The measurement of patients' expectations for health care: a review and psychometric testing of a measure of patients' expectations

BACKGROUND

There is recognition of the importance of measuring patients' experiences, expectations and satisfaction.

OBJECTIVES

To assess the literature on the concept and measurement of patients' expectations for health care, and to develop and test a measure of patients' expectations, using adult patients in community, general practice and hospital outpatient departments in Greater London, Norwich and Essex, UK.

DATA SOURCES

Major electronic databases including the British Nursing Index, EMBASE, MEDLINE, PsycINFO and the Applied Social Sciences Index and Abstracts were searched between 2000 and 2009.

REVIEW METHODS

Narrative review, semi-structured exploratory study and surveys of GP patients and hospital outpatients immediately before and after their surgery/clinic visit to measure their pre-visit expectations for their health care and their post-visit experiences (expectations met and satisfaction with visit) (site specific).

RESULTS

A total of 20,439 titles and 266 abstracts were identified, of which 211 were included in the review. Most research designs were weak, with small or selected samples, and a theoretical frame of reference was rarely stated. The origin of questions about expectations was often absent, questions were frequently untested and those with reported reliability or validity data had generally mixed results. In the survey data the expectations measures met acceptability criteria for reliability; all exceeded the threshold of α = 0.70, in each mode of administration and sample type. Items and subscales also correlated at least moderately with those variables that they were expected to be associated with, supporting their validity. The item means within subscales were generally similar between samples and all-item-total correlations exceeded the acceptability threshold. Descriptive findings revealed that most patients ideally expected cleanliness, information about where to go, convenient and punctual appointments and helpful reception staff, the doctor to be knowledgeable, clear and easy to understand, to be involved in treatment decisions and to experience a reduction in symptoms/problems. Expectations least likely to be met included being seen on time and choice of hospital/doctor (items requested by the ethics committee). Other items that had low met expectations included helpfulness of reception staff, doctor being respectful and treating with dignity (hospital sample), doctor knowledgeable (hospital), being given reassurance, receiving advice about health/condition, information about cause and management of condition and information about benefits/side effects of treatment, being given an opportunity to discuss problems, and the three items on outcome expectancies. Previous consultations/experiences of health services and health-care staff/professionals most commonly influenced expectations. Overall, pre-visit realistic expectations were lower than patients' ideals or hopes. Most post-visit experiences indicated some unmet expectations (e.g. cause and management of health/condition, benefits/side effects of treatments) and some expectations that were exceeded. Generally, GP patients reported higher pre-visit expectations and post-visit met expectations. Correlations between subscale domains were strongest between the structure and process of health care, doctor-patient communication style and doctor's approach to giving information, all common indicators of the quality of health care, supporting the validity of the measures. The post-visit experiences subscale significantly predicted single-item summary ratings of overall met expectations and satisfaction. GP rather than hospital patients were also independently predictive of expectations met. Other predictors were having no/little anxiety/depression, older age (satisfaction) and fewer effects of health on quality of life (met expectations).

LIMITATIONS

The surveys in clinics were based on convenience, not random sampling methods.

CONCLUSIONS

These findings have implications for establishing the quality of health services and informing their improvement. Awareness of the patient's met and unmet expectations should enable staff to understand the patient's perspective and improve communication. This study examined the perspective of the patient only; it is not possible to examine the extent to which any expectations might have been unrealistically too high or too low. This is a challenge for future research.

FUNDING

The National Institute for Health Research Health Technology Assessment programme and the National Co-ordinating Centre for Research Methodology (NCCRM).

The Patients Preferences Questionnaire for Angina treatment: results and psychometrics from 383 patients in primary care in England

OBJECTIVES

To develop a psychometrically valid Patient Preferences Questionnaire for Angina treatment (PPQA).

SETTING

Seven general practices across England in 2007.

SUBJECTS

Convenience sample of 383 patients with diagnosed angina.

METHOD

Postal self-administered questionnaire survey using the full-length PPQA. This comprised 54 items about the three main treatment modalities for angina: medication, angioplasty and coronary artery bypass grafting.

RESULTS

The full PPQA was reduced to 18 items, six for each of the three subscales (treatment modalities), by standard psychometric methods. The reduced PPQA was psychometrically sound and valid, although confirmatory factor analyses with a larger sample are required.

CONCLUSION

The PPQA is a potentially useful instrument to help clinicians understand patients' angina treatment preferences.

Predicting catastrophic decline in mobility among older people

OBJECTIVE

to investigate the associations between chronic health conditions, psychosocial and environmental factors and catastrophic decline in mobility among older people.

DESIGN

longitudinal cohort.

SETTING

national sample living in private households.

PARTICIPANTS

nine hundred and ninety-nine adults aged > or = 65 years at initial interview, of which 786 agreed to take part in a follow-up survey 12 months later, and 531 responded to the questionnaire.

MEASUREMENTS

catastrophic decline in mobility: inability to do any of the three activities of daily living items-walking 400 yards, climbing up and down stairs or steps and getting on a bus-having been capable of independently doing all three one year earlier.

RESULTS

similar annual rates of catastrophic decline were reported for men and women: 4.8 [95% confidence interval (CI) 2.7-8.3] and 4.6% (2.4-8.6), respectively. Strong associations were found between catastrophic decline and age > 70 years, hearing problems and health deterioration, odds ratio (OR) 3.7 (95% CI 1.1-11.8), 2.8 (1.1-7.3) and 4.3 (1.2-14.7), respectively. Poor perceptions of health, loss of control and feeling fearful also appeared to be important: below average summary psychological status, OR 6.5 (1.9-22.3). Inability to do heavy housework, carry heavy shopping or bend to cut own toenails, indicating poor functional reserve capacity, was strongly associated with decline, OR 6.8 (2.2-20.8).

