Search results
Found 18147 matches for
We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
The time course and regional variations of lipid peroxidation after diffuse brain injury in rats.
Free radicals are generated after head injury. These radicals rapidly react with polyunsaturated fatty acids in the cell membrane and cause membrane destruction. This process is called lipid peroxidation. Malondialdehyde (MDA) is one of the end products of lipid peroxidation, and it is a frequently used indicator of lipid peroxidation in biological tissues. Using a diffuse head injury animal model, we studied the time course of lipid peroxidation in different regions of injured rat brains. In the present study, the MDA levels were 36.7%, 41.8%, and 35.1% greater than sham at one hour after injury at the frontal, parietal, and brain stem, respectively (p < 0.0001). The MDA levels in these regions continued to increase and peaked a 4 hours after the injury. The levels slowly decreased, and by 24 hours, they were still significantly higher than the sham control's. The elevation of MDA levels was less in the striatum and the temporal regions at one hour. They were 16.9% and 13.3%, respectively (p < 0.002). The MDA levels in these two regions continued to increase even after 4 hours of injury, but the degree of elevation never exceeded 35%. The results demonstrate that there is an immediate, posttraumatic burst of MDA production, suggesting the formation of free radicals after diffuse head injury. Even though all the regions sampled show the same effect, certain regions are less affected by this diffuse head injury animal model.
An estimation of the functional disability burden in elderly Chinese age 70 years and over.
A cross-sectional survey of functional status among elderly Hong Kong Chinese aged 70 years and over was carried out to estimate the current burden of disability. Two thousand and thirty-two subjects (999 men, 1033 women) were recruited by random sampling of the old age and disability allowance schemes covering over 90% of the elderly population, stratified by sex and 5-year age groups. Functional ability was administered using the Barthel Index. The duration of disability, if any, was also noted. The prevalence of disability for different activities of daily living varied from 0.8% to 26% (lowest for feeding and highest for climbing stairs and bathing). The prevalence was higher for women than men, and higher in the older age group for both sexes. Men in the 80+ age group had shorter duration of disability compared with those in the 70-79 age group, and compared with women. Using disability years (estimated number of elderly with disability in the population x median duration of disability) as an estimate of disability burden, the number ranges from approximately 19,000 (inability to feed) to 100,000 (inability to climb stairs). This estimate may be useful in the planning of service provisions for the formal and informal care sector.
Somatostatin reduces gastric mucosal blood flow in patients with portal hypertensive gastropathy: a randomized, double-blind crossover study.
Agents which decrease gastric mucosal blood flow (GMBF) are postulated to have beneficial effects in arresting gastrointestinal bleeding in cirrhotic patients with portal hypertension. Our objective was to test the hypothesis that in a dose that significantly lowers wedged hepatic venous pressure (WHVP), a bolus injection of somatostatin will significantly decrease GMBF in patients with portal hypertensive gastropathy (PHG). In this placebo-controlled, double-blind, crossover study, 20 cirrhotic patients with PHG were randomly assigned to receive either somatostatin followed by placebo (Group A) or placebo followed by somatostatin (Group B). Wedged hepatic venous pressure was monitored. GMBF in the antrum and corpus was assessed by reflectance spectrophotometry. Indices of hemoglobin concentration (IHb) and indices of oxygen content (ISO2) were recorded. Nine patients were assigned to Group A, and 11 to Group B. Mild PHG was seen in 16 patients, and severe PHG in 4 patients. Baseline WHVP, IHb, and ISO2 were similar in both treatment groups. Wedged hepatic venous pressure (WHVP) was significantly lowered [median, 17.6%; interquartile range (-27.0,-12.6%); P = 0.0008] after a 250-microg bolus injection of somatostatin. This dose of somatostatin significantly reduced IHb both in the antrum [-10.2% (-23.4, 0.4%)] and in the corpus [-5.8% (-16.6, 5.6%)] compared to placebo (P = 0.02 and 0.04, respectively). Intravenous bolus injection of 250 microg somatostatin significantly reduces WHVP and GMBF in patients with PHG. Whether this ability to decrease the GMBF in PHG makes somatostatin an effective treatment in acute gastrointestinal bleeding in PHG deserves to be studied.
Prediction of therapeutic failure after adrenaline injection plus heater probe treatment in patients with bleeding peptic ulcer.
