Performance of EQ-5D, howRu and Oxford hip & knee scores in assessing the outcome of hip and knee replacements

BACKGROUND

We aimed to compare the performance of EQ-5D-3 L and howRu, which are short generic patient-reported outcome measures (PROMs), in assessing the outcome of hip and knee replacements, using the Oxford Hip Score (OHS) and the Oxford Knee Scores (OKS) for comparison.

METHODS

Outcome was assessed as the difference between pre-surgery and 6-month post-surgery scores. We used a large sample from the NHS PROMs database, which used EQ-5D-3 L, and a small cohort of patients having the same operations collected by MyClinicalOutcomes (MCO), which used howRu. Both cohorts completed the OHS (hips) or the OKS (knees).

RESULTS

The change (outcome) between pre-op and post-op scores as measured by howRu was greater than that measured by EQ-5D, relative to that measured by OHS or OKS. For hip replacements, the correlation for change measured by howRu and OHS was r = 0.77 (0.66-0.85). The corresponding correlation for change measured by EQ-5D Index and OHS was r = 0.64 (0.63-0.64). For knee replacements the correlation between change in howRu and OKS was r = 0.86 (0.75-0.92); between EQ-5D Index and OKS r = 0.59 (0.58-0.60).

CONCLUSIONS

For hip and knee replacement, the outcome measured by howRu was more highly correlated with that measured by the condition-specific Oxford Hip and Knee Scores than were EQ-5D Index or EQ-VAS. The magnitude of change before and after surgery was also greater.

Open Source Paradigm: A Synopsis of The Cathedral and the Bazaar for Health and Social Care

BACKGROUND

Open source software (OSS) is becoming more fashionable in health and social care, although the ideas are not new. However progress has been slower than many had expected.

OBJECTIVE

The purpose is to summarise the Free/Libre Open Source Software (FLOSS) paradigm in terms of what it is, how it impacts users and software engineers and how it can work as a business model in health and social care sectors.

METHOD

Much of this paper is a synopsis of Eric Raymond's seminal book The Cathedral and the Bazaar, which was the first comprehensive description of the open source ecosystem, set out in three long essays. Direct quotes from the book are used liberally, without reference to specific passages. The first part contrasts open and closed source approaches to software development and support. The second part describes the culture and practices of the open source movement. The third part considers business models.

CONCLUSION

A key benefit of open source is that users can access and collaborate on improving the software if they wish. Closed source code may be regarded as a strategic business risk that that may be unacceptable if there is an open source alternative. The sharing culture of the open source movement fits well with that of health and social care.

Mechanisms of vasodilation to PTH 1-84, PTH 1-34, and PTHrP 1-34 in rat bone resistance arteries

Parathyroid hormone (PTH) augments bone metabolism and bone mass when given intermittently. Enhanced blood flow is requisite to support high tissue metabolism. The bone arteries are responsive to all three PTH analogs, which may serve to augment skeletal blood flow during intermittent PTH administration.

INTRODUCTION

PTH augments bone metabolism. Yet, mechanisms by which PTH regulates bone blood vessels are unknown. We deciphered (1) endothelium-dependent and endothelium-independent vasodilation to PTH 1-84, PTH 1-34, and PTHrP 1-34, (2) the signaling pathways (i.e., endothelial nitric oxide synthase [eNOS], cyclooxygenase [COX], protein kinase C [PKC], and protein kinase A [PKA]), and (3) receptor activation.

METHODS

Femoral principal nutrient arteries (PNAs) were given cumulative doses (10(-13)-10(-8) M) of PTH 1-84, PTH 1-34, and PTHrP 1-34 with and without signaling pathway blockade. Vasodilation was also determined following endothelial cell removal (i.e., denudation), PTH 1 receptor (PTH1R) inhibition and to sodium nitroprusside (SNP; a nitric oxide [NO] donor).

RESULTS

Vasodilation was lowest to PTH 1-34, and maximal dilation was highest to PTHrP 1-34. Inhibition of eNOS reduced vasodilation to PTH 1-84 (-80 %), PTH 1-34 (-66 %), and PTHrP 1-34 (-48 %), evidencing the contribution of NO. Vasodilation following denudation was eliminated (PTH 1-84 and PTHrP 1-34) and impaired (PTH 1-34, 17 % of maximum), highlighting the importance of endothelial cells for PTH signaling. Denuded and intact PNAs responded similarly to SNP. Both PKA and PKC inhibition diminished vasodilation in all three analogs to varying degrees. PTH1R blockade reduced vasodilation to 1, 12, and 12 % to PTH 1-84, PTH 1-34, and PTHrP 1-34, respectively.