CONCLUSION

psychosocial factors are as strongly associated with catastrophic decline as deterioration in health status. Interventions to reduce the risk of catastrophic decline may require management of psychosocial problems as well as health condition components.

Individual quality of life in long-term survivors of Hodgkin's lymphoma--a comparative study

This study aimed to use an individual approach in evaluating QoL in long-term survivors of Hodgkin's lymphoma (HL) and their view of what impact the disease has had on life using an extended version of the The Schedule for the Evaluation of the Individual quality of life-Direct Weighting (SEIQoL-DW). Adult long-term survivors from HL (n = 121) were compared with a randomly selected sample of the general population in Stockholm (n = 236). The results showed that the most commonly nominated areas (> 50% of patients and controls) important in life were family, personal health, work and relations to other people. The HL survivors mentioned leisure and finances less frequently than the controls. However, neither the current status in the different areas nor the QoL index score differed between survivors and controls. Thoughts and worries around disease, fatigue and loss of energy and late effects on skin and mucous membrane were the most commonly reported problems following HL. Sixty-six percent of the survivors reported a change in their view of life and of themselves. Demographic and disease characteristics did not influence the ratings of the chosen areas. In conclusion, long-term survivors of HL seem to have adapted well to the situation of having had a life-threatening disease and undergoing treatment, as measured with SEIQoL-DW. The extended Swedish version with a disease-specific module could be of great value when identifying specific issues that are important for the patient at time of evaluation.

A multidimensional model of the quality of life in older age

The broad aim of the research presented here was to define the constituents and indicators of quality of life (QoL) in older age, in order to offer a more multidimensional and useful model of quality of life, based on the perspectives of older people themselves. This paper focuses on the extent to which self-evaluations of global QoL are influenced by health, psychological and social variables, and social circumstances. It reports the results of a national survey of the quality of life in people aged 65 and over, living at home in Britain. Multiple regression analysis with the self-evaluation of quality of life rating as the dependent variable showed that the overall model (Model 9) of QoL indicators explained 26.7% of the variance in quality of life ratings. This is sizeable given the amorphous nature of this concept. The main independent predictors of self-rated global quality of life were: social comparisons and expectations, personality and psychological characteristics (optimism-pessimism), health and functional status and personal and neighbourhood social capital. These variables explained the highest proportion of the variance between groups in their quality of life ratings. Socio-economic indicators contributed relatively little to the model.

Validation and normative data of health status measures in older people: the Islington study

BACKGROUND

Health related quality of life scales have been developed to measure a global picture of health and well-being from the patient's perspective. Separate validation of these measures in older people is important, as different areas of life are prioritized as important in older people and population norms for health status measures can differ with age.

OBJECTIVES

The aims of this paper were to examine the validity and acceptability of two health status measures the 12-item Health Status Questionnaire (HSQ-12) and 12-item Short Form Health Survey SF-12, and to present population norms in older people.

SETTING

A door-to-door survey in Islington, a borough of inner London.

SUBJECTS AND METHODS

The subjects were allocated to complete either the SF-12 (n = 541) or the HSQ-12 (n = 544) by alternating the questionnaires with each household visited. The first 135 people who completed the HSQ-12 were visited approximately 18 months later. Acceptability was measured examining the completion rate of the scales, and on a three-point scale. The short-CARE was used to elicit psychiatric symptoms and diagnoses. We collected data on health and social care, and subjective health problems.

RESULTS

Both scales distinguished between subjects with and without a variety of health states, including self-defined health problems, health problems diagnosed by valid scales, problems with vision and hearing, and receipt of health or social services. The HSQ-12, but not the SF-12, could distinguish between people with and without dementia, and had high completion rates for those living in the community but not in 24-hour care. Linear regression models demonstrated sensitivity to change in health status for the HSQ-12.

CONCLUSION

The SF-12 and HSQ-12 are acceptable and valid as health status instruments in large community-based studies of older people. The HSQ-12, but not the SF-12, is acceptable and valid for people with dementia.

The concept of quality of life in relation to health

This paper will discuss the broadening of the concept of health to include social and psychological concepts, as well as physical health, and the movement away from narrow conceptions of health and disease. In Europe and in USA, some specialties, particularly in psychiatry and cancer, have made considerable progress in the development of broader measurements of outcome in relation to health related quality of life. Others, such as cardiology and rheumatology have been more limited (concentrating on role functioning or return to work at most). Across all specialties, however, there has been an increasing interest in measuring outcome of health care in relation to the patient's quality of life.

Suffering in deference: a focus group study of older cardiac patients' preferences for treatment and perceptions of risk

OBJECTIVES

To explore older people's experiences of health care in relation to their medical condition (ischaemic heart disease), their understanding of health risks, treatment preferences, and the impact of different treatments on their quality of life.

DESIGN

Qualitative study based on five focus groups.

SETTING

Five local heart support groups across London.

PARTICIPANTS

38 patients aged 56 and over who were members of local heart support groups, diagnosed with ischaemic heart disease.

MAIN OUTCOME MEASURE

Analysis of patients' narratives to identify key themes and issues using the framework method of qualitative data analysis.

