The low uptake of breast screening in cities is a major public health issue and may be due to organisational factors: a Census-based record linkage study

BACKGROUND

Cancer screening uptake is generally lower in UK cities but quantifying city-level effects from causes due to population composition that comprise cities is hampered by data limitations.

METHODS

A unique data linkage project combining a 2001 Census-based longitudinal study in Northern Ireland with the NHS Breast Screening Program. Validated uptake in the three years following the Census for Belfast Metropolitan Urban Area was compared against the rest of the country with adjustment for cohort attributes defined at Census.

RESULTS

Belfast Metropolitan Urban Area contained 34.8% of invited women but a greater proportion who rented their accommodation (40.3%) or who did not have a car (47.1%). After full adjustment for demographic and socio-economic factors, Belfast Metropolitan Urban Area uptake was lower for first and subsequent screen (Odds ratio (OR) 0.72; 95% CIs 0.66, 0.78 and OR 0.58; 95% CIs 0.55, 0.62 respectively). There were no significant interactions between patient characteristics and area of residence indicating that all residents in Belfast Metropolitan Urban Area are equally affected.

CONCLUSION

The reduced uptake of screening in cities is a major public health issue; the effects are large and a large proportion of the population are affected, organisational factors appear to be the primary cause. Strategies to correct this imbalance might help reduce inequalities in health.

The effect of superstition on the day of discharge from maternity units in Northern Ireland: "A Saturday flit is a short sit"

The impetus for evidence-based practice arose from the science of maternity and childcare. Yet this has to coexist with patient preferences which are often based on a belief system far removed from science. This paper shows how a superstition, which suggests that moving on a Saturday is unlucky, affects a large proportion of discharges from maternity units in Northern Ireland. This is a descriptive study of the 77 018 patients admitted to maternity units in Northern Ireland between 1994/95 and 1996/97. Overall 3819 (35.7%) fewer patients than expected were discharged on Saturday and 2445 (23.2%) and 1834 (17.4%) more than expected were discharged on Friday and Sunday respectively. This means that at least 8097 patients were probably affected by the superstition. In an evidence-based world patient preferences are still evident.

Field trauma care in the 21st century

The nature of trauma care on the modern battlefield is changing quickly. Leading figures in UK field trauma care spoke at a recent meeting of the Haywood Club. The challenge of modern warfare, the evolving evacuation chain and the command and governance of field trauma care were explored.

Perceived and reported access to the general practitioner: an international comparison of universal access and mixed private/public systems

Timely and convenient access to primary healthcare is essential for the health of the population as delays can incur additional health and financial costs. Access to health care is under increasing scrutiny as part of the drive to contain escalating costs, while attempting to maintain equity in service provision. The objective was to compare primary care services in Republic of Ireland and Northern Ireland, and to report on perceived and reported access to GP services in universal access and mixed private/public systems. A questionnaire study was performed in Northern Ireland (NI) and the Republic of Ireland (ROI). Patients of 20 practices in the ROI and NI were contacted (n = 22,796). Main outcome measures were overall satisfaction and the access to GP services. Individual responses and scale scores were derived using the General Practice Assessment Questionnaire (G-PAQ). The response rate was 52% (n = 11,870). Overall satisfaction with GP practices was higher in ROI than in NI (84.2% and 80.9% respectively). Access scores were higher in ROI than in NI (69.2% and 57.0% respectively) Less than 1 in 10 patients in ROI waited two or more working days to see a doctor of choice (8.1%) compared to almost half (45.0%) in NI. In NI overall satisfaction decreased as practice size increased; 82.8%, 80.4%, and 75.8%. In both systems, in large practices, accessibility is reduced when compared to smaller practices. The faster access to GP services in ROI may be due to the deterrent effect of the consultation charge freeing up services although, as it is the poorest and sickest who are deterred by the charge this improved accessibility may come at a significant cost in terms of equity. The underlying concern for policy makers centres around provision of equitable services.

The economic burden of schizophrenia in Canada in 2004

OBJECTIVE

To estimate the financial burden of schizophrenia in Canada in 2004.

METHODS

A prevalence-based cost-of-illness (COI) approach was used. The primary sources of information for the study included a review of the published literature, a review of published reports and documents, secondary analysis of administrative datasets, and information collected directly from various federal and provincial government programs and services. The literature review included publications up to April 2005 reported in MedLine, EMBASE and PsychINFO. Where specific information from a province was not available, the method of mean substitution from other provinces was used. Costs incurred by various levels/departments of government were separated into healthcare and non-healthcare costs. Also included in the analysis was the value of lost productivity for premature mortality and morbidity associated with schizophrenia. Sensitivity analysis was used to test major cost assumptions used in the analysis. Where possible, all resource utilization estimates for the financial burden of schizophrenia were obtained for 2004 and are expressed in 2004 Canadian dollars (CAN dollars).

