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Mercer SW, Lunan CJ, MacRae C, Henderson DA, Fitzpatrick B, Gillies J, Guthrie B, Reilly J. Half a century of the inverse care law: A comparison of general practitioner job satisfaction and patient satisfaction in deprived and affluent areas of Scotland. Scott Med J 2023; 68:14-20. [PMID: 36250546 DOI: 10.1177/00369330221132156] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND AND AIMS The 'inverse care law', first described in 1971, results from a mismatch of healthcare need and healthcare supply in deprived areas. GPs in such areas struggle to cope with the high levels of demand resulting in shorter consultations and poorer patient outcomes. We compare recent national GP and patient satisfaction data to investigate the ongoing existence of this disparity in Scotland. METHODS AND RESULTS Secondary analysis of cross-sectional national surveys (2017/2018) on upper and lower deprivation quintiles. GP measures; job satisfaction, job stressors, positive and negative job attributes. Patient measures; percentage positive responses per practice on survey questions on access and consultation quality. GPs in high deprivation areas reported lower job satisfaction and positive job attributes, and higher job stressors and negative job attributes compared with GPs in low deprivation areas. Patients living in high deprivation areas reported lower satisfaction with access and consultation quality than patients in low deprivation areas. These differences in GP and patient satisfaction persisted after adjusting for confounding variables. CONCLUSIONS Lower GP work satisfaction in deprived areas was mirrored by lower patient satisfaction. These findings add to the evidence that the inverse care law persists in Scotland, over 50 years after it was first described.
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Affiliation(s)
- Stewart W Mercer
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | | | - Clare MacRae
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - David Ag Henderson
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Bridie Fitzpatrick
- Institute for Health and Wellbeing, 3526University of Glasgow, Glasgow, Scotland, UK
| | - John Gillies
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Bruce Guthrie
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Johanna Reilly
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
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Chng NR, Hawkins K, Fitzpatrick B, O'Donnell CA, Mackenzie M, Wyke S, Mercer SW. Implementing social prescribing in primary care in areas of high socioeconomic deprivation: process evaluation of the 'Deep End' community Links Worker Programme. Br J Gen Pract 2021; 71:e912-e920. [PMID: 34019479 PMCID: PMC8463130 DOI: 10.3399/bjgp.2020.1153] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/13/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Social prescribing involving primary care-based 'link workers' is a key UK health policy that aims to reduce health inequalities. However, the process of implementation of the link worker approach has received little attention despite this being central to the desired impact and outcomes. AIM To explore the implementation process of such an approach in practice. DESIGN AND SETTING Qualitative process evaluation of the 'Deep End' Links Worker Programme (LWP) over a 2-year period, in seven general practices in deprived areas of Glasgow. METHOD The study used thematic analysis to identify the extent of LWP integration in each practice and the key factors associated with implementation. Analysis was informed by normalisation process theory (NPT). RESULTS Only three of the seven practices fully integrated the LWP into routine practice within 2 years, based on the NPT constructs of coherence, cognitive participation, and collective action. Compared with 'partially integrated practices', 'fully integrated practices' had better shared understanding of the programme among staff, higher staff engagement with the LWP, and were implementing all aspects of the LWP at patient, practice, and community levels of intervention. Successful implementation was associated with GP buy-in, collaborative leadership, good team dynamics, link worker support, and the absence of competing innovations. CONCLUSION Even in a well-resourced government-funded programme, the majority of practices involved had not fully integrated the LWP within the first 2 years. Implementing social prescribing and link workers within primary care at scale is unlikely to be a 'quick fix' for mitigating health inequalities in deprived areas.