RESULTS

Cardiac patients would prefer to follow the cardiologist's recommendation for treatment, based on their medical expertise. If offered a choice, many said they would prefer to take medication, at least initially, as they would rather not undergo surgery. However, they accepted that, depending on their medical condition, they might not have a choice. Other factors that participants said affected their choice of treatments included their state of health, treatment outcomes, families' feelings, their age, and the previous number of operations they had undergone. They found it difficult to discuss risk in terms of numbers; most felt that a 3% risk of death from surgery was low. Instead, they discussed risk in terms of likelihood of treatment restoring quality of life. Patients expressed the fear that medication was not a cure and that surgical revascularisation is a traumatic experience that does not necessarily last forever. Participants felt that they needed further information on the impact of surgery and medication to make a more informed choice. Other barriers they felt they had faced in being treated were problems in accessing cardiologists and age discrimination.

CONCLUSION

It was apparent from these focus groups that few patients were involved in medical decision making about their treatment. Most preferred the doctor to make the decision and did want to be involved. Despite their experiences as cardiac patients, they required much more information about treatment options for their condition before being able to make informed choices, where appropriate. Improved access to specialist care (cardiologists) and equal treatment by age are also required before patients' preferences can be elicited in practice.

Suffering in deference: a focus group study of older cardiac patients' preferences for treatment and perceptions of risk

OBJECTIVES

To explore older people's experiences of health care in relation to their medical condition (ischaemic heart disease), their understanding of health risks, treatment preferences, and the impact of different treatments on their quality of life.

DESIGN

Qualitative study based on five focus groups.

SETTING

Five local heart support groups across London.

PARTICIPANTS

38 patients aged 56 and over who were members of local heart support groups, diagnosed with ischaemic heart disease.

MAIN OUTCOME MEASURE

Analysis of patients' narratives to identify key themes and issues using the framework method of qualitative data analysis.

RESULTS

Cardiac patients would prefer to follow the cardiologist's recommendation for treatment, based on their medical expertise. If offered a choice, many said they would prefer to take medication, at least initially, as they would rather not undergo surgery. However, they accepted that, depending on their medical condition, they might not have a choice. Other factors that participants said affected their choice of treatments included their state of health, treatment outcomes, families' feelings, their age, and the previous number of operations they had undergone. They found it difficult to discuss risk in terms of numbers; most felt that a 3% risk of death from surgery was low. Instead, they discussed risk in terms of likelihood of treatment restoring quality of life. Patients expressed the fear that medication was not a cure and that surgical revascularisation is a traumatic experience that does not necessarily last forever. Participants felt that they needed further information on the impact of surgery and medication to make a more informed choice. Other barriers they felt they had faced in being treated were problems in accessing cardiologists and age discrimination.

CONCLUSION

It was apparent from these focus groups that few patients were involved in medical decision making about their treatment. Most preferred the doctor to make the decision and did want to be involved. Despite their experiences as cardiac patients, they required much more information about treatment options for their condition before being able to make informed choices, where appropriate. Improved access to specialist care (cardiologists) and equal treatment by age are also required before patients' preferences can be elicited in practice.

Equity in access to exercise tolerance testing, coronary angiography, and coronary artery bypass grafting by age, sex and clinical indications

OBJECTIVES

To assess whether patients with heart disease in a single UK hospital have equitable access to exercise testing, coronary angiography, and coronary artery bypass graft surgery (CABG).

METHOD

Retrospective analysis of patients' medical case notes (n = 1790), tracking each case back 12 months and forward 12 months from the patient's date of entry to the study.

SETTING

Single UK district hospital in the Thames Region.

PATIENTS

Patients (elective and emergency) with a cardiac ICD inpatient code at discharge or death, or who were referred to cardiology or care of the elderly unit over a 12 month period in 1996-7 (new episodes) were included.

RESULTS

Analysis of 1790 hospital case notes revealed that, despite having indications for intervention identical to those of younger patients, older patients (that is, those aged > 75 years) and women, independently, were significantly less likely to undergo exercise tolerance testing (exercise ECG) and cardiac catheterisation. The similar trends for age and access to CABG did not achieve significance. While clinical priority scores also independently predicted access to cardiac catheterisation and CABG, considerable numbers of patients in high clinical priority groups were not referred for either procedure.

CONCLUSIONS

The management and treatment of older patients and women with cardiac disease may be different from that of younger patients and men. Given the similarity of the indications for treatment and the lack of significant contraindications or comorbidities as a cause for these differences, one possible explanation is that these patients are being discriminated against principally because of their age and sex. Although clinical priority scores independently predicted access to catheterisation and CABG, large proportions of patients in high priority groups were not referred. This implies that the New Zealand priority scoring system may be more equitable than UK practice. The cost implications of redressing these inequities in service provision would be considerable.

Mapping of 13 horse genes by fluorescence in-situ hybridization (FISH) and somatic cell hybrid analysis

We report fluorescence in-situ hybridization (FISH) and somatic cell hybrid mapping data for 13 different horse genes (ANP, CD2, CLU, CRISP3, CYP17, FGG, IL1RN, IL10, MMP13, PRM1, PTGS2, TNFA and TP53). Primers for PCR amplification of intronic or untranslated regions were designed from horse-specific DNA or mRNA sequences in GenBank. Two different horse bacterial artificial chromosome (BAC) libraries were screened with PCR for clones containing these 13 Type I loci, nine of which were found in the libraries. BAC clones were used as probes in dual colour FISH to confirm their precise chromosomal origin. The remaining four genes were mapped in a somatic cell hybrid panel. All chromosomal assignments except one were in agreement with human-horse ZOO-FISH data and revealed new and more detailed information on the equine comparative map. CLU was mapped by synteny to ECA2 while human-horse ZOO-FISH data predicted that CLU would be located on ECA9. The assignment of IL1RN permitted analysis of gene order conservation between HSA2 and ECA15, which identified that an event of inversion had occurred during the evolution of these two homologous chromosomes.

