Understanding ethnic and other socio-demographic differences in patient experience of primary care: evidence from the English General Practice Patient Survey

BACKGROUND

Ethnic minorities and some other patient groups consistently report lower scores on patient surveys, but the reasons for this are unclear. This study examined whether low scores of ethnic minority and other socio-demographic groups reflect their concentration in poorly performing primary care practices, and whether any remaining differences are consistent across practices.

METHODS

Using data from the 2009 English General Practice Patient Survey (2 163 456 respondents from 8267 general practices) this study examined associations between patient socio-demographic characteristics and 11 measures of patient-reported experience.

FINDINGS

South Asian and Chinese patients, younger patients, and those in poor health reported a less positive primary care experience than White patients, older patients and those in better health. For doctor communication, about half of the overall difference associated with South Asian patients (ranging from -6 to -9 percentage points) could be explained by their concentration in practices with low scores, but the other half arose because they reported less positive experiences than White patients in the same practices. Practices varied considerably in the direction and extent of ethnic differences. In some practices ethnic minority patients reported better experience than White patients. Differences associated with gender, Black ethnicity and deprivation were small and inconsistent.

CONCLUSION

Substantial ethnic differences in patient experience exist in a national healthcare system providing universal coverage. Improving the experience of patients in low-scoring practices would not only improve the quality of care provided to their White patients but it would also substantially reduce ethnic group differences in patient experience. There were large variations in the experiences reported by ethnic minority patients in different practices: practices with high patient experience scores from ethnic minority patients could be studied as models for quality improvement.

Best Practice Guidelines for use of OSCEs: Maximising value for student learning

Objective structured clinical examinations (OSCEs) are a regular component of Bachelor of Nursing (BN) programs within Australia and internationally. OSCEs are a valuable strategy to assess 'fitness to practice' at the students' expected level of clinical practice within a nursing context where the importance of accurate patient assessment is paramount. This report discusses the integration of seven proposed 'Best Practice Guidelines' (BPG) into an undergraduate BN program in Queensland, Australia. A range of learning and assessment strategies was introduced in accordance with the adoption of these guidelines to maximise student engagement. There is some evidence that these strategies have directly assisted in enhanced student confidence around clinical practice and provide preliminary evidence of the effectiveness of BPG for OSCEs within nursing programs internationally.

Drag force and surface roughness measurements on freshwater biofouled surfaces

The detrimental effect of biofilms on skin friction for near wall flows is well known. The diatom genera Gomphonema and Tabellaria dominated the biofilm mat in the freshwater open channels of the Tarraleah Hydropower Scheme in Tasmania, Australia. A multi-faceted approach was adopted to investigate the drag penalty for biofouled 1.0 m x 0.6 m test plates which incorporated species identification, drag measurement in a recirculating water tunnel and surface characterisation using close-range photogrammetry. Increases in total drag coefficient of up to 99% were measured over clean surface values for biofouled test plates incubated under flow conditions in a hydropower canal. The effective roughness of the biofouled surfaces was found to be larger than the physical roughness; the additional energy dissipation was caused in part by the vibration of the biofilms in three-dimensions under flow conditions. The data indicate that there was a roughly linear relationship between the maximum peak-to-valley height of a biofilm and the total drag coefficient.

Factors influencing the discrimination and classification of prostate cancer cell lines by FTIR microspectroscopy

In this study we obtained Fourier transform infrared (FTIR) spectra of fixed prostate cell lines of differing types as well as the primary epithelial cells from benign prostatic hyperplasia (BPH). Results showed that by using multivariate chemometric analysis it was possible to discriminate and classify these cell lines, which gave rise to sensitivity and specificity values of >94% and >98%, respectively. Following on from these results the possible influences of different factors on the discrimination and classification of the prostate cell lines were examined. Firstly, the effect of using different growth media during cell culturing was investigated, with results indicating that this did not influence chemometric discrimination. Secondly, differences in the nucleus-to-cytoplasm (N/C) ratio were examined, and it was concluded that this factor was not the main reason for the discrimination and classification of the prostate cancer (CaP) cell lines. In conclusion, given the fact that neither growth media nor N/C ratio could totally explain the classification it is likely that actual biochemical differences between the cell lines is the major contributing factor.

A gene expression profiling approach assessing celecoxib in a randomized controlled trial in prostate cancer

BACKGROUND

We performed a pilot study, looking at the COX-2 inhibitor celecoxib, on newly diagnosed prostate cancer patients in the neo-adjuvant setting using DNA microarray analysis.

PATIENTS AND METHODS

This was a single-blinded, randomized controlled phase II presurgical (radical prostatectomy) 28-day trial of celecoxib versus no drug in patients with localized T1-2 N0 M0 prostate cancer. cDNA microarray analysis was carried out on prostate cancer biopsies taken from freshly obtained radical prostatectomy samples. Results were confirmed by qPCR analysis of a selection of genes.

