impressively low mortality and morbidity profile during the first 2 years of its introduction into the UK, prevention of bile duct injury is the most important issue to be addressed in all laparoscopic cholecystectomy training programmes.

Bile Ducts↗
PubMed1997

Results of directional coronary atherectomy in Northern New England. Northern New England Cardiovascular Disease Study Group.

The role of directional coronary atherectomy (DCA) in interventional cardiology remains uncertain. We report the Northern New England regional experience with DCA from 1991 to 1994. Data were collected on 11,178 patients having had an intervention on a single lesion in a single vessel (798 DCAs; 10,380 percutaneous transluminal angioplasties [PTCA]). The use of DCA increased from 1.8% of interventions in 1991 to 10% in 1994. Compared with PTCA, DCA patients were younger, more often men, had more 1-vessel disease and more coronary artery bypass surgery (CABG). DCA was more often used in the left anterior descending artery, in vein grafts, for restenoses, for subtotal occlusions, and with type A lesions. Angiographic success (96.7%) and clinical success (93%) were good. Adverse events were rare: mortality 0.9%, emergent CABG 2.2%, nonfatal myocardial infarction 2.8%. After adjusting for case-mix, there was no difference between DCA and PTCA for in-hospital mortality (odds ratio [OR] = 1.03, 95% confidence interval [CI] 0.44 to 2.43, p = 0.95) or need for emergent CABG (OR = 1.27, 95% CI 0.77 to 2.10, p = 0.34). Atherectomy patients were more likely to have a nonfatal myocardial infarction (OR = 2.0, 95% CI 1.26 to 3.20, p <0.01), to sustain an injury to the femoral or brachial artery (OR = 2.89, 95% CI 1.52 to 5.51, p <0.01), and to have a clinically successful procedure (OR = 1.37, 95% CI 1.01 to 1.88, p = 0.05). Our results support the relative safety and effectiveness of DCA as its use disseminated into the region.

Aged↗
PubMed1999

Changing outcomes in percutaneous coronary interventions: a study of 34,752 procedures in northern New England, 1990 to 1997. Northern New England Cardiovascular Disease Study Group.

OBJECTIVES: We sought to evaluate the changing outcomes of percutaneous coronary interventions (PCIs) in recent years. BACKGROUND: The field of interventional cardiology has seen considerable growth in recent years, both in the number of patients undergoing procedures and in the development of new technology. In view of recent changes, we evaluated the experience of a large, regional registry of PCIs and outcomes over time. METHODS: Data were collected from 1990 to 1997 on 34,752 consecutive PCIs performed at all hospitals in Maine (two), New Hampshire (two) and Vermont (one) supporting these procedures, and one hospital in Massachusetts. Univariate and multivariate regression analyses were used to control for case mix. Clinical success was defined as at least one lesion dilated to <50% residual stenosis and no adverse outcomes. In-hospital adverse outcomes included coronary artery bypass graft surgery (CABG), myocardial infarction and mortality. RESULTS: Over time, the population undergoing PCIs tended to be older with increasing comorbidity. After adjustment for case mix, clinical success continued to improve from a low of 88.2% in earlier years to a peak of 91.9% in recent years (p trend <0.001). The rate of emergency CABG after PCI fell in recent years from a peak of 2.3% to 1.3% (p trend <0.001). Mortality rates decreased slightly from 1.2% to 1.1% (p trend 0.007). CONCLUSIONS: There has been a significant improvement in clinical outcomes for patients undergoing PCIs in northern New England, including a significant decline in the need for emergency CABG.

Angioplasty, Balloon, Coronary↗
PubMed1999

The relationship between operator volume and outcomes after percutaneous coronary interventions in high volume hospitals in 1994-1996: the northern New England experience. Northern New England Cardiovascular Disease Study Group.

OBJECTIVES: The purpose of this study was to examine the relationship between annual operator volume and outcomes of percutaneous coronary interventions (PCIs) using contemporaneous data. BACKGROUND: The 1997 American College of Cardiology (ACC)/American Heart Association task force based their recommendation that interventionists perform > or = 75 procedures per year to maintain competency in PCI on data collected largely in the early 1990s. The practice of interventional cardiology has since changed with the availability of new devices and drugs. METHODS: Data were collected from 1994 through 1996 on 15,080 PCIs performed during 14,498 hospitalizations by 47 interventional cardiologists practicing at the five high volume (>600 procedures per hospital per year) hospitals in northern New England and one Massachusetts-based institution that support these procedures. Operators were categorized into terciles based on their annualized volume of procedures. Multivariate regression analysis was used to control for case-mix. In-hospital outcomes included death, emergency coronary artery bypass graft surgery (eCABG), non-emergency CABG (non-eCABG), myocardial infarction (MI), death and clinical success (> or = 1 attempted lesion dilated to < 50% residual stenosis and no death, CABG or MI). RESULTS: Average annual procedure rates varied across terciles from low = 68, middle = 115 and high = 209. After adjusting for case-mix, clinical success rates were comparable across terciles (low, middle and high terciles: 90.9%, 88.8% and 90.7%, Ptrend = 0.237), as were all the adverse outcomes including death (low-risk patients = 0.45%, 0.41%, 0.71%, Ptrend = 0.086; high-risk patients = 5.68%, 5.99%, 7.23%, Ptrend = 0.324), eCABG (1.74%, 2.05%, 1.75%, Ptrend = 0.733) and MI (2.57%, 1.90%, 1.86%, Ptrend = 0.065). CONCLUSIONS: Using current data, there is no significant relationship between operator volumes averaging > or = 68 per year and outcomes at high volume hospitals. Future efforts should be directed at determining the generalizability of these results.