A national evaluation of specialists' clinics in primary care settings

BACKGROUND

Encouraged by the increased purchasing power of general practitioners (GPs), specialist-run clinics in general practice and community health care settings (known as specialist outreach clinics) have increased rapidly across England. The activities of local commissioning schemes within primary care groups are likely to accelerate this trend.

AIM

To evaluate the costs, processes, and benefits of specialists' outreach clinics held in GPs' surgeries, compared with hospital outpatient clinics.

DESIGN OF STUDY

A case-referent (comparative) study comparing the characteristics of outreach clinics (cases) with matched outpatient control clinics.

SETTING

Thirty-eight outreach clinics, compared with 38 matched outpatient clinics as controls, covering 14 hospital trust areas across England.

METHOD

Self-administered questionnaires were given to patients in both clinic settings. These covered processes, satisfaction, personal costs, and health status, with postal follow-up at six months to assess health outcomes. Self-administered questionnaires were also given to the specialists and GPs whose clinics were included in the study (individual patient clinical sheet and an attitude questionnaire), practice managers, and trust accountants (process and costs questionnaire). Evaluation of the costs, processes, and benefits of specialist outreach clinics versus hospital outpatient clinics was carried out by comparing questionnaire responses.

RESULTS

In comparison with outpatients, outreach clinic patients spent less time on the waiting lists for appointments to see the specialist, they had shorter waiting times in clinics, fewer follow-up appointments, and were more likely to be completely discharged after the sampled attendance. Outreach patients were more satisfied than outpatients with the range of clinic process items asked about. Most doctors felt that the outreach clinic was 'worthwhile'. While patients' personal costs were lower in outreach than in outpatients clinics, NHS costs were more expensive per patient in outreach. The benefits of outreach clinics on patients' health status at six months' follow-up were relatively small.

CONCLUSIONS

Outreach clinics are a means of improving access to specialist services for patients, in addition to improving the efficiency and quality of health care. Most results were similar across specialties and areas. The benefits of the outreach service need to be weighed against their substantially higher NHS costs, in comparison with outpatients clinics. Outreach clinics are unlikely to be financially justifiable for NHS funding given that the impact on patients' health status was small.

Efficiency of care at the primary-secondary interface: variations with GP fundholding

The aim of the study was to investigate the processes of referral for out-patients care and the interface with general practice, from the perspective of the patient, the patient's general practitioner and hospital specialist. The analyses reported here present variations with fundholding and non-fundholding general practice. The design was a questionnaire survey of out-patients, their hospital specialists and general practitioners, in six, randomly sampled district health authorities in the North Thames Region, with stratification by area. The measures included validated items and scales on process, quality and patient satisfaction with services. Fundholders were more likely to have technical equipment and services available within the practice. There were no differences between fundholders and non-fundholders and the number of out-patient attendances made by their patients, hospital out-patient waiting list times, patients' waiting times in hospital clinics, nor in patients' satisfaction with out-patients and other process indicators. Fundholding is currently being replaced with the proposed wider locality commissioning schemes, with GPs, health authorities and other purchasing bodies acting in partnership. Health authority commissioning will be required to reflect the preferences of GPs. Participants in these schemes will need to pay particular attention to the areas where research indicates that fundholding GPs made little difference to increasing the efficiency and effectiveness of health care both in their own practices and at the primary-secondary care interface.

Evaluation of outreach clinics held by specialists in general practice in England

OBJECTIVES

To measure the processes of care, health benefits and costs of outreach clinics held by hospital specialists in primary care settings.

DESIGN

The study was designed as a case-referent (comparative) study in which the features of 19 outreach clinics (cases) were compared with matched outpatient clinics (controls). The measuring instruments were self administered questionnaires. Patients were followed up at six months to reassess health status. The specialties included in the study were cardiology, ENT, general medicine, general surgery, gynaecology and rheumatology.

SETTING

Specialist outreach clinics in general practice in England, with matched outpatient clinic controls.

SUBJECTS

Consecutive patient attenders in the outreach and outpatient clinics, their specialists, the outreach patients' general practitioners, practice managers and trust accountants. Patients' response rate at baseline: 78% (1420).

MAIN OUTCOME MEASURES

Patient satisfaction, doctors' attitudes, processes and health outcomes, costs.

RESULTS

Outreach patients were more satisfied with the processes of their care than outpatients, their access to specialist care was better than that for outpatients and they were more likely to be discharged. Doctors reported that the main advantages of the outreach clinic were improved patient access to specialists and convenience for patients, in comparison with outpatients, and most GPs and specialists felt the outreach clinic was "worthwhile". At six month follow up, the health status of the outreach sample had significantly improved more than that of the outpatients on all eight sub-scales of the HSQ-12, but this was probably because of their better starting point at baseline. The impact of outreach on health outcomes was small. The NHS costs of outreach were significantly higher than outpatients. An increase in outreach clinic size would reduce cost per patient, but would lead to the loss of most of the clinics' benefits.

CONCLUSIONS

While the process of care was of higher quality in outreach than in outpatients, and the efficiency of care was also greater in the latter, the effect on patients' health outcomes was small. Responsiveness to patients' views and preferences is an essential component of good quality service provision. However, the greater cost of outreach raises the issue of whether improvements in the quality and efficiency of health care, without a substantial impact on health outcomes, is money well spent in a publicly funded health service. On the other hand, the real costs of outreach in comparison with outpatients clinics can probably only be truly estimated in a longitudinal study with a resource based costing model derived from documented patient attendances and treatment costs over time in relation to longer term outcome (for example, at a two year end point).