CONCLUSIONS

Vasodilation of femoral PNAs to the PTH analogs occurred via activation of the endothelial cell PTH1R for NO-mediated events. PTH 1-84 and PTHrP 1-34 primarily stimulated PKA signaling, and PTH 1-34 equally stimulated PKA and PKC signaling.

Prevalence and predictors of psychotropic medication use: results from the Northern Ireland Study of Health and Stress

BACKGROUND

To identify the predictors of psychotropic medication use and to determine rates and patterns of use in Northern Ireland (NI) among the general population and various subgroups.

METHOD

Analysis of data from the NI Study of Health and Stress, a representative household survey undertaken between 2004 and 2008 with 4340 individuals. Respondents were asked about prescribed psychotropic medication use in the previous 12 months along with a series of demographic questions and items regarding experience of traumatic life events. Mental health disorders were assessed using the World Health Organization's Composite International Diagnostic Interview.

RESULTS

Females, individuals aged 50-64 years old, those who were previously married, and those who had experienced a traumatic lifetime event were more likely to have taken any psychotropic medication. Use of any psychotropic medication in the population in the previous 12 months was 14.9%. Use among individuals who met the criteria for a 12-month mental health disorder was 38.5%. Almost one in ten individuals (9.4%) had taken an antidepressant.

CONCLUSIONS

Compared with other countries, NI has high proportions of individuals using psychotropic medication in both the general population and those who met the criteria for a 12-month mental disorder. However, these results still suggest possible under treatment of mental disorders in the country. In addition, rates of use in those with no disorder are relatively high. The predictors of medication use are similar to findings in other countries. Possible research and policy implications are discussed.

Metadata requirements for portals

Consensus around the requirements for metadata in patient and clinical portals would provide a sound basis for the adoption of standards. We propose a set of requirements for metadata in a way that is generic and platform independent. These requirements cover both Clinical Documents and Clinical Statements, addressing the what, who, when and where of each item.

Comparison of howRU and EQ-5D measures of health-related quality of life in an outpatient clinic

This paper reports on a head-to-head study of howRU and EQ-5D on patients with cardiovascular disease. howRU is a short generic measure of health-related quality of life comprising 39 words, designed for routine use, which we compare with EQ-5D (230 words). Patients attending a clinic completed both instruments. Completed data were available for 116 patients, 51% female, mean age 56 and SD 20. howRU is shorter, has better readability statistics, a higher completion rate, a wider range of states used and a smaller ceiling effect than EQ-5D. The correlations of howRU with EQ-5D are similar to those of EQ-5D with other validated instruments.

A short generic patient experience questionnaire: howRwe development and validation

Background

Patient experience is a key quality outcome for modern health services, but most existing survey methods are long and setting-specific. We identified the need for a short generic questionnaire for tracking patient experience.

Methods

We describe the development and validation of the howRwe questionnaire. This has two items relating to clinical care (treat you kindly; listen and explain) and two items relating to the organisation of care (see you promptly; well organised) as perceived by patients. Each item has four responses (excellent, good, fair and poor). The questionnaire was trialled in 828 patients in an orthopaedic pre-operative assessment clinic (PAC).

Results

The howRwe questionnaire is shorter (29 words) and more readable (Flesch-Kincaid grade score 2.2) than other questionnaires with broadly similar objectives. Psychometric properties in this sample are good with Cronbach’s α=0.82. Following a change to the appointments system in the clinic, howRwe showed improvement in promptness and organisation, but not in kindness and communication, showing that it can distinguish between the clinical and organisational aspects of patient experience.

Conclusions

howRwe meets the criteria for a short generic patient experience questionnaire that is suitable for frequent use. In the validation study of PAC patients, it showed good psychometric properties and concurrent, construct and discriminant validity.