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Affiliation(s)
- Nai Rui Chng
- Institute of Health and Wellbeing, College of Social Sciences, University of Glasgow, Glasgow
| | - Katie Hawkins
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh
| | - Bridie Fitzpatrick
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow
| | - Catherine A O'Donnell
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow
| | - Mhairi Mackenzie
- Institute of Health and Wellbeing, College of Social Sciences, University of Glasgow, Glasgow
| | - Sally Wyke
- Institute of Health and Wellbeing, College of Social Sciences, University of Glasgow, Glasgow
| | - Stewart W Mercer
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh
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Hayes H, Gibson J, Fitzpatrick B, Checkland K, Guthrie B, Sutton M, Gillies J, Mercer SW. Working lives of GPs in Scotland and England: cross-sectional analysis of national surveys. BMJ Open 2020; 10:e042236. [PMID: 33127639 PMCID: PMC7604859 DOI: 10.1136/bmjopen-2020-042236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/23/2020] [Accepted: 10/06/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The UK faces major problems in retaining general practitioners (GPs). Scotland introduced a new GP contract in April 2018, intended to better support GPs. This study compares the career intentions and working lives of GPs in Scotland with GPs in England, shortly after the new Scotland contract was introduced. DESIGN AND SETTING Comparison of cross-sectional analysis of survey responses of GPs in England and Scotland in 2017 and 2018, respectively, using linear regression to adjust the differences for gender, age, ethnicity, urbanicity and deprivation. PARTICIPANTS 2048 GPs in Scotland and 879 GPs in England. MAIN OUTCOME MEASURES Four intentions to reduce work participation (5-point scales: 1='none', 5='high'): reducing working hours; leaving medical work entirely; leaving direct patient care; or continuing medical work but outside the UK. Four domains of working life: job satisfaction (7-point scale: 1='extremely dissatisfied', 7='extremely satisfied'); job stressors (5-point-scale: 1='no pressure', 5='high pressure); positive and negative job attributes (5-point scales: 1='strongly disagree', 5='strongly agree'). RESULTS Compared with England, GPs in Scotland had lower intention to reduce work participation, including a lower likelihood of reducing work hours (2.78 vs 3.54; adjusted difference=-0.52; 95% CI -0.64 to -0.41), a lower likelihood of leaving medical work entirely (2.11 vs 2.76; adjusted difference=-0.32; 95% CI -0.42 to -0.22), a lower likelihood of leaving direct patient care (2.23 vs 2.93; adjusted difference=-0.37; 95% CI -0.47 to -0.27), and a lower likelihood of continuing medical work but outside of the UK (1.41 vs 1.61; adjusted difference=-0.2; 95% CI -0.28 to -0.12). GPs in Scotland reported higher job satisfaction, lower job stressors, similar positive job attributes and lower negative job attributes. CONCLUSION Following the introduction of the new contract in Scotland, GPs in Scotland reported significantly better working lives and lower intention to reduce work participation than England.
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Affiliation(s)
- Helen Hayes
- Health Organisation, Policy and Economics Research Group, Centre for Primary Care & Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - Jonathan Gibson
- Health Organisation, Policy and Economics Research Group, Centre for Primary Care & Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | | | - Kath Checkland
- Health Organisation, Policy and Economics Research Group, Centre for Primary Care & Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - Bruce Guthrie
- Usher Institute, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics Research Group, Centre for Primary Care & Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - John Gillies
- Usher Institute, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | - Stewart W Mercer
- Usher Institute, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
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Thorn J, Man MS, Chaplin K, Bower P, Brookes S, Gaunt D, Fitzpatrick B, Gardner C, Guthrie B, Hollinghurst S, Lee V, Mercer SW, Salisbury C. Cost-effectiveness of a patient-centred approach to managing multimorbidity in primary care: a pragmatic cluster randomised controlled trial. BMJ Open 2020; 10:e030110. [PMID: 31959601 PMCID: PMC7044971 DOI: 10.1136/bmjopen-2019-030110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Patients with multiple chronic health conditions are often managed in a disjointed fashion in primary care, with annual review clinic appointments offered separately for each condition. This study aimed to determine the cost-effectiveness of the 3D intervention, which was developed to improve the system of care. DESIGN Economic evaluation conducted alongside a pragmatic cluster-randomised