The process of outpatient referral and care: the experiences and views of patients, their general practitioners, and specialists

BACKGROUND

The primary care system in the United Kingdom, involving the general practitioner (GP) as gatekeeper to further services, has helped to keep health care costs down. Despite this, unexplained variation in referral rates and increasing health care costs have led to the search for methods of improving efficiency. There is relatively little recent descriptive data on the processes of care at the primary-secondary care interface. The study reported here provides information about this.

AIM

To analyse the patterns and process of care for the referral of outpatients, together with the views of patients, their GPs, and specialists.

METHOD

A questionnaire survey of outpatients, their hospital specialists, and GPs in randomly sampled district health authorities in the North Thames Region. The measures included items and scales measuring satisfaction and processes.

RESULTS

Almost all of the outpatients thought that their consultation with the specialist was 'necessary' and 'worthwhile'. Most of the GPs felt that they could not have given the study patients the care, treatment, and investigations they received in hospital, and most of the sampled patients' attendances were rated by the specialists as 'appropriate'. However, for just over one-fifth of new patients, the specialists reported that the GP could have done more tests and examinations prior to referring the study patient. Large proportions of GPs in this survey also reported having technical equipment in their practices, as well as direct access to a range of services and hospital-based facilities.

CONCLUSION

A large amount of work is carried out in general practice prior to the hospital referral of patients, and GPs have direct access to some technologies and services that can act to reduce the burden on hospitals. The discrepancy between GPs' and specialists, perceptions about the potential for further investigative work prior to patient referral merits further investigation.

Short Form 36 (SF-36) Health Survey questionnaire: which normative data should be used? Comparisons between the norms provided by the Omnibus Survey in Britain, the Health Survey for England and the Oxford Healthy Life Survey

BACKGROUND

Population norms for the attributes included in measurement scales are required to provide a standard with which scores from other study populations can be compared. This study aimed to obtain population norms for the Short Form 36 (SF-36) Health Survey Questionnaire, derived from a random sample of the population in Britain who were interviewed at home, and to make comparisons with other commonly used norms.

METHODS

The method was a face-to-face interview survey of a random sample of 2056 adults living at home in Britain (response rate 78 per cent). Comparisons of the SF-36 scores derived from this sample were made with the Health Survey for England and the Oxford Healthy Life Survey.

RESULTS

Controlling for age and sex, many of mean scores on the SF-36 dimensions differed between the three datasets. The British interview sample had better total means for Physical Functioning, Social Functioning, Mental Health, Energy/Vitality, and General Health Perceptions. The Health (interview) Survey for England had the lowest (worst) total mean scores for Physical Functioning, Social Functioning, Role Limitations (physical), Bodily Pain, and Health Perceptions. The postal sample in central England had the lowest (worst) total mean scores for Role Limitations (emotional), Mental Health and Energy/Vitality.

CONCLUSION

Responses obtained from interview methods may suffer more from social desirability bias (resulting in inflated SF-36 scores) than postal surveys. Differences in SF-36 means between surveys are also likely to reflect question order and contextual effects of the questionnaires. This indicates the importance of providing mode-specific population norms for the various methods of questionnaire administration.

What determines the choice of procedure in stress incontinence surgery? The use of multilevel modeling

The purpose of this study was to identify the determinants of choice of surgical procedure (anterior colporrhaphy, colposuspension, or needle suspension) to treat stress incontinence in women. We used multilevel modeling of data on 271 patients in 18 hospitals in England in 1993-94. Patient-related factors included sociodemographic details, anatomical diagnosis, symptom severity, symptom impact, previous treatment, parity, comorbidity, and general health status. Surgeon-related factors were specialty, grade, and annual volume of procedures undertaken. Hospital teaching status was considered. Some patient-related factors were associated with choice of procedure: women with a concomitant genital prolapse, with a history of high parity, and with no previous nonsurgical treatment were more likely to undergo an anterior colporrhaphy than a colposuspension or needle suspension (although this finding could be confounded by surgical specialty). In addition, women were more likely to be treated by colposuspension if their surgeon specialized in incontinence surgery (measured by annual volume of cases). Finally, being treated by needle suspension depended on there being a consultant surgeon familiar with the procedure at the hospital attended. While choice of surgical procedure depends partly on the patient's anatomical diagnosis, it is also dependent on the specialty of the surgeon whom she consults and the hospital that she attends. This variability, in turn, could have implications for the patient (as the relative effectiveness of the different procedures is unknown) and for the purchasers of care (as the relative cost-effectiveness of procedures is also unknown).

Impact of surgery for stress incontinence on the social lives of women

OBJECTIVE

To assess the feasibility of collecting disease-specific and generic data on the impact of surgery on the social lives of women with stress incontinence; to describe the social impact of surgery in a representative group; and to determine the effect of timing on the assessment of outcome.

DESIGN

Longitudinal study; questionnaires before and three, six, and twelve months after surgery.

SETTING

Eighteen hospitals in North Thames region.

PARTICIPANTS

Four hundred and forty-two women undergoing surgery for stress incontinence between January 1993 and June 1994.

MAIN OUTCOME MEASURES

Post-operative recovery time, stress incontinence symptom impact index, activities of daily living, and cost of protection.

