General practice management of illicit drug users in Scotland: a national survey

AIMS

To describe the level of involvement of general practitioners (GPs) in the management of illicit drug dependency; nature of current practice in the management of illicit drug dependency; influence of guidelines on practice; GP training experience and needs; and to consider the policy implications of the findings.

DESIGN

A cross-sectional postal questionnaire survey.

SETTING

General practice in Scotland.

PARTICIPANTS

A 1 : 4 randomized sample (n = 926) of general practice principals, stratified according to age, gender and number of practice partners.

MEASUREMENTS

A structured postal questionnaire.

FINDINGS

A 63% response rate was achieved after two reminders (n = 583). Sixty per cent of respondents treated drug users, 51.5% provided methadone maintenance but only 58% used doses in the recommended range. Maintenance prescribing of dihydrocodeine and benzodiazepines was provided by 24% and 44.8% of respondents, respectively. While 79.3% had received the national clinical guidelines only 22.5% believed this had influenced their practice. Only a third of respondents had received drug dependency training. Beliefs about whether prescribing for drug misusers is part of a GPs professional remit was split.

CONCLUSIONS

There was relatively high involvement with drug users, with methadone maintenance being the most common treatment provided. Maintenance prescribing of dihydrocodeine and benzodiazepines were common despite a lack of clinical evidence supporting the effectiveness of these treatments. This may reflect the nature of the presenting drug problems and highlights the difficulties some GPs may face in managing multiple drug dependencies within current guidelines. Further local training to implement guidelines along with trials of alternative treatments currently outwith guidelines should be considered.

Transepithelial resistance and inulin permeability as endpoints in in vitro nephrotoxicity testing

Transepithelial electrical resistance (RT) and the flux of fluorescein isothiocyanate (FITC) across Madin Darby canine kidney (MDCK) strain 1 cells and porcine epithelial kidney (LLC-PK1) monolayers were compared between three laboratories for a range of nephrotoxins. The precision of the REMS AutoSampler was similar to that of the Ussing chamber and the ENDOHM technique, but superior to using chopstick electrodes, for measurements of resistance. The nephrotoxins used were selective for the proximal tubule, and in all cases, LLC-PK1 cells were more sensitive than MDCK cells. In most cases, change in RT was a more sensitive indicator of damage than alterations in FITC flux. The REMS system provides high intra-plate precision for RT measurements and is a higher throughput system, which is applicable to screening for nephrotoxicity in vitro.

Decision-making by healthcare payers

Healthcare payers are faced with the need to allocate finite resources to maximize population health. To assist in decision-making, healthcare payers are increasingly using health outcomes information and economic analyses. Healthcare payers are often under pressure to make early decisions (around the time of product launch), when the evidence available is imperfect. They must also consider the equitable distribution of resources between therapeutic areas. Tools to help healthcare payers reach transparent and objective decisions include cost-utility analysis and decision modelling. In practice, healthcare payers in different countries (for example, Ireland, France and Canada) vary in the approaches taken to reimbursement and formulary listing decisions. The key to decision-making among healthcare payers is the provision of appropriate evidence, comparing any new treatment approach to current best practice, in situations corresponding to real life. When data assumptions have to be made, these should be clearly stated with consideration of the impact of varying the assumptions. The impact on budgets should also be considered.

The use of local accident and emergency injury surveillance to monitor the impact of a lay safety community programme

To study prospectively the injury patterns in under 14 year olds presenting to casualty. To use this information to assess the impact of a local Community Childhood Accident Prevention Project (CCAPP) Prospective injury surveillance was collected on all attendees under 14 years of age. Casualty attendance for the members of the Safety Club and matched controls were analysed. Of the 4,267 attendees there was the expected male predominance. 2,261 (53%) of injuries occurred at home, 574 (13.5%) on the road, 553 (13%) at school with 202 (4.7%) during sports. Priority areas noted were high falls > 1 metre, road accidents, burns and poisonings. Those participating in the program demonstrated significantly (p-value < 0.05) reduced admission rates and head injury rates when compared to non-participants. The above database allows us to analyse injury patterns and to assess the success of an EU-sponsored local injury prevention campaign in areas of high social deprivation.