trial. SETTING General practices in three centres in England and Scotland. PARTICIPANTS 797 adults with three or more chronic conditions were randomised to the 3D intervention, while 749 participants were randomised to receive usual care. INTERVENTION The 3D approach: comprehensive 6-monthly general practitioner consultations, supported by medication reviews and nurse appointments. PRIMARY AND SECONDARY OUTCOME MEASURES The primary economic evaluation assessed the cost per quality-adjusted life year (QALY) gained from the perspective of the National Health Service (NHS) and personal social services (PSS). Costs were related to changes in a range of secondary outcomes (QALYs accrued by both participants and carers, and deaths) in a cost-consequences analysis from the perspectives of the NHS/PSS, patients/carers and productivity losses. RESULTS Very small increases were found in both QALYs (adjusted mean difference 0.007 (-0.009 to 0.023)) and costs (adjusted mean difference £126 (£-739 to £991)) in the intervention arm compared with usual care after 15 months. The incremental cost-effectiveness ratio was £18 499, with a 50.8% chance of being cost-effective at a willingness-to-pay threshold of £20 000 per QALY (55.8% at £30 000 per QALY). CONCLUSIONS The small differences in costs and outcomes were consistent with chance, and the uncertainty was substantial; therefore, the evidence for the cost-effectiveness of the 3D approach from the NHS/PSS perspective should be considered equivocal. TRIAL REGISTRATION NUMBER ISCRTN06180958.
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Affiliation(s)
- Joanna Thorn
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mei-See Man
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, Population Health Sciences, University of Bristol, Bristol, UK
| | - Katherine Chaplin
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Sara Brookes
- Bristol Randomised Trials Collaboration, Population Health Sciences, University of Bristol, Bristol, UK
| | - Daisy Gaunt
- Bristol Randomised Trials Collaboration, Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Caroline Gardner
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Bruce Guthrie
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK
| | - Sandra Hollinghurst
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Victoria Lee
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Stewart W Mercer
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
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Mercer SW, Fitzpatrick B, Grant L, Chng NR, McConnachie A, Bakhshi A, James-Rae G, O'Donnell CA, Wyke S. Effectiveness of Community-Links Practitioners in Areas of High Socioeconomic Deprivation. Ann Fam Med 2019; 17:518-525. [PMID: 31712290 PMCID: PMC6846279 DOI: 10.1370/afm.2429] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/23/2019] [Accepted: 03/26/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To assess the effect of a primary care-based community-links practitioner (CLP) intervention on patients' quality of life and well-being. METHODS Quasi-experimental cluster-randomized controlled trial in socioeconomically deprived areas of Glasgow, Scotland. Adult patients (aged 18 years or older) referred to CLPs in 7 intervention practices were compared with a random sample of adult patients from 8 comparison practices at baseline and 9 months. PRIMARY OUTCOME health-related quality of life (EQ-5D-5L, a standardized measure of self-reported health-related quality of life that assesses 5 dimensions at 5 levels of severity). SECONDARY OUTCOMES well-being (Investigating Choice Experiments for the Preferences of Older People Capability Measure for Adults [ICECAP-A]), depression (Hospital Anxiety and Depression Scale, Depression [HADS-D]), anxiety (Hospital Anxiety and Depression Scale, Anxiety [HADS-A]), and self-reported exercise. Multilevel, multiregression analyses adjusted for baseline differences. Patients were not blinded to the intervention, but outcome analysis was masked. RESULTS Data were collected on 288 and 214 (74.3%) patients in the intervention practices at baseline and follow-up, respectively, and on 612 and 561 (92%) patients in the comparison practices. Intention-to-treat analysis found no differences between the 2 groups for any outcome. In subgroup analyses, patients who saw the CLP on 3 or more occasions (45% of those referred) had significant improvements in EQ-5D-5L, HADS-D, HADS-A, and exercise levels. There was a high positive correlation between CLP consultation rates and patient uptake of suggested community resources. CONCLUSIONS We were unable to prove the effectiveness of referral to CLPs based in primary care in deprived areas for improving patient outcomes. Future efforts to boost uptake and engagement could improve overall outcomes, although the apparent improvements in those who regularly saw the CLPs may be due to reverse causality. Further research is needed before wide-scale deployment of this approach.
