"Cold calling" in psychiatric follow up studies: is it justified?

BACKGROUND

The ethics of cold calling-visiting subjects at home without prior appointment agreed-in follow up research studies has received little attention although it is perceived to be quite common. We examined the ethical implications of cold calling in a study of subjects with defined neurotic disorders followed up 12 years after initial assessment carried out to determine outcome in terms of symptoms, social functioning, and contact with health services. The patients concerned were asked at original assessment if they would agree to be followed up subsequently and although they agreed no time limit was put on this.

OBJECTIVES

To decide if cold calling was ethically justifiable and, if so, to set guidelines for researchers.

DESIGN

The study was a cohort study of patients with neurotic disorder treated initially for 10 weeks in a randomised controlled trial.

FINDINGS

At follow up by a research medical practitioner 18 of the 210 patients had died and of the remaining 192 patients 186 (97%) were seen or had a telephone interview. Four patients refused and two others did not have interviews but agreed to some data being obtained. However, only 104 patients (54%) responded to letters inviting them to make an appointment or to refuse contact and the remainder were followed up by cold calling, with most patients agreeing readily to the research interview. The findings illustrate the dilemma of the need to get the maximum possible data from such studies to achieve scientific validity (and thereby justify the ethics of the study) and the protection of subjects' privacy and autonomy.

CONCLUSIONS

More attention needs to be paid to consent procedures if cold calling is to be defended on ethical grounds but it is unreasonable to expect this to be obtained at the beginning of a research study in a way that satisfies the requirements for informed consent. A suggested way forward is to obtain written consent for the research at the time that cold calling takes place before beginning the research.

Incentives and clinical governance: money following quality?

This paper attempts to define quality (particularly in terms of evidence-based health care) and considers the incentives available to bring about improvements in quality. It examines the contribution that economics, as a discipline, can make to the debate on clinical governance. It considers the nature and importance of clinical governance, measuring quality, objectives and behaviour in questions raised concerning objectives and individual and team behaviour.

Assessing payback from NHS reactive research programmes

Aims to assess retrospectively the payback from NHS reactive research programmes in the Northern and Yorkshire region. A questionnaire was sent to all recipients of regional reactive research programme funding (biomedical, health services research (HSR), and primary and community care programmes) between 1 April 1991 and 31 March 1996. The sample available for analysis involved 174 respondents covering 119 projects, with a total financial value of 2.2 million Pounds. The main outcome measures used were peer-reviewed publications, changes in individual practice, changes in NHS service delivery and organisation, and impact on the careers of researchers. Overall, 119 projects produced 230 peer-reviewed publications: this was achieved at an average cost of 10,673 Pounds, 6,386 Pounds and 22,310 Pounds per publication for the biomedical, HSR, and primary and community care programmes respectively. From the qualitative data analysis, important changes in individual practice and NHS service delivery were identified by respondents. The researchers in our sample appeared to have attracted over 6 million Pounds in R&D funding related to the initial regional grant. Although based on self-report, there is evidence to suggest that the return on investment from NHS R&D can be substantial, taking a broad view of benefits to the NHS and to researchers. The findings also confirm the need for more effective dissemination and implementation of research findings.

Inter-provincial variation in government drug formularies

In Canada, coverage for ambulatory prescription drug expenditures is provided to some groups by provincial drug plans through a provincial formulary. Little is known about the drugs provincial formularies give access to. We report the variation in availability of new drug molecules (NDM) across provincial formularies. We identified 108 NDM approved in Canada between 1991 and 1998. From each drug plan bulletin or formulary, we abstracted names of NDM listed as per 15 January 1999. We compared the level of listing across provinces using kappa coefficients. In the Quebec, BC, Manitoba and Saskatchewan formularies, more than 70% of the NDM were listed. In four provinces, this proportion was lower than 50%. In general, the agreement between formularies was poor. There is a wide variation across provinces in terms of NDM listed in the formularies. This variation reflects inter-provincial differences in the way drugs are selected for coverage.