An outbreak of Rift Valley fever in Northeastern Kenya, 1997-98

In December 1997, 170 hemorrhagic fever-associated deaths were reported in Garissa District, Kenya. Laboratory testing identified evidence of acute Rift Valley fever virus (RVFV). Of the 171 persons enrolled in a cross-sectional study, 31(18%) were anti-RVFV immunoglobulin (Ig) M positive. An age-adjusted IgM antibody prevalence of 14% was estimated for the district. We estimate approximately 27,500 infections occurred in Garissa District, making this the largest recorded outbreak of RVFV in East Africa. In multivariable analysis, contact with sheep body fluids and sheltering livestock in one s home were significantly associated with infection. Direct contact with animals, particularly contact with sheep body fluids, was the most important modifiable risk factor for RVFV infection. Public education during epizootics may reduce human illness and deaths associated with future outbreaks.

Aging and accumulation of microdamage in canine bone

Fractures associated with minimal trauma are common in aged human beings. However, bone safety margins are better preserved in aged dogs, which are rarely affected with minimal trauma fractures. Although the hierarchical architecture of canine and human compact bone is similar, the precise reasons for this species difference are unclear. Cyclic loading of bone during normal daily activity leads to the formation of microcracks within the tissue matrix of compact bone. Using a standard bulk-staining technique with basic fuchsin, we examined calcified transverse sections of the mid-diaphysis of the canine humerus from dogs of varying ages. We found that the amount of microdamage and porosity increased exponentially with aging, although the increases were relatively small, compared with human bone. Gender (female, ovariohysterectomized female, male, castrated male) did not have a significant effect on the amount of microdamage or porosity in bone. Alterations to the local material properties of bone tissue, or alterations to the local tissue repair responses, may play a role in the accumulation of microdamage in bone with aging. Determination of osteocyte lacunar density (number of osteocyte lacunae per bone area) and activation frequency (number of actively remodeling osteons per bone area per year) indicated that these variables declined exponentially with aging. There also was a trend for bone from dogs with low osteocyte lacunar density to have a higher microcrack density, but not higher porosity. Furthermore, bones with a high activation frequency did not accumulate microcracks or porosity. Taken together, these data suggest that, in canine bone, although a certain minimum number of osteocytes may be essential for an operational network that forms part of the signaling pathways that orchestrate repair of bone microdamage, increases in porosity with aging may not be directly associated with impaired function of the osteocyte network within bone.

Costs and benefits of cervical screening IV: valuation by women of the cervical screening programme

OBJECTIVES

To assess the value of the cervical smear test to women, taking account of the positive and negative aspects of the cervical screening service.

DESIGN

A postal survey.

SETTING

Tayside Health Board region of Scotland.

PARTICIPANTS

A sample of 2000 women aged 20-59.

MAIN OUTCOME MEASURES

Maximum willingness to pay (WTP) for a cervical smear test.

RESULTS

Women were prepared to pay 50.20 British pounds per smear on a 3-yearly basis. Willingness to pay was positively related to income, but unrelated to age and whether or not the respondent had previously had a smear.

CONCLUSIONS

Previous studies have estimated the cost per screen or cost per life year saved by cervical screening. This study used the economic instrument of WTP to take account of other potential (dis)benefits to women. The value women place on having a smear was more than the cost to the National Health Service (NHS) of providing the service. The output of a WTP study is potentially useful at the policy level. Future work should explore both the value of alternative approaches to cervical screening, and the value of competing health care interventions.

Minimally invasive, radioguided surgery for primary hyperparathyroidism

BACKGROUND

Primary hyperparathyroidism affects 1 in 700 individuals in the United States. A single adenoma is responsible in over 85% of cases. Surgery remains the most effective treatment. This study was designed to assess the feasibility of minimally invasive radioguided parathyroidectomy (MIRP) with confirmation of excision by ex vivo radioactivity alone.

METHODS

Seventy-five consecutive patients with primary hyperparathyroidism were prospectively studied. Following sestamibi scan, patients underwent unilateral neck exploration guided by a handheld gamma probe, which was also used to measure ex vivo radioactivity of excised tissue.

RESULTS

The sestamibi scan was positive in 88% of the patients. A small incision (mean, 3.2+/-0.3 cm) was sufficient. Ectopic gland sites were localized in five patients with positive scans and single adenomas. Mean operative time was 48 minutes (range, 15-125 minutes), with shorter procedures after the initial 20 cases (mean, 24 vs. 72 minutes; P < .01). Radioguided parathyroidectomy was successful in 97%, with a mean follow-up of 11 months (range, 1-26 months). As noted previously, adenomatous parathyroid glands contained more than 20% of the background radioactivity.