RESULTS

Multiple genes were differentially expressed in response to celecoxib treatment. Statistical analysis of microarray data indicated 24 genes were up-regulated and 4 genes down-regulated as a consequence of celecoxib treatment. Gene changes e.g. survivin, SRP72kDa, were associated with promoting apoptotic cell death, enhancement of antioxidant processes and tumour suppressor function (p73 and cyclin B1 up-regulation).

CONCLUSION

Celecoxib at 400 mg b.i.d. for 4 weeks perioperatively gave rise to changes in gene expression in prostate cancer tissue consistent with enhancement of apoptosis and tumour suppressor function. Given the short time interval for the duration of this study, the data are encouraging and provide a good rationale for conducting further trials of celecoxib in prostate cancer.

Examining how contexts shape young children's perspectives of health

BACKGROUND

We know that the social conditions in which children live exert a strong influence on their health; yet, we do not know how children's experience of these conditions of daily life shape their perspectives of health.

METHODS

Through ethnographic research methods, the first author spent 1 year with the 14 6-year-old children involved in this research and examined how the contexts of daily life influenced the children's perspectives of health. The children involved in this study all lived in a neighbourhood characterized as having a complex of mid to high range of neighbourhood factors associated with vulnerability.

RESULTS

The findings demonstrate that the children were able to articulate the health requirements of physical activity and healthy eating that supports their health. However, there was a disparity between the children's health knowledge, their perceptions and their contextual realities in relation to health. Children spoke of concerns for their physical safety within their schools and neighbourhoods; their lack of free range of play, and that they had few opportunities to play with or get to know neighbourhood friends.

CONCLUSION

Professionals in contact with children and families who live in challenging social conditions need to be aware of how these contexts shape children's understanding of their own health potential.

Patient and physician reporting of symptoms and health-related quality of life in trials of treatment for early prostate cancer: considerations for future studies

AIMS

Clinical trials in early prostate cancer (EPC) have used a variety of outcome measures, including patient-reported outcomes (PROs) and physician-reported data. We review published studies and suggest a set of outcome measures and a portfolio of more detailed questionnaire options to produce a more homologous data set for future clinical trials.

MATERIALS AND METHODS

A literature search combining the terms 'quality of life' or 'symptoms' and 'prostate cancer' or 'prostate adenocarcinoma' was carried out. Relevant papers were reviewed to assess key areas of toxicity and quality of life (QoL). These were discussed by a panel with a special interest in the assessment of QoL measures and PROs.

RESULTS

Twenty-one validated candidate questionnaires were identified. The Short Form 12 was recommended due to its combination of brevity and assessment of pain, general and mental health, physical, social and emotional function. Specific questionnaires should assess localised symptoms after treatment, including sexual function, erectile dysfunction, bowel function and lower urinary tract symptoms (LUTS). The modular use of separate symptom indices was recommended. For sexual function, the International Index of Erectile Function and the International Continence Society questionnaire were considered the best available. The International Continence Society Male Short Form questionnaire best addressed LUTS. Incontinence of stool (solid, liquid or gas) and its effect on function should be assessed. The Vaizey questionnaire is recommended. The Radiation Therapy Oncology Group scale, which is physician administered, remains helpful in studies including radiotherapy, as it places current trials within appropriate historical context. Rates of procedures to treat complications and pharmaceutical interventions for treatment-related symptoms should be recorded at the time of each questionnaire follow-up.

CONCLUSION

Although novel therapies may produce different toxicities, the current recommendations should help to produce trial protocols that will allow comparable data to be generated within clinical trials comparing outcome from surgery, radiotherapy and other targeted ablative therapies for EPC.

Plethysmography and impulse oscillometry assessment of tiotropium and ipratropium bromide; a randomized, double-blind, placebo-controlled, cross-over study in healthy subjects

AIMS

Spirometry, plethysmography and impulse oscillometry (IOS) measure different aspects of lung function. These methods have not been compared for their ability to assess long- and short-acting anticholinergic agents. We therefore performed a double-blind, placebo-controlled, four-way cross-over study in 30 healthy subjects.

METHODS

Single doses of tiotropium bromide (Tio) 54 and 18 mcg, ipratropium bromide (IB) 40 mcg and placebo were administered. Specific conductance (sGaw), total lung capacity (TLC), inspiratory capacity (IC) and residual volume (RV) were measured using plethysmography, while IOS measured resistance (R5-25) and reactance (RF and X5). Pulmonary function was measured for 26 h post dose.

RESULTS

Tio caused significant improvements in sGaw, forced expiratory voume in 1 s (FEV(1)), maximum mid-expiratory flow (MMEF) and R5-R25 at time points up to 26 h, with no clear differences between doses. IB improved the same parameters, but only up to 8 h. The weighted mean change (0-24 h) caused by Tio 54 mcg compared with placebo for FEV(1) was 240 ml (95% confidence interval 180, 300), while for sGaw the ratio of geometric means (Tio compared with placebo) was 1.35 (1.28, 1.41). Neither drug caused consistent statistically significant changes in RF, forced vital capacity, TLC or IC over 26 h. RV was significantly improved from 8 to 24 h by Tio 54 mcg only.

CONCLUSIONS

In addition to spirometry, IOS resistance measurements and sGaw can distinguish between the effects of long- and shortacting anticholinergic effects in healthy subjects.