Mutations within a furin consensus sequence block proteolytic release of ectodysplasin-A and cause X-linked hypohidrotic ectodermal dysplasia

X-linked hypohidrotic ectodermal dysplasia (XLHED) is a heritable disorder of the ED-1 gene disrupting the morphogenesis of ectodermal structures. The ED-1 gene product, ectodysplasin-A (EDA), is a tumor necrosis factor (TNF) family member and is synthesized as a membrane-anchored precursor protein with the TNF core motif located in the C-terminal domain. The stalk region of EDA contains the sequence -Arg-Val-Arg-Arg156-Asn-Lys-Arg159-, representing overlapping consensus cleavage sites (Arg-X-Lys/Arg-Arg( downward arrow)) for the proprotein convertase furin. Missense mutations in four of the five basic residues within this sequence account for approximately 20% of all known XLHED cases, with mutations occurring most frequently at Arg156, which is shared by the two consensus furin sites. These analyses suggest that cleavage at the furin site(s) in the stalk region is required for the EDA-mediated cell-to-cell signaling that regulates the morphogenesis of ectodermal appendages. Here we show that the 50-kDa EDA parent molecule is cleaved at -Arg156Asn-Lys-Arg(159 downward arrow)- to release the soluble C-terminal fragment containing the TNF core domain. This cleavage appears to be catalyzed by furin, as release of the TNF domain was blocked either by expression of the furin inhibitor alpha1-PDX or by expression of EDA in furin-deficient LoVo cells. These results demonstrate that mutation of a functional furin cleavage site in a developmental signaling molecule is a basis for human disease (XLHED) and raise the possibility that furin cleavage may regulate the ability of EDA to act as a juxtacrine or paracrine factor.

Longitudinal study of the influence of life events and personality status on diagnostic change in three neurotic disorders

It has been known for many years that diagnosis within the neurotic spectrum of disorders is temporally unstable and also that life events can be major precipitants of change in symptoms. Reasons for this instability could include inherent inadequacy of current diagnostic practice, the influence of life events as an agent of diagnostic shift, and an innate course of disorder with features dependent on the stage at which disorder presents (e.g., development of panic to agoraphobia). These possibilities were examined in a prospective study that was initially a randomised controlled trial. Two hundred ten patients recruited from primary care psychiatric clinics with DSM-III diagnosed dysthymic, generalised anxiety, and panic disorders were randomly allocated to either drug treatment (mainly antidepressants), cognitive-behaviour therapy, or self-help therapy over a 2 year period, irrespective of original diagnosis. Life events were recorded by using a standard procedure over the period 6 months before starting treatment and at five occasions over 2 years; 181 (86%) of the patients had follow-up data and 76% maintained compliance with the original treatment allocated over the 2 years; and 155 of the 181 patients (86%) had at least one diagnostic change in this period. There was no difference in the number of diagnostic changes between the three original diagnostic groups, but dysthymic disorder changed more frequently to major depressive episode than did GAD or panic disorder (20; 11; 12) (%) and panic disorder changed more frequently to agoraphobia (with or without panic) than did dysthymia or GAD (18; 8; 6) (%). There was no relationship between loss events and depressive diagnoses or between addition events and anxiety diagnoses, but greater numbers of conflict events were associated with diagnostic change. More life events were associated with the flamboyant and dependent personality disorders, reinforcing other evidence that many life events are internally generated by personality characteristics and cannot be regarded as truly independent.