BACKGROUND: Continued or recurrent bleeding after endoscopic treatment for bleeding ulcer is a major adverse prognostic factor. Identification of such ulcers may allow for alternate treatments. AIM: To determine factors predicting treatment failure with combined adrenaline injection and heater probe thermocoagulation. METHODS: Consecutive patients with bleeding peptic ulcers who received endoscopic therapy between January 1995 and March 1998 were studied. Data on clinical presentation, endoscopic findings, and treatment outcomes were collected prospectively. Multiple logistic regression analysis was used to identify independent risk factors for treatment failure. RESULTS: During the study period, 3386 patients were admitted with bleeding peptic ulcers: 1144 (796 men, 348 women) with a mean age of 62.5 (SD 17.6) years required endoscopic treatment. There were 666 duodenal ulcers (58.2%), 425 gastric ulcers (37.2%), and 53 anastomotic ulcers (4.6%). Initial haemostasis was successful in 1128 patients (98.6%). Among them, 94 (8.2%) rebled in a median time of 48 hours (range 3-480). Overall failure rate was 9.6%. Mortality rate was 5% (57/1144). Multiple logistic regression analysis revealed that hypotension (odds ratio (OR) 2.21, 95% confidence interval (CI) 1.40-3.48), haemoglobin level less that 10 g/dl (OR 1.87, 95% CI 1.18-2.96), fresh blood in the stomach (OR 2.15, 95% CI 1.40-3.31), ulcer with active bleeding (OR 1.65, 95% CI 1.07-2.56), and large ulcers (OR 1.80, 95% CI 1.15-2.83) were independent factors predicting rebleeding. CONCLUSIONS: Larger ulcers with severe bleeding at presentation predict failure of endoscopic therapy.
Estimating a preference-based single index from the overactive bladder questionnaire
Objectives: The aim of the study is to estimate a preference-based single index for calculating quality-adjusted life years for patients with overactive bladder (OAB), based on a survey of the UK general population using the 5-dimensional health classification system OAB-5D, derived from the validated Overactive Bladder Questionnaire (OAB-q). Methods: An interview valuation survey of members of public in the South Yorkshire, UK was undertaken using the time-trade-off method. Each respondent was randomly allocated to one of 14 blocks, and valued seven states each plus the "pits" state, so that a total of 99 states were valued. A number of multivariate regression models were estimated for predicting a total of 3125 health state values defined by the classification. Models were compared and selected using a set of criteria, including overall diagnosis by adjusted R-squared, the sign and significance of individual parameter estimates, the relative size of coefficients within a given dimension and predictive ability. Results: The mean model was recommended for use in economic evaluation. Conclusion: This will permit the cost-effectiveness of new interventions to be assessed in patients with OAB using existing and future OAB-q data sets. © 2008, International Society for Pharmacoeconomics and Outcomes Research (ISPOR).
DETERMinants of quality of life, care and costs, and consequences of INequalities in people with Dementia and their carers (DETERMIND): A protocol paper
© 2019 John Wiley & Sons, Ltd. Objectives: DETERMIND (DETERMinants of quality of life, care and costs, and consequences of INequalities in people with Dementia and their carers) is designed to address fundamental, and, as yet unanswered questions about inequalities, outcomes and costs following diagnosis with dementia. These answers are needed to improve the quality of care and equity of access to care, and therefore the quality of life, of people with dementia and their carers. Method: DETERMIND is a programme of research consisting of seven complementary workstreams (WS) exploring various components that may result in unequal dementia care:. WS1: Recruitment and follow-up of the DETERMIND cohort—900 people with dementia and their carers from three geographically and socially diverse sites within six months following diagnosis, and follow them up for three years. WS2: Investigation of the extent of inequalities in access to dementia care. WS3: Relationship between use and costs of services and outcomes. WS4: Experiences of self-funders of care. WS5: Decision-making processes for people with dementia and carers. WS6: Effect of diagnostic stage and services on outcomes. WS7: Theory of Change informed strategy and actions for applying the research findings. Outcomes: During the life of the programme, analysing baseline results and then follow-up of the DETERMIND cohort over 3 years, we will establish evidence on current services and practice. DETERMIND will deliver novel, detailed data on inequalities in dementia care and what drives positive and negative outcomes and costs for people with dementia and carers, and identify factors that help or hinder living well with dementia.