A blinded, randomized controlled trial of neo-adjuvant celecoxib in patients with early prostate cancer

4563

Background: Celecoxib inhibits tumorigenesis in many in vitro and in vivo models by anti-angiogenesis, induction of apoptosis, and inhibition of tumour cell proliferation and hypoxia. Methods: 45 cT1–2 prostate cancer patients were block randomized 2:1 to four weeks celecoxib 400mg b.d. or no drug prior to radical prostatectomy (RP). Tumour immunohistochemistry was performed for cell proliferation (Ki-67), angiogenesis (CD-31, VEGF, VEGF-R2), hypoxia (HIF-1), apoptosis (TUNEL), and COX-2. All scoring was performed blind by PS and a random 20% were validated blindly by an immunopathologist (SBF). In 19 patients (12 celecoxib-treated, 7 control), peri-operative peripheral zone biopsies were subjected to cDNA microarray analysis to identify differences in gene expression profiling (GEP) between the groups. Results: There was ‘substantial’ (kappa >0.6) or ‘almost perfect’ (kappa >0.8) inter-observer agreement in immunoscoring for all stains. Baseline scores were not significantly different between the celecoxib and control groups. In the celecoxib group, RP scores were significantly lower for Ki-67 (p = 0.036), and non-significantly lower for hypoxia (p = 0.15), KDR (p = 0.16), COX-2 (p = 0.19), microvessel density (p = 0.53), and VEGF (p = 0.83); tumour apoptosis was non-significantly higher (p = 0.26). MANOVA of the full model of stains showed that the difference between the two groups approached statistical significance (p = 0.058), and this was visualized with principal component analysis. GEP revealed that 76 genes were significantly differentially expressed between the celecoxib and control groups using uncorrected t-tests. In the celecoxib group, the tumour suppressor gene p73 and genes associated with protection against oxidative stress were significantly up-regulated; genes associated with cell adhesion were significantly down-regulated, consistent with a reduction in metastatic potential. Conclusions: Celecoxib appears to have marked anti-cancer effects on prostate tumours, most notably affecting cell cycle regulation, oxidative stress, and cell signalling. It may therefore be a promising agent in the management of prostate cancer and warrants further investigation.

No significant financial relationships to disclose.

Habitual physical activity and sedentary behaviour in a clinical sample of obese children

OBJECTIVE

To objectively measure habitual physical activity and sedentary behaviour in a clinical sample of obese children and to compare with age- and sex-matched non-obese controls.

DESIGN

Pairwise comparison of obese children matched for age and gender with non-obese controls.

SUBJECTS

A total of 116 obese children (body mass index (BMI)> or =98th centile) and 53 non-obese control children (BMI<85th centile). Controls were matched with 53 of the obese children (mean age 8.6, s.d. 2.0 years; 25 M and 28 F).

MEASUREMENT

Habitual physical activity and sedentary behaviour were measured over a 7-day period using CSA accelerometers. Total physical activity (mean accelerometry count per minute (c.p.m.)), percentage of monitored time in sedentary behaviour, light and moderate to vigorous intensity physical activity (MVPA) were compared.

RESULTS

Obese children (n=116) spent on average 80.4% of their monitored time in sedentary behaviour and 2.5% of their monitored time in MVPA. Total activity (mean c.p.m.) was significantly higher in the non-obese group (n=53) than the obese group (n=53), 729 vs 648 c.p.m.; 95% confidence interval (CI) 7, 155. Time spent in sedentary behaviour averaged 80.9% (s.d. 6.6) in the obese group and 79.3% (s.d. 6.2) in the non-obese group, with no significant between-group difference (95% CI -3.9, 0.6). Light intensity activity was similar in the obese and non-obese groups (15.9 vs 17.3%; 95% CI -0.3, 3.0). Participation in MVPA was significantly higher in the non-obese vs obese group (3.9 vs 2.4%; 95% CI 0.6, 2.0).

CONCLUSION

This study supports the hypothesis that a clinical sample of obese children is less physically active than non-obese children, although the difference in total activity and MVPA between the groups was small.

Northern political culture?: Political behaviour in Nunavut

The realities of political life in Nunavut suggest that levels of political engagement would be lower than that found in southern Canada. The absence of political parties affects both the method of political campaigning and the operation of the legislature while the existence of Inuit birthright organizations provide a parallel system of governance and several more opportunities to vote and to stand for election. Levels of turnout are lower than average for federal elections and lower still for the birthright organizations. For territorial elections, however, turnout levels are much higher. An analysis of predictors of voting demonstrates that age, income and education have a positive impact on turnout. Inuit, and those with positive evaluations of the land claim and Nunavut, are also more likely to vote. In its investigation of political office, the paper also demonstrates that there are elected positions for 1% of the population in Nunavut, compared with .0075% in a typical Canadian community. The paper is the first to examine political behaviour in the North from a quantitative perspective and carefully points out methodological issues affecting the treatment of data. It ends by arguing that southern models of political behaviour should be treated with caution in Nunavut.