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Affiliation(s)
- Stewart W Mercer
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Bridie Fitzpatrick
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Lesley Grant
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Nai Rui Chng
- College of Social Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Andisheh Bakhshi
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Greg James-Rae
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Catherine A O'Donnell
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Sally Wyke
- College of Social Sciences, University of Glasgow, Glasgow, United Kingdom
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Abstract
Leading an academic discipline poses moral and ethical challenges, requiring a special set of capabilities. Leadership in a clinical academic discipline involves leading the transformation of education, research, leadership and patient care. Daily struggles within strategic, political and cultural milieu are the norm and effective leaders are able to navigate through these struggles and see opportunities for growth.
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Affiliation(s)
- S Koka
- Loma Linda University, Loma Linda, USA.
| | - K Baba
- Showa University, Tokyo, Japan
| | - C Ercoli
- Eastman Institute of Oral Health, University of Rochester, New York, USA
| | | | - X Jiang
- Shanghai Jiao Tong University, Shanghai, China
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7
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Salisbury C, Man MS, Chaplin K, Mann C, Bower P, Brookes S, Duncan P, Fitzpatrick B, Gardner C, Gaunt DM, Guthrie B, Hollinghurst S, Kadir B, Lee V, McLeod J, Mercer SW, Moffat KR, Moody E, Rafi I, Robinson R, Shaw A, Thorn J. A patient-centred intervention to improve the management of multimorbidity in general practice: the 3D RCT. Health Serv Deliv Res 2019. [DOI: 10.3310/hsdr07050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
People with multimorbidity experience impaired quality of life, poor health and a burden from treatment. Their care is often disease-focused rather than patient-centred and tailored to their individual needs.
Objective
To implement and evaluate a patient-centred intervention to improve the management of patients with multimorbidity in general practice.
Design
Pragmatic, cluster randomised controlled trial with parallel process and economic evaluations. Practices were centrally randomised by a statistician blind to practice identifiers, using a computer-generated algorithm.
Setting
Thirty-three general practices in three areas of England and Scotland.
Participants
Practices had at least 4500 patients and two general practitioners (GPs) and used the EMIS (Egton Medical Information Systems) computer system. Patients were aged ≥ 18 years with three or more long-term conditions.
Interventions
The 3D (Dimensions of health, Depression and Drugs) intervention was designed to offer patients continuity of care with a named GP, replacing separate reviews of each long-term condition with comprehensive reviews every 6 months. These focused on individualising care to address patients’ main problems, attention to quality of life, depression and polypharmacy and on disease control and agreeing treatment plans. Control practices provided usual care.
Outcome measures
Primary outcome – health-related quality of life (assessed using the EuroQol-5 Dimensions, five-level version) after 15 months. Secondary outcomes – measures of illness burden, treatment burden and patient-centred care. We assessed cost-effectiveness from a NHS and a social care perspective.
Results
Thirty-three practices (1546 patients) were randomised from May to December 2015 [16 practices (797 patients) to the 3D intervention, 17 practices (749 patients) to usual care]. All participants were included in the primary outcome analysis by imputing missing data. There was no evidence of difference between trial arms in health-related quality of life {adjusted difference in means 0.00 [95% confidence interval (CI) –0.02 to 0.02]; p = 0.93}, illness burden or treatment burden. However, patients reported significant benefits from the 3D intervention in all measures of patient-centred care. Qualitative data suggested that both patients and staff welcomed having more time, continuity of care and the patient-centred approach. The economic analysis found no meaningful differences between the intervention and usual care in either quality-adjusted life-years [(QALYs) adjusted mean QALY difference 0.007, 95% CI –0.009 to 0.023] or costs (adjusted mean difference £126, 95% CI –£739 to £991), with wide uncertainty around point estimates. The cost-effectiveness acceptability curve suggested that the intervention was unlikely to be either more or less cost-effective than usual care. Seventy-eight patients died (46 in the intervention arm and 32 in the usual-care arm), with no evidence of difference between trial arms; no deaths appeared to be associated with the intervention.