Elective hospital admissions: secondary data analysis and modelling with an emphasis on policies to moderate growth
Background The English NHS faces financial pressures that may render the growth rates of elective admissions seen between 2001/2 and 2011/12 unsustainable. A better understanding of admissions growth, and the influence of policy, are needed to minimise the impact on health gain for patients. Objectives This project had several objectives: (1) to better understand the determinants of elective activity and policy to moderate growth at minimum health loss for patients; (2) to build a rich data set integrating health, practice and local area data to study general practitioner (GP) referrals and resulting admissions; (3) to predict patients whose treatment is unlikely to be cost-effective using patient-reported outcomes and to examine variation in provider performance; and (4) to study how policies that aim to reduce elective admissions may change demand for emergency care. The main drivers of elective admissions growth have increased either supply of or demand for care, and could include, for example, technical innovations or increased awareness of treatment benefits. Of the factors studied, neither system reform nor population ageing appears to be a key driver. The introduction of the prospective payment tariff ‘Payment by Results’ appears to have led to primary care trusts (PCTs) having increasingly similar lengths of stay. In deprived areas, increasing GP supply appears to moderate elective admissions. Reducing the incidence of single-handed practices tends to reduce referrals and admissions. Policies to reduce referrals are likely to reduce admissions but treatments may be particularly reduced in the lowest referring practices, in which resulting health loss may be greatest. In this model, per full-time equivalent, female and highly experienced GPs identify more patients admitted by specialists. Results It appears from our studies that some patient characteristics are associated with not achieving sufficient patient gain to warrant cost-effective treatment. The introduction of independent sector treatment centres is estimated to have caused an increase in emergency activity rates at local PCTs. The explanations offered for increasing elective admissions indicate that they are manageable by health policy. Conclusions Further work is required to understand some of the results identified, such as whether or not high-volume Clinical Commissioning Groups are fulfilling unmet need; why some practices refer at low rates relative to admissions; why the period effect, which results from factors that equally affect all in the study at a point in time, dominates in the age–period–cohort analysis; and exactly how the emergency and elective sections of hospital treatment interact. This project relies on the analysis of secondary data. This type of research does not easily facilitate the important input of clinical experts or service users. It would be beneficial if other methods, including surveys and consultation with key stakeholders, could be incorporated into future research now that we have uncovered important questions.
The ageing society and emergency hospital admissions
© 2017 Elsevier B.V. There is strong policy interest, in England as elsewhere, in slowing the growth in emergency hospital admissions, which for older people increased by 3.3% annually between 2001/2 and 2012/3. Resource constrains have increased the importance of understanding rising emergency admissions, which in policy discourse is often explained by population aging. This study examines how far the rise in emergency admissions of people over 65 was due to population ageing, how far to the changing likelihood of entering hospital at each age, and how far to other factors which might be more amenable to policy measures. It shows that: admission rates rose with age from age 40 upward but each successive birth cohort experienced lower emergency admission rates after standardising for age and other effects. This downward cohort effect largely offset the consequences of an older and larger population aged over 65. Other factors which could explain increasing admissions, such as new technologies or rising expectations, appear more important than the changing size and age structure of the population as drivers of rising emergency admissions in old age. These findings suggest that stemming the rate of increase in emergency admissions of older people may be feasible, if challenging, despite population ageing.
Long-term care reforms in OECD countries successes and failures
© Policy Press 2016. All rights reserved. Since the early 1990s, long-term care policies have undergone significant transformations across OECD countries. In some countries these changes have responded to the introduction of major policy reforms while in others, significant transformations have come about through the accumulation of incremental policy changes. The book brings together evidence from over 15 years of care reform to examine changes in long-term care systems occurring in OECD countries. It discusses and compares key changes in national policies and examines the main successes and failures of recent reforms. Finally, it suggests possible policy strategies for the future in the sector. With contributions from a wide range of experts across EECD countries, this book is essential reading for academics, researchers and policy-makers in the field of long-term care policy.