Risk assessment and suicide prevention in primary care

General practitioners (GPs) are assumed to occupy an important position in the prevention of suicide through the introduction of risk assessment techniques commonly used in psychiatric practice. Despite this theoretical role for primary care services, it remains unclear how frequently GPs implement risk assessment in patients who may be vulnerable to suicide. To address this, a retrospective survey of probable suicides was conducted within a primary care setting utilizing a questionnaire of GPs who had experienced a patient suicide and was augmented by hospital and coroners' records. 85% of questionnaires were returned and 61 deaths were adjudged as suicides during the year long census period. 75% of suicides were male and 54% were aged under 35.28% were in contact with psychiatric services prior to death, although 60% had some diagnosis of mental disorder. GPs had little knowledge of a patient's life circumstances in up to half of cases. Recording of risk assessment occurred in 38% of subjects, was positively associated with prior psychiatric contact (p = 0.001) but negatively associated with presence of physical illness (p = 0.004), older patient age (p = 0.04), and GPs length in practice (p = 0.05). One GP felt their suicide case was preventable. The low rate of risk assessment and limited knowledge of patient lifestyle point to the need for active engagement of GPs in future suicide prevention strategies and should influence the content of training programs in primary care.

Risk assessment and suicide prevention in primary care

General practitioners (GPs) are assumed to occupy an important position in the prevention of suicide through the introduction of risk assessment techniques commonly used in psychiatric practice. Despite this theoretical role for primary care services, it remains unclear how frequently GPs implement risk assessment in patients who may be vulnerable to suicide. To address this, a retrospective survey of probable suicides was conducted within a primary care setting utilizing a questionnaire of GPs who had experienced a patient suicide and was augmented by hospital and coroners' records. 85% of questionnaires were returned and 61 deaths were adjudged as suicides during the year long census period. 75% of suicides were male and 54% were aged under 35.28% were in contact with psychiatric services prior to death, although 60% had some diagnosis of mental disorder. GPs had little knowledge of a patient's life circumstances in up to half of cases. Recording of risk assessment occurred in 38% of subjects, was positively associated with prior psychiatric contact (p = 0.001) but negatively associated with presence of physical illness (p = 0.004), older patient age (p = 0.04), and GPs length in practice (p = 0.05). One GP felt their suicide case was preventable. The low rate of risk assessment and limited knowledge of patient lifestyle point to the need for active engagement of GPs in future suicide prevention strategies and should influence the content of training programs in primary care.

Population requirement for adult critical-care beds: a prospective quantitative and qualitative study

BACKGROUND

The provision of adult critical-care facilities is not based on a rational or scientific assessment of need. We aimed to define the numbers of adult critical-care beds required for a population of 500000.

METHODS

In five hospitals in Wales, UK, we classified patients who might be suitable for critical care in intensive-care or high-dependency units. On every 12th day for 1 calendar year, we counted the numbers of such patients admitted in a defined geographical population. A panel of ten intensivists made consensus decisions about whether individual patients were in the appropriate unit. The data were used to predict the numbers of beds and units required for the population.

FINDINGS

4058 patients were suitable for critical care, of whom 3028 lived in the study area. 56.4% were in general wards, 22.3% in high-dependency units, and 21.3% in intensive-care units. The mean risk of death was 22.0% and the in-hospital death rate 17.3%. According to the masked consensus, 41.3% of patients required high-dependency beds and 21.5% intensive-care beds. Mean risk of death increased from general wards (14.7%) to high-dependency units (19.2%) to intensive care (37.0%). Based on the consensus decisions, the average daily requirement of intensive-care beds was 21 and of high-dependency beds 43; to meet needs 95% of times required 30 and 55 beds, respectively, in a single critical-care unit.

INTERPRETATION

We estimated, scientifically, numbers of adult critical-care beds required to meet population needs. Studies are necessary periodically to track changes in admissions requiring critical care.

Cognitive difficulty in physicians

PURPOSE

Remediation of some incompetent physicians has proven difficult or impossible. The authors sought to determine whether physicians with impaired competency had neuropsychological impairment sufficient to explain their incompetence and their failure to improve with remedial continuing medical education (CME).

METHOD

During a one-year period, 1996-97, all 27 participants in the Physician Review Program (PREP) conducted at McMaster University, a physician competency assessment program, undertook a detailed neuropsychological screening battery.

RESULTS

Nearly all physicians assessed as competent also performed well on the neuropsychological testing. However, a significant number (about one third) of the physicians who performed poorly on the competency assessment had neuropsychological impairments sufficient to explain their poor performances. The difficulties were more marked in elderly physicians.