The history of the Read Codes: the inaugural James Read Memorial Lecture 2011

General practitioner (GP) computing has its origins in the 1970s when the benefits of clinical coding and prescribing were demonstrated. During the early 1980s Dr James Read, working with Abies Informatics Ltd, developed the eponymous Read Codes, which were broader and more comprehensive than other schemes, yet intuitive and easy to use. In 1988 a joint working party of the Royal College of General Practitioners (RCGP) and the British Medical Association (BMA) recommended that the Read Codes be adopted nationally. The Read Codes have been used by almost all GPs in the UK since the mid-1990s. Many developments in general practice, including GP fundholding (where GPs held the budgets to commission elective care for their patients), the Quality and Outcomes Framework (QOF - pay for performance for improving chronic disease management) and GP commissioning (the current NHS reform in which primary care leads commissioning of services for their patients) would have been impossible without all GPs using a common clinical coding scheme. Systematized Nomenclature For Medicine - Clinical Terms (SNOMED CT) is a merger of the Read Codes with SNOMED RT - the original SNOMED reference terminology developed by the American College of Pathologists.

Sintero server scalable interoperability framework for DALLAS communities

We describe a prototype open source UK-scalable Health Information Exchange (HIE) to support patient-centric care, translational research and other secondary uses. It has been designed by interoperability experts to standardise information flows across the patient path—for example from home, work, mobile, clinical and community care locations. Sintero enables secure information sharing within the patient’s named ‘circle of care’ including family, third sector, social care, community pharmacy, specialist care networks and named statutory (e.g. NHS) carers. Patients may access to their own personal health records and manage consents for their sharing and secondary uses. Sintero’s infrastructure is a low-cost ‘commodity’ approach to delivering scalable DALLAS community solutions. It does this by taking a collaborative approach to capacity development, working with NHS informatics and frontline innovation centres towards efficient use of the technology by the workforce. There is a strong focus on delivery of patient value by continuous measurement and systematic feedback of outcomes. Sintero is being made available to UK DALLAS communities on a collaborative basis.

Evaluation of a new short generic measure of health status: howRu

BACKGROUND

Quality of life is paramount for patients and clinicians, but existing measures of health were not developed for routine use.

OBJECTIVES

This paper describes the development and testing of a new generic tool for measuring health related quality of life (HRQoL) with direct comparison to the SF-12 Health Survey.

METHODS

The new tool (howRu) has four items (discomfort, distress, disability and dependence), rated using four levels (none, a little, quite a lot and extreme), providing 256 possible states (4(4)); it has an aggregate scoring scheme with a range from 0 (worst) to 12 (best). Psychometric properties were examined in a telephone survey, which also recorded SF-12.

RESULTS

The howRu script is shorter than SF-12 (45 words vs 294 words) and has better readability statistics. 2751 subjects, all with long-term conditions (average age 62, female 62.8%), completed the survey; 21.7% were at the ceiling (no reported problems on any dimension); 0.9% at the floor. Inter-item correlations, Cronbach's alpha and principal factor analysis suggest that a single summary score is appropriate. Correlations between the physical and mental components of both howRu and SF-12 were as expected. Across all patients the howRu score was correlated with PCS-12 (r=0.74), MCS-12 (r=0.49) and the sum of PCS-12 and MCS-12 (r=0.81). Subjects were classified by howRu score, primary condition, the number of conditions suffered, age group, duration of illness and area of residence. Across all six classifications, the correlation of the mean howRu score with the mean PCS-12 for each class was r=0.91, with MCS-12, r=0.45 and with the sum of PCS-12 and MCS-12, r=0.97.

CONCLUSIONS

howRu is a new short generic measure of HRQoL, with good psychometric properties. It generates similar aggregate results to SF-12. It could provide a quick and easy way for practitioners to monitor the health of patients with long-term conditions.