RESULTS

The estimated number of persons with schizophrenia in Canada in 2004 was 234 305 (95% CI, 136 201-333 402). The direct healthcare and non-healthcare costs were estimated to be 2.02 billion CAN dollars in 2004. There were 374 deaths attributed to schizophrenia. This combined with the high unemployment rate due to schizophrenia resulted in an additional productivity morbidity and mortality loss estimate of 4.83 billion CAN dollars, for a total cost estimate in 2004 of 6.85 billion CAN dollars. By far the largest component of the total cost estimate was for productivity losses associated with morbidity in schizophrenia (70% of total costs) and the results showed that total cost estimates were most sensitive to alternative assumptions regarding the additional unemployment due to schizophrenia in Canada.

CONCLUSIONS

Despite significant improvements in the past decade in pharmacotherapy, programs and services available for patients with schizophrenia, the economic burden of schizophrenia in Canada remains high. The most significant factor affecting the cost of schizophrenia in Canada is lost productivity due to morbidity. Programs targeted at improving patient symptoms and functioning to increase workforce participation has the potential to make a significant contribution in reducing the cost of this severe mental illness in Canada.

Evidence of prostate cancer screening in a UK region

OBJECTIVE

To examine the pattern of use of prostate-specific antigen (PSA) testing in a UK region, where National Health Service policy does not recommend screening for prostate cancer.

SUBJECTS AND METHODS

Data were collected on all PSA tests in Northern Ireland between 1990 and 1999. Annual rates of PSA testing were calculated by age, GP Practice and year.

RESULTS

In all, 165 862 PSA tests were performed on 84 669 men, and over a third of men aged > or = 50 years had at least one PSA test. Men aged < 50 years accounted for 12.9% of first tests. The proportion of tests from primary care increased from 47.2% in 1993 to 67.0% in 1999. The mean age of men tested once decreased from 65.6 to 61.9 years (P trend < 0.001) and the proportion with an elevated PSA level also declined during the period. Repeat testing increased with PSA level (P < 0.001) but 29.4% of men with a PSA level of < or = 4 ng/mL also had repeat testing. Raised PSA values were more common from hospital than primary care (32.4% vs 20.6%, P < 0.001) and in older men. Test rates varied 100-fold across general practices, a finding not explained by sociodemographic factors, but one which reflects differential adherence to national guidelines, suggesting that general practitioners are key targets for attempting to rationalise the use of the PSA test.

CONCLUSION

These findings suggest that PSA screening is taking place against evidence-based advice and has resulted in over 20 000 men being designated as having a raised PSA level, creating a need for further assessment.

A randomized controlled trial using instant photography to diagnose and manage dermatology referrals

BACKGROUND

Fifteen percent of GP consultations are for dermatological conditions; 4% of these are referred to a dermatologist. There are long waiting lists for dermatology appointments. This study examines the value of instant photography in managing dermatology referrals.

OBJECTIVE

The purpose of our study was to compare outcomes of referral for dermatology appointments between patients whose referral letters do or do not include instant photograph(s).

METHODS

Patients (136), referred to a dermatologist by GPs in two urban health centres, were randomly allocated to study and control groups. Instant photographs, taken by the GP, were included in the referral letters. Control group patients were given out-patient appointments in the usual way. The numbers of study group patients needing an appointment for diagnosis or management and with a changed diagnosis after face-to-face consultation were recorded. Waiting time from referral to appointment or management plan was recorded for both groups.

RESULTS

For 63% of the study group (45/71), a diagnosis and a management plan were made without the patient requiring an appointment. This included 38% (27/71) who, after diagnosis and initial management, needed an appointment and 25% (18/71) who did not. The remainder of the study group (37%; 26/71) required a face-to-face consultation. The mean time for formulation of a management plan for patients without an appointment was 17 days (SD = 11); waiting times for appointments in study and control groups were similar (mean 55 days; SD = 40).

CONCLUSIONS

Instant photography is helpful in managing dermatology referrals and offers the potential to reduce numbers requiring an out-patient appointment by 25%.

Mental health in Northern Ireland: have "the Troubles" made it worse?

OBJECTIVES

To measure the effects of the civil unrest (the Troubles) on the mental health of the general population of Northern Ireland.

DESIGN

A secondary analysis of a nationally representative population survey conducted in 1997.

SETTING

Northern Ireland.

METHODS

This is an analysis of the 1694 respondents (aged 16-64) who had their mental health assessed using the 12 question version of the General Health Questionnaire (GHQ). The effects of the Troubles was based on the responses to two survey questions; one asking about the impact on respondent's area; the second about the impact on the life of the respondent or their family. To model simultaneous effects, multiple logistic regression models were constructed with GHQ case as the dependent variable, the impact of the Troubles questions as independent variables, and the demographic, socioeconomic, and health related factors as covariates.