CONCLUSION

A significant minority of incompetent physicians have cognitive impairments sufficient to explain both their incompetence and, probably, their failure to improve with remedial CME. Testing physicians for these impairments is important: to detect and treat reversible conditions, to manage irreversible conditions that preclude successful educational intervention, and to facilitate compensation in this instance. Serious consideration should be given to the incorporation of neuropsychological screening in all intensive physician review programs.

Contracting for quality: does length matter?

OBJECTIVES

To examine whether longer-term contracts for health services will shift attention away from concern for finance and activity levels and towards the achievement of better quality services.

METHODS

Analysis of 288 contracts from the British National Health Service (NHS) and 12 semi-structured interviews with staff from provider (NHS hospital trusts) and purchaser (health authorities) organisations.

RESULTS

No relationship was found between the duration of a contract and the duration of service specifications or quality frameworks. The annual contracting cycle is concerned largely with ensuring that all parties stay within activity targets and financial constraints, and this is unlikely to be affected by a shift to longer-term contracts. The setting of standards and initiatives to improve quality is largely independent of the contracting process and the duration of contracts, and relies on relationships rather than contracts.

CONCLUSIONS

It is optimistic to expect longer-term contracts automatically to produce a greater focus on quality and the incentives needed to ensure that improvements in quality are delivered. However, this may not matter as issues of quality are being addressed more appropriately in the British NHS through a variety of other routes.

Effect of discussion and deliberation on the public's views of priority setting in health care: focus group study

OBJECTIVE

To investigate the extent to which people change their views about priority setting in health care as a result of discussion and deliberation.

DESIGN

A random sample of patients from two urban general practices was invited to attend two focus group meetings, a fortnight apart.

SETTING

North Yorkshire Health Authority.

SUBJECTS

60 randomly chosen patients meeting in 10 groups of five to seven people.

MAIN OUTCOME MEASURES

Differences between people's views at the start of the first meeting and at the end of the second meeting, after they have had an opportunity for discussion and deliberation, measured by questionnaires at the start of the first meeting and the end of the second meeting.

RESULTS

Respondents became more reticent about the role that their views should play in determining priorities and more sympathetic to the role that healthcare managers play. About a half of respondents initially wanted to give lower priority to smokers, heavy drinkers, and illegal drug users, but after discussion many no longer wished to discriminate against these people.

CONCLUSION

The public's views about setting priorities in health care are systematically different when they have been given an opportunity to discuss the issues. If the considered opinions of the general public are required, surveys that do not allow respondents time or opportunity for reflection may be of doubtful value.

Is community-based treatment an add-on or a substitution for hospital treatment of alcoholism? Some evidence from Canada

OBJECTIVES

This study determined whether the development of community treatment of alcohol problems acted as an add-on or a substitution for the utilization of inpatient hospital services in Ontario.

METHODS

Complex modelling and graphic analyses using econometric multiple regression techniques were performed on data for the 48 counties of Ontario (Canada) for the period 1972 to 1988, combining both cross-sectional and time series analysis.

RESULTS

After controlling for differences in alcohol consumption, in health care characteristics such as the supply of physicians or hospital occupancy rates, and in socioeconomic characteristics of the population, when community treatment became available, hospital utilization for the treatment of alcohol problems decreased and community services were substituting for hospital treatment. In addition, nonresidential services had an overall greater importance in producing this effect (elasticities at the mean of -0.11 to -0.14 depending on the region) than community-based residential treatment. The effect was larger in the southern than in the northern counties of Ontario. Testing of the modelling techniques showed statistically significant and satisfactory modelling of the forces at work.

CONCLUSIONS

Where community-based treatment was available, it was used in preference to inpatient hospital treatment; however, there may be a slightly more complex relationship present in the southern urban counties (which contain the larger metropolitan areas) than in the northern and southern rural counties..