RESULTS

Post-operative recovery was uneventful for most women, but three months after surgery 24% of those in paid employment beforehand were still on sick or unpaid leave. Most women (75%) reported that stress incontinence had less adverse impact on their lives three months after surgery, though 18% reported no change, and 7% felt life was worse. The likelihood of improvement was similar regardless of whether pre-operative urodynamic studies had been conducted. The extent of improvement was dependent on pre-operative severity. Similar findings were obtained six and twelve months after surgery. After an initial slight but nonsignificant deterioration in their ability to carry out activities of daily living, women gained a slight benefit from surgery (proportion with no or only slight limitation rose from 72% to 82%; P=0.0001). The mean cost of protection (pads and towels) fell from 8.59 pound sterling a month before surgery to 2.99 pound sterling a month one year after surgery, by which time 68% of women were not using protection. In contrast, 11% were still spending over 10 pound sterling a month.

CONCLUSIONS

It is possible to collect standard data on the impact of surgery on social functioning and, thus, provide women with better information on likely outcomes. The benefits of pre-operative urodynamic investigations need to be assessed. The stability of the outcome measures over the first post-operative year suggest that outcomes need to be assessed only once and at any time from three to twelve months after the operation.

Impact of surgery for stress incontinence on morbidity: cohort study

OBJECTIVES

To describe the impact of surgery for stress incontinence on the severity of symptoms, other mental and physical symptoms, and overall health. To describe the incidence of postoperative complications.

DESIGN

Prospective cohort study; questionnaires completed by patients before and 3, 6, and 12 months after surgery. Questionnaires completed by surgeons both before and after surgery.

SETTING

18 hospitals in the North Thames region.

SUBJECTS

442 women treated surgically for stress incontinence between January 1993 and June 1994. 367 women returned the 3 month questionnaire; 364 returned the 6 month questionnaire; and 359 returned the 12 month questionnaire. 49 surgeons provided perioperative information on 285 of the 442 women and postoperative information on 278.

MAIN OUTCOME MEASURES

Stress incontinence symptom severity index, other urinary symptoms, bowel function, mental health, complications, global measures.

RESULTS

Most women (288; 87%) reported an improvement in the severity of their stress incontinence, though only 92 (28%) were cured (continent). These improvements persisted for at least 12 months. The likelihood of improvement was similar regardless of whether urodynamic pressure studies had been conducted before surgery. Following surgery, women were less likely to suffer from urinary frequency, nocturia, postvoid fullness, dysuria, and urgency. While mental health improved for 194 (71%), a quarter of women reported deterioration. Only 37 (10%) were satisfied with postoperative pain control. A third experienced one or more complications while in hospital, most commonly difficulty urinating. This problem affected 1 in 11 women after discharge. A year after surgery two thirds of women reported feeling better (251; 72%), that the outcome met or exceeded their expectations (230; 66%), and that they would recommend the operation to a friend in a similar situation (239; 68%), and that they would recommend the operation to a friend in a similar situation (239; 68%). Surgeons tended to be more optimistic about the effects of surgery; they were satisfied with the outcome in 176 (85%) cases and would again treat 245 (94%) of the women as they had done previously.

CONCLUSIONS

Although surgery reduces the severity of stress incontinence it is not as effective as current textbooks suggest. Women considering surgery should be provided with more accurate information on the likelihood of an improvement in symptoms and the occurrence of complications, including postoperative pain. Urgency and urge incontinence should not be considered contraindications to surgery. The need for urodynamic assessment before surgery should be reappraised.

Discriminative power of the health status questionnaire 12 in relation to age, sex, and longstanding illness: findings from a survey of households in Great Britain

STUDY OBJECTIVE

To assess the ability of the health status questionnaire 12 (HSQ-12) to discriminate between older and younger age groups, its appropriateness for use with an older population in terms of the spread of responses across categories, floor or ceiling effects, and its ability to discriminate between those with and without a reported longstanding illness and type (sensitivity and specificity).

DESIGN AND SETTING

The vehicle for the study was the Office for National Statistics (ONS) omnibus survey in Great Britain. The sampling frame was the British post-code address file of "small users", stratified by region, and socioeconomic factors. This file includes all private household addresses. The postal sectors were selected with probability proportional to size. Within each sector 30 addresses were selected randomly. The number of selected addresses was 3000.

PARTICIPANTS

Altogether 1912 adults aged 16 and over were interviewed in person in their own homes, giving a response rate of 72%.

MEASURES

The HSQ-12, and the ONS general household survey questions on longstanding illness; the ONS omnibus standard sociodemographic items.

MAIN RESULTS

There were exceptionally high rates of item response in all age groups. The score differences by construct (e.g., age group, sex, longstanding illness) were in the expected directions with statistically significant age gradients. Age was associated with most of the HSQ-12 domains, although this association had interactions with longstanding illness or sex. The differences in HSQ-12 scores with reported longstanding illness and type of longstanding illness made theoretical sense, which supports the discriminative power of the scale. The frequency distributions for HSQ-12 items in relation to age and sex, and by reporting of longstanding illness are also presented here in order to demonstrate ceiling effects. Most respondents in all age groups achieved high (good) scores on the "social functioning" subscale. The HSQ-12 had good results for specificity when tested against reporting of a longstanding illness, although this was at the expense of sensitivity.

CONCLUSIONS

The results support the use of the HSQ-12 with older populations, particularly for those with chronic illnesses, although it will reveal relatively few problems among younger populations. The results presented here indicate that it will require supplementation with more sensitive disease and/or domain specific scales in the areas of interest or intervention, but it provides an acceptable, brief, core measure of health related quality of life. This paper present the first British normative data using the HSQ-12.