RESULTS

21.3% (361) of respondents said that the Troubles had either "quite a bit" or "a lot" of impact on their lives or the lives of their families and 25.1% (418) reported a similar impact on their area of residence. The likelihood of psychological morbidity increased the greater the extent to which the Troubles affected the respondent's area or life, the association being stronger for the second factor. Neither demographic nor socioeconomic factors significantly diminished this relation although adjusting for health related factors did attenuate the magnitude of the odd ratios especially for the effects of the Troubles on area of residence.

CONCLUSION

It is probable that mental health of the population of Northern Ireland has been significantly affected by the Troubles. Whether this is attributable to the violence in itself or to other aspects of the Troubles is unclear and whether any additional inputs from psychiatric services are needed requires further study.

Can diagnostic triage by general practitioners or rheumatology nurses improve the positive predictive value of referrals to early arthritis clinics?

OBJECTIVES

To determine whether diagnostic triage by general practitioners (GPs) or rheumatology nurses (RNs) can improve the positive predictive value of referrals to early arthritis clinics (EACs).

METHODS

Four GPs and two RNs were trained in the assessment of early inflammatory arthritis (IA) by four visits to an EAC supervised by hospital rheumatologists. Patients referred to one of three EACs were recruited for study and assessed independently by a GP, an RN and one of six rheumatologists. Each assessor was asked to record their clinical findings and whether they considered the patient to have IA. Each was then asked to judge the appropriateness of the referral according to predetermined guidelines. The rheumatologists had been shown previously to have a satisfactory level of agreement in the assessment of IA.

RESULTS

Ninety-six patients were approached and all consented to take part in the study. In 49 cases (51%), the rheumatologist judged that the patient had IA and that the referral was appropriate. The assessments of GPs and RNs were compared with those of the rheumatologists. Levels of agreement were measured using the kappa value, where 1.0 represents total unanimity. The kappa value was 0.77 for the GPs when compared with the rheumatologists and 0.79 for the RNs. Significant stiffness in the morning or after rest and objective joint swelling were the most important clinical features enabling the GPs and RNs to discriminate between IA and non-IA conditions.

CONCLUSION

Diagnostic triage by GPs or RNs improved the positive predictive value of referrals to an EAC with a degree of accuracy approaching that of a group of experienced rheumatologists.

An analysis of perioperative care

Perioperative nursing requires an appreciation of patients' needs throughout the episode of care. This article presents a critical analysis and examination of the perioperative care of a patient undergoing total abdominal hysterectomy. In addition to analysing the efficacy of care delivery in the perioperative setting, we will explore the application of nursing theory and research to everyday practice and the degree to which a hospital's infrastructure facilitates quality care.

Telerheumatology--diagnostic accuracy and acceptability to patient, specialist, and general practitioner

This study examines the diagnostic accuracy and acceptability of telemedicine in the field of rheumatology. One hundred patients had a telephone and televisual consultation and the results were compared with a face-to-face consultation. While the telephone consultations were often unsatisfactory, the televisual consultations were highly accurate (97%) and acceptable to patients, general practitioners, and specialists.

General practice out-of-hours service, variations in use and equality in access to a doctor: a cross-sectional study

BACKGROUND

There is increasing dissatisfaction among general practitioners (GPs) with their 24 hour commitment despite the demand for GP services outside ordinary working hours. The creation of out-of-hours co-operatives has been welcomed by participating GPs and their families and patient satisfaction is generally high. However, there have been concerns about the lack of patient consultation in their development and on the quality of care provided.

OBJECTIVES

To examine geographical variation in the rates of out-of-hours calls and to see if there is any systematic variation in how the co-operative that covers the area responds to calls.

DESIGN OF STUDY

A secondary data analysis of 110,357 calls received by the co-operative during the second year of its operation.

SETTING

A co-operative with four centres providing out-of-hours care for one mostly rural Health Board in Northern Ireland.

METHOD

Deprivation score and mortality and long-term illness ratios provided indicators of need at an area level. Proximity to the four co-operative centres was measured as the distance in kilometres and estimated travel time (in minutes) along the road network.

RESULTS

Out-of-hours call ratios were proportional to the area deprivation score and proximity to the co-operative centres, though not to area indicators of ill health. Older patients were more likely to be seen by the GP and females over the age of 15 years were more likely to receive telephone advice only (adjusted odds ratio [OR] = 0.785, 95% confidence intervals [CI] 0.756-0.816, P < 0.001). Each kilometre from the centres reduced the likelihood of seeing the GP (OR = 0.978, 95% CI = 0.976-0.979, P < 0.001). Even after controlling for potential confounders a large difference remained in how centres responded to calls.

CONCLUSIONS

It is not certain whether these inequalities in services delivery represent inequity as the apposite level or type of response cannot be determined until more is known about the appropriateness of the demand for out-of-hours medical care.