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.

Differential matrix metalloproteinase expression in cases of multiple sclerosis and stroke

Multiple sclerosis (MS) and stroke pathology are characterized blood-brain barrier breakdown, leucocyte emigration, and tissue destruction. Each process is thought to involve the matrix metalloproteinases (MMP), but little is known of their expression. We undertook to investigate whether MMP expression is dependent on the nature of the CNS lesion and whether expression would coincide with the histopathology. MS or cerebral-infarct tissue was examined for the presence of gelatinase-A, gelatinase-B, matrilysin and stromelysin-1. Gelatinases A and B and matrilysin expression was found to be up-regulated in microglia/macrophages within acute MS lesions. In active-chronic MS lesions, matrilysin and gelatinase-A expression was pronounced in the active borders. In chronic MS lesions, the expression of matrilysin was confined to macrophages within perivascular cuffs. The pattern of MMP expression in infarct lesions differed considerably. Gelatinase-B was strongly expressed by neutrophils in tissue from patients up to 1 week after an infarct, whereas gelatinase-A and matrilysin staining was much less marked. From 1 week to 5 years, neutrophils were absent and the large number of macrophages present were expressing matrilysin and gelatinase A. Only a low level of gelatinase-A and matrilysin expression was observed in normal brain controls. Thus, MMPs are expressed in inflammatory lesions in the CNS, but their individual expression is dependent on the nature and chronicity of the lesion. However, the general pattern of expression, in perivascular cuffs and in active lesions, supports a role for these enzymes as mediators of blood-brain barrier breakdown and tissue destruction, both in MS and in cerebral ischaemia.

Patients' views of nurse prescribing

In 1994 the law was changed to allow nurses to prescribe from a limited formulary. The Department of Health commissioned research to evaluate nurse prescribing in eight pilot sites in England. This article presents part of this research. In particular, it examines how patients perceived the role of nurses and health visitors as prescribers. The study involved interviewing patients seen by community nurses before and after the introduction of nurse prescribing. The advantages patients identified coincided with the anticipated benefits, while the disadvantages that had been anticipated before the study were not confirmed. Patients were positive about nurses as prescribers and in some instances preferred nurses to doctors.

Axonal damage in acute multiple sclerosis lesions

One of the histological hallmarks of early multiple sclerosis lesions is primary demyelination, with myelin destruction and relative sparing of axons. On the other hand, it is widely accepted that axonal loss occurs in, and is responsible for, the permanent disability characterizing the later chronic progressive stage of the disease. In this study, we have used an antibody against amyloid precursor protein, known to be a sensitive marker of axonal damage in a number of other contexts, in immunocytochemical experiments on paraffin embedded multiple sclerosis lesions of varying ages in order to see at which stage of the disease axonal damage, in addition to demyelination, occurs and may thus contribute to the development of disability in patients. The results show the expression of amyloid precursor protein in damaged axons within acute multiple sclerosis lesions, and in the active borders of less acute lesions. This observation may have implications for the design and timing of therapeutic intervention, one of the most important aims of which must be the reduction of permanent disability.

Nurses' and GPs' views of the nurse prescribers' formulary

This article presents the findings from the evaluation of nurse prescribing, undertaken in eight demonstration sites since October 1994. The authors examine in particular the nurses' prescribing behaviour and the type of items nurses and GPs would like to see added to the formulary. The opportunities for prescribing and the limitations of the formulary for health visitors and practice nurses are highlighted.

Analysis of hospitalization rates by electoral ward: relationship to accessibility and deprivation data

The objective of this paper is to investigate the relevance of access to hospital services in explaining utilization rates at a District Health Authority level in the UK. In order to test the hypothesis that access is important, it is necessary to develop a means of scoring access factors and then combining these scores with other more recognized influences on hospitalization rates e.g. deprivation measures. Acknowledging that hospitalization rates are not merely products of a population's socio-economic characteristics, the effect of accessibility to hospital services for the resident population is investigated through the derivation of an access score using both private and public transport from electoral ward of residence. Deprivation and accessibility to services were both found to be significant factors in determining hospitalization rates at electoral ward level. The chosen supply variable--number of GPs--was not found to be significant in any of the models developed using linear regression techniques. To conclude, it appears that access plays an important role in determining hospitalization rates within a given population. If high hospitalization rates are accepted as an indicator of effectively met demand then policy makers may have to consider increasing the accessibility of hospital services.