Activities of daily living: changes in functional ability in three samples of elderly and very elderly people

OBJECTIVES

to investigate changes in functional ability and physical health, psychiatric morbidity, life satisfaction, service use and social support.

DESIGN

a structured interview survey of three samples of elderly people living at home at two points in time. The three samples comprised one census of people aged 85 and over [City (of London) and Hackney], and two random samples of people aged 65-84 (City and Hackney and Braintree). The follow-up interviews took place 2.5-3 years after the baseline interviews.

SETTING

City and Hackney (East London) and Braintree (Essex). Respondents were interviewed at home by one of 12 trained interviewers.

SUBJECTS

630 people aged 85+ at baseline (70% response rate) and 78% of survivors re-interviewed at follow-up; 464 people aged 65-84 in Hackney at baseline (67% response rate), and 83% of survivors re-interviewed; 276 people aged 65-84 in Braintree at baseline (82% response rate), and 78% of survivors re-interviewed.

MAIN OUTCOME MEASURES

scores on scales of functional ability, psychiatric morbidity, life satisfaction and social support, and items measuring number and type of health symptoms and services used.

CONCLUSIONS

decreasing levels of physical functioning were associated with poor mental health, trouble with feet and problems with muscles and joints. There were no associations with level of physical functioning and use of rehabilitative or general medical services, use of social worker or carer relief. Few respondents used preventive or rehabilitation services.

Evaluation of specialists' outreach clinics in general practice in England: process and acceptability to patients, specialists, and general practitioners

OBJECTIVES

The wider study aimed to evaluate specialists' outreach clinics in relation to their costs, processes, and effectiveness, including patients' and professionals' attitudes. The data on processes and attitudes are presented here.

DESIGN

Self administered questionnaires were drawn up for patients, their general practitioners (GPs) and specialists, and managers in the practice. Information was sought from hospital trusts. The study formed a pilot phase prior to a wider evaluation.

SETTING

Nine outreach clinics in general practices in England, each with a hospital outpatient department as a control clinic were studied.

SUBJECTS

The specialties included were ear, nose, and throat surgery; rheumatology; and gynaecology. The subjects were the patients who attended either the outreach clinics or hospital outpatients clinics during the study period, the outreach patients' GPs, the outreach patients' and outpatients' specialists, the managers in the practices, and the NHS trusts which employed the specialists.

MAIN OUTCOME MEASURES

Process items included waiting lists, waiting times in clinics, number of follow up visits, investigations and procedures performed, treatment, health status, patients' and specialists' travelling times, and patients' and doctors' attitudes to, and satisfaction with, the clinic.

RESULTS

There was no difference in the health status of patients in relation to the clinic site (ie, outreach and hospital outpatients' clinics) at baseline, and all but one of the specialists said there were no differences in casemix between their outreach and outpatients' clinics. Patients preferred, and were more satisfied with, care in specialists' outreach clinics in general practice, in comparison with outpatients' clinics. The outreach clinics were rated as more convenient than outpatients' clinics in relation to journey times; those outreach patients in work lost less time away from work than outpatients' clinic patients due to the clinic attendance. Length of time on the waiting list was significantly reduced for gynaecology patients; waiting times in clinics were lower for outreach patients than outpatients across all specialties. In addition, outreach patients were more likely to be first rather than follow up attenders; rheumatology outreach patients were more likely than hospital outpatients to receive therapy. GPs' referrals to hospital outpatients' clinics were greatly reduced by the availability of outreach clinics. Both specialists and GPs saw the main advantages of outreach clinics in relation to the greater convenience and better access to care for patients. Few of the specialists and GPs in the outreach practices held formal training and education sessions in the outreach clinic, although over half of the GPs felt that their skills/expertise had broadened as a result of the outreach clinic.

CONCLUSIONS

The processes of care (waiting times, patient satisfaction, convenience to patients, follow up attendances) were better in outreach than in outpatients' clinics. However, waiting lists were only significantly reduced for gynaecology patients, despite both GPs and consultants reporting reduced waiting lists for patients as one of the main advantages of outreach. Whether these improvements merit the increased cost to the specialists (in terms of their increased travelling times and time spent away from their hospital base) and whether the development of what is, in effect, two standards of care between practices with and without outreach can be stemmed and the standard of care raised in all practices (eg, by sharing outreach clinics between GPs in an area) remain the subject of debate. As the data were based on the pilot study, the results should be viewed with some caution, although statistical power was adequate for comparisons of sites if not specialties.

Appropriateness of admission and the last 24 hours of hospital care in medical wards in an east London teaching group hospital

OBJECTIVE

To assess the rates of inappropriateness of admission and last day of care on adult medical wards in an east London hospital, to identify associations with any inappropriateness and to assess what services need to be improved or provided if patients assessed as "inappropriate" are to be more appropriately placed in the future.

DESIGN

From the patients' medical notes, nursing notes and ward charts, a trained reviewer with nursing and university qualifications collected concurrent information about each patient's first 24 hours as an in-patient and about the last 24 hours of care preceding discharge. Patients were also interviewed before discharge and 7-10 days after discharge, and their health status and level of satisfaction about the discharge process assessed.

SETTING

The three adult medical wards at the Homerton Hospital in Hackney, east London. This hospital is within the St Bartholomew's Hospital Teaching Hospital Group.

SUBJECTS

The case-notes of a random sample of 625 adult in-patients were reviewed.

END POINTS

Appropriateness of admission and last day of care.