CONCLUSIONS

MIRP is a feasible alternative to bilateral dissection with the advantages of guided dissection and rapid confirmation, and may become the procedure of choice for primary hyperparathyroidism.

Assessing women's preferences for intrapartum care

BACKGROUND

Recent government reports have recommended involving consumers in the planning of health services. Although satisfaction surveys have traditionally been used, they have several limitations. This paper describes a relatively new method of eliciting consumer preferences that allows respondents (women) to indicate the importance that they attribute to specific aspects of a service. The aim was to explore the feasibility of using a discrete choice experiment to assess the importance to women of different aspects of intrapartum care.

METHODS

In this pilot study of 301 women at low obstetric risk, data were collected using an anonymous self-complete questionnaire given to each participant by the midwife at the booking visit.

RESULTS

The results of the regression model suggest that respondents prefer maternity units that offer greater continuity of caregiver, more methods of pain relief, continuous fetal heart rate monitoring, a homely appearance, routine involvement of medical staff, and greater involvement for the woman in the decision-making process. Although all attributes were important to women, they were not all of equal importance. For example, if continuity of caregiver were achieved at the expense of decreasing the availability of pain relief then women would be worse off.

CONCLUSIONS

The discrete choice experiment appears to be a useful tool in assessing the strength of women's preferences for different aspects of maternity care. Future research should include a qualitative approach to explore in greater depth the processes involved in shaping women's preferences.

Use of discrete choice experiments to elicit preferences

This paper considers the application of discrete choice experiments for eliciting preferences in the delivery of health care. Drawing upon the results from a recently completed systematic review, the paper summarises the application of this technique in health care. It then presents a case study applying the technique to rheumatology outpatient clinics. 200 patients were questioned about the importance of six attributes: staff seen (junior doctor or specialist nurse); time in waiting area; continuity of contact with same staff; provision of a phone-in/advice service; length of consultation; and change in pain levels. The systematic review indicated that discrete choice experiments have been applied to a wide number of areas and a number of methodological issues have been addressed. Consistent with this literature, the case study found evidence of both rationality and theoretical validity of responses. The approach was used to establish the relative importance of different attributes, how individuals trade between these attributes, and overall benefit scores for different clinic configurations. The value of attributes was estimated in terms of time, and this was converted to a monetary measure using the value of waiting time for public transport. Discrete choice experiments represent a potentially useful instrument for eliciting preferences. Future methodological work should explore issues related to the experimental design of the study, methods of data collection and analysis, and satisfaction with the economic axioms of the instrument. Collaborative work with psychologists and qualitative researchers will prove useful in this research agenda.

Data analyst technician: an innovative role for the pharmacy technician

The development of an innovative role for the pharmacy technician is described. The role of the pharmacy technician was based on a needs assessment and the expertise of the pharmacy technician selected. Initial responsibilities of the technician included chart reviews, benchmarking surveys, monthly financial impact analysis, initiative assessment, and quality improvement reporting. As the drug-use and disease-state management (DUDSM) program expanded, pharmacist activities increased, requiring the expansion of data analyst technician (DAT) duties. These new responsibilities included participation in patient assessment, data collection and interpretation, and formulary enforcement. Most recently, technicians' expanded duties include maintenance of a physician compliance profiling database, quality improvement reporting and graphing, active role in patient risk assessment and database management for adult vaccination, and support of financial impact monitoring for other institutions within the health system. This pharmacist-technician collaboration resulted a threefold increase in patient assessments completed per day. In addition, as the DUDSM program continues to expand across the health system, an increase in DAT resources from 0.5 to 1.0 full-time equivalent was obtained. The role of the DAT has increased the efficiency of the DUDSM program and has provided an innovative role for the pharmacy technician.

Hyponatremia and leukopenia associated with oxcarbazepine following carbamazepine therapy

Straightforward reports of unusual drug experiences are included in this section. While selected references may be cited, the purpose of a Drug Experience report is not to present an extensive review of the literature. A related section, Grand Rounds, includes papers that are well-documented patient case reports with a thorough review of the important literature to help put the case in perspective. Authors should report serious adverse drug reactions to the FDA medical products reporting program (MedWatch). Such reporting will not jeopardize the chances that AJHP will publish manuscripts on the same drug reactions.