Development of a web-based tool for the assessment of health and economic outcomes of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA)
© 2015 Boehler et al.;. Background: The European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) is a European Commission led policy initiative to address the challenges of demographic change in Europe. For monitoring the health and economic impact of the social and technological innovations carried out by more than 500 stakeholder's groups ('commitments') participating in the EIP on AHA, a generic and flexible web-based monitoring and assessment tool is currently being developed. Aim: This paper describes the approach for developing and implementing this web-based tool, its main characteristics and capability to provide specific outcomes that are of value to the developers of an intervention, as well as a series of case studies planned before wider rollout. Methods: The tool builds up from a variety of surrogate endpoints commonly used across the diverse set of EIP on AHA commitments in order to estimate health and economic outcomes in terms of incremental changes in quality adjusted life years (QALYs) as well as health and social care utilisation. A highly adaptable Markov model with initially three mutually exclusive health states ('baseline health', 'deteriorated health' and 'death') provides the basis for the tool which draws from an extensive database of epidemiological, economic and effectiveness data; and also allows further customisation through remote data entry enabling more accurate and context specific estimation of intervention impact. Both probabilistic sensitivity analysis and deterministic scenario analysis allow assessing the impact of parameter uncertainty on intervention outcomes. A set of case studies, ranging from the pre-market assessment of early healthcare technologies to the retrospective analysis of established care pathways, will be carried out before public rollout, which is envisaged end 2015. Conclusion: Monitoring the activities carried out within the EIP on AHA requires an approach that is both flexible and consistent in the way health and economic impact is estimated across interventions and commitments. The added value for users of the MAFEIP-tool is its ability to provide an early assessment of the likelihood that interventions in their current design will achieve the anticipated impact, and also to identify what drives interventions' effectiveness or efficiency to guide further design, development or evaluation.
Primum non nocere: Shared informed decision making in low back pain - A pilot cluster randomised trial
© 2014 Patel et al.; licensee BioMed Central Ltd. Background: Low back pain is a common and disabling condition leading to large health service and societal costs. Although there are several treatment options for back pain little is known about how to improve patient choice in treatment selection. The purpose of this study was to pilot a decision support package to help people choose between low back pain treatments. Methods: This was a single-centred pilot cluster randomised controlled trial conducted in a community physiotherapy service. We included adults with non-specific low back pain referred for physiotherapy. Intervention participants were sent an information booklet prior to their first consultation. Intervention physiotherapists were trained to enhance their skills in shared informed decision making. Those in the control arm received care as usual. The primary outcome was satisfaction with the treatment received at four months using a five-point Likert Scale dichotomised into "satisfaction" (very satisfied or somewhat satisfied) and "non-satisfaction" (neither satisfied nor dissatisfied, somewhat dissatisfied or very dissatisfied). Results: We recruited 148 participants. In the control arm 67% of participants were satisfied with their treatment and in the intervention arm 53%. The adjusted relative risk of being satisfied was 1.28 (95% confidence interval 0.79 to 2.09). For most secondary outcomes the trend was towards worse outcomes in the intervention group. For one measure; the Roland Morris Disability Questionnaire, this difference was clinically important (2.27, 95% confidence interval 0.08 to 4.47). Mean healthcare costs were slightly lower (£38 saving per patient) within the intervention arm but health outcomes were also less favourable (0.02 fewer QALYs); the estimated probability that the intervention would be cost-effective at an incremental threshold of £20,000 per QALY was 16%. Conclusion: We did not find that this decision support package improved satisfaction with treatment; it may have had a substantial negative effect on clinical outcome, and is very unlikely to prove cost-effective. That a decision support package might have a clinically important detrimental effect is of concern. To our knowledge this has not been observed previously. Decision support packages should be formally tested for clinical and cost-effectiveness, and safety before implementation. Trial registration: Current Controlled Trials ISRCTN46035546 registered on 11/02/10.
Modeling a preference-based index for two condition-specific measures (asthma and overactive bladder) using a nonparametric bayesian method
Background Conventionally, parametric models were used for health state valuation data. Recently, researchers started to explore the use of nonparametric Bayesian methods in this area. Objectives We present a nonparametric Bayesian model to estimate a preference-based index for two condition-specific five-dimensional health state classifications, one for asthma (five-dimensional Asthma Quality of Life Utility Index) and the other for overactive bladder (five-dimensional Overactive Bladder Quality of Life-Utility Index). Methods Samples of 307 and 311 members of the UK general population valued 99 health states selected from a total of 3125 health states defined by each of the measures using the time trade-off technique. The article presents the results of the nonparametric model and compares it with the original model estimated using a conventional parametric random-effects model. The different methods are compared theoretically and in terms of empirical performance across the two data sets. It also reports the effect of respondent characteristics on health state valuations. Results The nonparametric models were found to be better at predicting health state values within the estimation sample than without in terms of root mean square error and the patterns of standardized residuals. Some respondent characteristics were found to explain variation in health state values, but these did not have a significant effect on the health states values when estimates were adjusted for sample differences with the general population. Conclusions The nonparametric Bayesian models are theoretically more appropriate than previously used parametric models and provide better utility estimates from the two condition-specific measures. Furthermore, the model is more flexible in estimating the effect of covariates. © 2014 International Society for Pharmacoeconomics and Outcomes Research (ISPOR).