Prevention of errors and user alienation in healthcare IT integration programmes

The design, development and implementation stages of integrated computer projects require close collaboration between users and developers, but this is particularly difficult where there are multiple specialties, organisations and system suppliers. Users become alienated if they are not consulted, but consultation is meaningless if they cannot understand the specifications showing exactly what is proposed. We need stringent specifications that users and developers can review and check before most of the work is done. Avoidable errors lead to delays and cost over-runs. The number of errors is a function of the likelihood of misunderstanding any part of the specification, the number of individuals involved and the number of choices or options. One way to reduce these problems is to provide a conceptual design specification, comprising detailed Unified Modelling Language (UML) class and activity diagrams, data definitions and terminology, in addition to conventional technology-specific specifications. A conceptual design specification needs to be straightforward to understand and use, transparent and unambiguous. People find structured diagrams, such as maps, charts and blueprints, easier to use than reports or tables. Other desirable properties include being technology-independent, comprehensive, stringent, coherent, consistent, composed from reusable elements and computer-readable (XML). When users and developers share the same agreed conceptual design specification, this can be one of the master documents of a formal contract between the stakeholders. No extra meaning should be added during the later stages of the project life cycle.

Developing a socio-economic measure to monitor access to tuberculosis services in urban Lilongwe, Malawi

OBJECTIVES

To develop locally appropriate measures of poverty for the National Tuberculosis Programme (NTP), Malawi, and to assess access to tuberculosis (TB) services by different socio-economic groups by establishing a socio-economic profile of current TB patients

DESIGN

A quantitative proxy measure of poverty was developed through regression analysis of data from the 1998 national Malawi Integrated Household Survey. A qualitative assessment of poverty was conducted in poor and non-poor settlements in urban Lilongwe to identify key indicators of socio-economic status. Both quantitative and qualitative indicators were used to assess the socioeconomic status of 179 TB patients who participated in a cross-sectional survey.

FINDINGS

The proxy measure of poverty and the qualitative indicators demonstrated similar ability to measure the poverty status of patients. The poverty head count among patients using the quantitative and qualitative indicators were 78% and 70%, respectively. Geographical analysis showed that 60% were from non-poor areas and only 15% (26/139) were from squatter settlements.

CONCLUSION

This study established a strategy for monitoring access to TB services using a proxy measure of poverty and qualitative indicators. This is a vital first step in developing an evidence base for pro-poor equitable TB services.

l -Arginine Transport in the Human Coronary and Peripheral Circulation

Background— Nitric oxide synthase (NOS) uses arginine for the production of nitric oxide (NO). High intracellular concentrations of arginine suggest that NOS activity should be independent of plasma arginine supply. However, under certain conditions, increased plasma arginine concentrations appear to be associated with increased NOS activity. The purpose of this study was to explore arginine transport within the human coronary and peripheral circulation

Methods and Results— Mass-labeled 15 N 2 -arginine was infused to steady state before cardiac catheterization in 31 patients. After diagnostic angiography, a catheter was placed in the coronary sinus. The transcardiac concentration gradient (aorta−coronary sinus) of 15 N 2 -arginine was used as a measure of arginine transport at baseline and during infusions of acetylcholine and N G -monomethyl- l -arginine (L-NMMA). No gradient was detected at rest. During the infusion of acetylcholine, a significant gradient was detected (2.5±1.2 μmol/L, P =0.01) corresponding to a fractional extraction of 11.7±7.5%. This is consistent with in vitro studies that suggest that stimulation of NOS induces arginine transport. During the infusion of L-NMMA, the concentration of 15 N 2 -arginine increased in the coronary sinus, producing a gradient of −3.9±1.3 μmol/L ( P =0.0002), corresponding to a fractional production of 20.5±5.0%. This is consistent with in vitro studies that suggest that L-NMMA induces the efflux of arginine from the cell to the extracellular space via transporter-mediated transstimulation.

Conclusions— The use of steady-state 15 N 2 -arginine to examine transorgan l -arginine gradients represents a novel tool for the study of l -arginine transport and the mechanisms of endothelial and NOS dysfunction.

Why British GPs use computers and hospital doctors do not

Almost all general medical practitioners (GPs) in the UK use computers, compared with less than one in ten of hospital doctors. This paper explains how this unexpected situation came about over a thirty-year period, identifying some of the successes and failures of British medical computing along the way. Twelve separate factors are considered. The major determinants have not been technical, but rather a strong tide of political backing for general practice and leadership from the profession at the highest level, which have combined to build an appropriate regulatory framework and financial incentives that have encouraged GPs to embrace computers. Hospital computing has some difficulties not met by GPs, but the main factor preventing progress has been the lack of any real incentive positive (carrot) or negative (stick), for hospital doctors to use computers.