Nurse-patient relationships: the context of nurse prescribing

Nurse prescribing was initiated in the United Kingdom in October 1994 in eight demonstration sites. The evaluation of this extension to the community nurses' role explored both economic and qualitative benefits to patients, carers, nurses and other health care professionals. In this paper the impact of nurse prescribing on patients is explored. Benefits experienced by patients are described along with the difficulties encountered. The patients' views regarding nurses as prescribers are also explored. Data were collected by means of interviews with patients/carers, the focus of which was to evaluate changes associated with nurse prescribing. Patients raised a number of issues associated with their relationship with nurses. Patients valued nurses for both their accessibility and approachability, which led them to discuss health issues which would not otherwise have been brought to the attention of the general practitioner. The arguments which support the incorporation of these qualities into an expanded nursing role are presented.

Identification of a new splice form of the EDA1 gene permits detection of nearly all X-linked hypohidrotic ectodermal dysplasia mutations

X-linked hypohidrotic ectodermal dysplasia (XLHED), the most common of the ectodermal dysplasias, results in the abnormal development of teeth, hair, and eccrine sweat glands. The gene responsible for this disorder, EDA1, was identified by isolation of a single cDNA that was predicted to encode a 135-amino-acid protein. Mutations in this splice form were detected in <10% of families with XLHED. The subsequent cloning of the murine homologue of the EDA1 gene (Tabby [Ta]) allowed us to identify a second putative isoform of the EDA1 protein (isoform II) in humans. This EDA1 cDNA is predicted to encode a 391-residue protein, of which 256 amino acids are encoded by the new exons. The putative protein is 94% identical to the Ta protein and includes a collagen-like domain with 19 repeats of a Gly-X-Y motif in the presumptive extracellular domain. The genomic structure of the EDA1 gene was established, and the complete sequence of the seven new exons was determined in 18 XLHED-affected males. Putative mutations, including 12 missense, one nonsense, and four deletion mutations, were identified in approximately 95% of the families. The results suggest that EDA1 isoform II plays a critical role in tooth, hair, and sweat gland morphogenesis, whereas the biological significance of isoform I remains unclear. Identification of mutations in nearly all of the XLHED families studied suggests that direct molecular diagnosis of the disorder is feasible. Direct diagnosis will allow carrier detection in families with a single affected male and will assist in distinguishing XLHED from the rarer, clinically indistinguishable, autosomal recessive form of the disorder.

Collecting patients' views and perceptions of continence services: the development of research instruments

This paper describes one part of a feasibility study carried out in England which examined the costs, quality and effectiveness of continence services in areas with different approaches to provision. It involved the design of instruments to collect the views and perceptions of patients and an investigation of ways to develop a methodology to implement comparative studies. It is the design and piloting of the questionnaires and the way patients responded that forms the focus of this paper. The main sample group recruited for the study were women who had recently sought formal help with urinary incontinence and were likely to receive conservative treatment or management in the community. They were interviewed and asked to complete four questionnaires at two points in time. A smaller sub-group of disabled women, interviewed only once, were included to compare cost profiles for different client groups. The questionnaires which were developed address the impact of urinary incontinence (using a standard scale), the effectiveness of service provision in terms of patients' clinical history, expectations and hoped-for outcomes, service receipt and its cost, and patients' satisfaction with several aspects of service provision. In total 118 women were interviewed, including 28 disabled women. The study generated a set of survey instruments which might be used for a variety of purposes including audit and future research and which could inform purchaser and provider decisions by using patients' perspectives of quality of life outcomes to enhance service development.

Decision making: the context of nurse prescribing

From October 1994 qualified district nurses and health visitors from eight demonstration sites in England have been able to prescribe from a limited list of formulary items. Data collected from nurses formed only one part of the evaluation of nurse prescribing. These data highlighted a number of areas where prescribing nurses were faced with difficult decisions. A number of authors have considered how both doctors and nurses make decisions, and the factors which may influence the decision making process. With reference to the literature this paper focuses on the findings related to decision making in the context of nurse prescribing.