Angioplasty, Balloon, Coronary↗
PubMed1995

The compulsory removal of elderly people in England and Wales under Section 47 of the National Assistance Act and its 1951 Amendment: a survey of its implementation in England and Wales in 1988 and 1989.

Section 47 of the National Assistance Act 1948 and its 1951 Amendment allow for the compulsory removal from their homes of predominantly elderly people to a place of safety. The Amendment has been in use for over 40 years. Little information is available on the workings of the Acts in England and Wales. For the period 1988 to 1989 inclusive, 771 requests for compulsory removal were received by 148 'proper officers'. We examined referrals and removals under the Acts. During this time 165 people were removed. The majority of referrals were from family practitioners (46%), but social workers also played a role (18%). Of the 165 people who were actually removed from their homes, 41 were removed under Section 47 of the National Assistance Act and 124 under its 1951 Amendment. The outcome of compulsory removal was only known in 126 instances. In 34% of cases the person was transferred to residential care and 24% returned home; 18% of the detainees died during their compulsory admission. The outcome varied significantly between health regions (chi 2 = 72; p < 0.001), with for example apparently high death rates in the North West, Trent and South West regions. For a disturbing 24% of people nothing is known of their fate. A mandatory reporting system to examine the use of this legislation is required.

Activities of Daily Living↗
PubMed2000

Increasing rates of cerebral palsy across the severity spectrum in north-east England 1964-1993. The North of England Collaborative Cerebral Palsy Survey.

OBJECTIVES: To report epidemiological trends in cerebral palsy including analyses by severity. DESIGN: Descriptive longitudinal study in north-east England. Every child with suspected cerebral palsy was examined by a developmental paediatrician to confirm the diagnosis. Severity of impact of disability was derived from a parent completed questionnaire already developed and validated for this purpose. SUBJECTS: All children with cerebral palsy, not associated with any known postneonatal insult, born 1964-1993 to mothers resident at the time of birth in the study area. MAIN OUTCOME MEASURES: Cerebral palsy rates by year, birth weight, and severity. Severity of 30% and above defines the more reliably ascertained cases; children who died before assessment at around 6 years of age are included in the most severe group (70% and above). RESULTS: 584 cases of cerebral palsy were ascertained, yielding a rate that rose from 1.68 per 1000 neonatal survivors during 1964-1968 to 2.45 during 1989-1993 (rise = 0.77; 95% confidence interval 0.2-1.3). For the more reliably ascertained cases there was a twofold increase in rate from 0.98 to 1.96 (rise = 0.98; 95% confidence interval 0.5-1.4). By birth weight, increases in rates were from 29.8 to 74.2 per 1000 neonatal survivors < 1500 g and from 3.9 to 11.5 for those 1500-2499 g. Newborns < 2500 g now contribute one half of all cases of cerebral palsy and just over half of the most severe cases, whereas in the first decade of this study they contributed one third of all cases and only one sixth of the most severe (chi(2) and chi(2) for trend p < 0.001). CONCLUSIONS: The rate of cerebral palsy has risen in spite of falling perinatal and neonatal mortality rates, a rise that is even more pronounced when the mildest and least reliably ascertained are excluded. The effect of modern care seems to be that many babies < 2500 g who would have died in the perinatal period now survive with severe cerebral palsy. A global measure of severity should be included in registers of cerebral palsy to determine a minimum threshold for international comparisons of rates, and to monitor changes in the distribution of severity.

Birth Weight↗
PubMed1982

Pitfalls in screening for neonatal hypothyroidism. Report of the New England Regional Screening Program and the New England Congenital Hypothyroidism Collaborative.

This report reviews problems encountered during the first five years of operation of the New England Regional Screening Program. Human error was responsible for either overlooked or delayed diagnosis and treatment in 14/159 infants with hypothyroidism. This group consisted of three infants who were never tested, six infants whose diagnosis was missed because of errors during the processing of the blood specimens, and five additional children in whom the diagnosis of hypothyroidism could not be made at birth because the concentrations of thyroid-stimulating hormone were not elevated. Many of the problems, most of which occurred during the first two years of the study, have been eliminated by improved communication and monitoring. This study emphasizes the potential vulnerability of all screening programs and underscores the need for physicians to continue to exercise their best clinical judgement regardless of the circumstances.

Congenital Hypothyroidism↗