MAIN OUTCOME MEASURES

The main instrument used was the Appropriateness Evaluation Protocol (AEP). This is an instrument devised to assess the appropriateness of adult patient admission to, and specific days of care in, acute hospital beds through case-note review against a structured set of criteria.

RESULTS

The study presented here reported that 31% of in-patient admissions to adult medical wards in an east London hospital were inappropriate, and also that 66% of the last days of stay were inappropriate.

CONCLUSIONS

There is clearly considerable room for improvement in relation to cooperation between service providers in order to maximise efficient bed use. Delays due to waiting for medications from pharmacy, and the combination of more "inappropriate" cases wanting help from social services after discharge with the fact that many of them were still in hospital because they were waiting for these services to be organized, suggest that inappropriateness could be reduced through increased efficiency or increased provision in these areas. The study reported here is unique in its inclusion of patient interview data.

Sociodemographic and symptomatic characteristics of women undergoing stress incontinence surgery in the UK

OBJECTIVES

To: (i) describe the sociodemographic characteristics of women undergoing surgery for stress incontinence in the UK and the ways in which they differ from women of a similar age in the general population: (ii) the severity and impact of their symptoms and their expectations of surgery and: (iii) their general state of health.

PATIENTS AND METHODS

A prospective cohort study was carried out on 442 women undergoing surgery for stress incontinence in 18 hospitals in the North Thames region between January 1993 and June 1994. Sociodemographic factors, stress incontinence severity, symptom impact scores, and general health status were measured.

RESULTS

Women undergoing surgery for stress incontinence were similar to their peers in the general population apart from being more likely to have smoked (61.4 against 51.1%), to have subsequently given up (39.5 and 25.3%) and to be of higher parity (> or = 4; 19.7 and 12.0%). Most women (81.6%) reported moderate to very severe stress incontinence. The impact of symptoms was correlated positively with severity (P < 0.001) after accounting for its positive correlation with mental health status (P < 0.005), socioeconomic status (P < 0.05) and its negative correlation with age (P < 0.02). Many women also suffered from other urinary symptoms including urgency (76%) and frequency (42.3%). Apart from their urinary problems, women were in good health (77% reported no or only mild coexistent conditions). However, a very high proportion (34.2%) had previously undergone a hysterectomy.

CONCLUSIONS

These results suggest that women undergoing stress incontinence surgery are remarkably similar to their peers, apart from their primary condition. The effect that stress incontinence has on women's lives depends not only on the severity of the problem but also on other factors. The high rate of previous hysterectomy warrants further study.

Does a dedicated discharge coordinator improve the quality of hospital discharge?

OBJECTIVE

To evaluate the effectiveness of the role of a discharge coordinator whose sole responsibility was to plan and coordinate the discharge of patients from medical wards.

DESIGN

An intervention study in which the quality of discharge planning was assessed before and after the introduction of a discharge coordinator. Patients were interviewed on the ward before discharge and seven to 10 days after being discharged home.

SETTING

The three medical wards at the Homerton Hospital in Hackney, East London.

PATIENTS

600 randomly sampled adult patients admitted to the medical wards of the study hospital, who were resident in the district (but not in institutions), were under the care of physicians (excluding psychiatry), and were discharged home from one of the medical wards. The sampling was conducted in three study phases, over 18 months.

INTERVENTIONS

Phase I comprised base line data collection; in phase II data were collected after the introduction of the district discharge planning policy and a discharge form (checklist) for all patients; in phase III data were collected after the introduction of the discharge coordinator.

MAIN MEASURES

The quality and out come of discharge planning. Readmission rates, duration of stay, appropriateness of days of care, patients' health and satisfaction, problems after discharge, and receipt of services.

RESULTS

The discharge coordinator resulted in an improved discharge planning process, and there was a reduction in problems experienced by patients after discharge, and in perceived need for medical and healthcare services. There was no evidence that the discharge coordinator resulted in a more timely or effective provision of community services after discharge, or that the appropriateness or efficiency of bed use was improved.

CONCLUSIONS

The introduction of a discharge coordinator improved the quality of discharge planning, but at additional cost.

The effects of illness on quality of life: findings from a survey of households in Great Britain

STUDY OBJECTIVE

To obtain national population norms on pertinent domains of quality of life, and the relative importance of these domains to people with reported longstanding illness.

DESIGN AND SETTING

The vehicle for the study was the Office of Population Censuses and Surveys omnibus survey in Great Britain. The sampling frame was the British postcode address file of "small users", stratified by region and socioeconomic factors. This file includes all private household addresses. The postal sectors are selected with probability proportional to size. Within each sector 30 addresses are selected randomly with an target size of 2000 adults.

PARTICIPANTS

The total number of adults interviewed was 2033 (one per sampled household), resulting in 2031 usable questionnaires, and representing a response rate of 77%.

MAIN RESULTS

Of those who reported a longstanding illness, the most common, freely mentioned, first most important effects of the longstanding illness on their lives were (in order of frequency) ability to get out and about/stand/walk/go out shopping, being able to work/find a job, and effects on social life/leisure activities. Analysis of the areas of life affected by longstanding illness, showed considerable variation in relation to the condition. For example, respondents with mental health disorders (mainly depression) were most likely to report as the first most important effect the availability of work/ability to work, followed by social life/leisure activities; respondents with digestive and endocrine (for example, diabetes) disorders were most likely to report dietary restrictions; while respondents with cardiovascular disease, respiratory, and musculoskeletal disorders were most likely to report ability to get out and about/stand/walk/go out shopping.

CONCLUSIONS

These results support the current trend of developing disease specific health related quality of life questionnaires rather than using generic scales.