Limitations
In this pragmatic trial, the implementation of the intervention was incomplete: 49% of patients received two 3D reviews over 15 months, whereas 75% received at least one review.
Conclusions
The 3D approach reflected international consensus about how to improve care for multimorbidity. Although it achieved the aim of providing more patient-centred care, this was not associated with benefits in quality of life, illness burden or treatment burden. The intervention was no more or less cost-effective than usual care. Modifications to the 3D approach might improve its effectiveness. Evaluation is needed based on whole-system change over a longer period of time.
Trial registration
Current Controlled Trials ISRCTN06180958.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 7, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Chris Salisbury
- Centre for Academic Primary Care, National Institute for Health Research School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mei-See Man
- Centre for Academic Primary Care, National Institute for Health Research School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Katherine Chaplin
- Centre for Academic Primary Care, National Institute for Health Research School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cindy Mann
- Centre for Academic Primary Care, National Institute for Health Research School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Bower
- National Institute for Health Research School for Primary Care Research, Centre for Primary Care, Division of Population of Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Sara Brookes
- Bristol Randomised Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Polly Duncan
- Centre for Academic Primary Care, National Institute for Health Research School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Caroline Gardner
- National Institute for Health Research School for Primary Care Research, Centre for Primary Care, Division of Population of Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Daisy M Gaunt
- Bristol Randomised Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Bruce Guthrie
- Population Health Sciences Division, School of Medicine, University of Dundee, Dundee, UK
| | - Sandra Hollinghurst
- Centre for Academic Primary Care, National Institute for Health Research School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Bryar Kadir
- Bristol Randomised Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Victoria Lee
- National Institute for Health Research School for Primary Care Research, Centre for Primary Care, Division of Population of Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - John McLeod
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Stewart W Mercer
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Keith R Moffat
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Emma Moody
- Bristol Clinical Commissioning Group, Bristol, UK
| | - Imran Rafi
- Royal College of General Practitioners, London, UK
| | | | - Alison Shaw
- Centre for Academic Primary Care, National Institute for Health Research School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Joanna Thorn
- Centre for Academic Primary Care, National Institute for Health Research School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Salisbury C, Man MS, Bower P, Guthrie B, Chaplin K, Gaunt DM, Brookes S, Fitzpatrick B, Gardner C, Hollinghurst S, Lee V, McLeod J, Mann C, Moffat KR, Mercer SW. Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. Lancet 2018; 392:41-50. [PMID: 29961638 PMCID: PMC6041724 DOI: 10.1016/s0140-6736(18)31308-4] [Citation(s) in RCA: 221] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/09/2018] [Accepted: 05/15/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND The management of people with multiple chronic conditions challenges health-care systems designed around single conditions. There is international consensus that care for multimorbidity should be patient-centred, focus on quality of life, and promote self-management towards agreed goals. However, there is little evidence about the effectiveness of this approach. Our hypothesis was that the patient-centred, so-called 3D approach (based on dimensions of health, depression, and drugs) for patients with multimorbidity would improve their health-related quality of life, which is the ultimate aim of the 3D intervention. METHODS We did this pragmatic cluster-randomised trial in general practices in England and Scotland. Practices were randomly allocated to continue usual care (17 practices) or to provide 6-monthly comprehensive 3D reviews, incorporating patient-centred strategies that reflected international consensus on best care (16 practices). Randomisation was computer-generated, stratified by area, and minimised by practice deprivation and list size. Adults with three or more chronic conditions were recruited. The primary outcome was quality of life (assessed with EQ-5D-5L) after 15 months' follow-up. Participants were not masked to group assignment, but analysis of outcomes was blinded. We analysed the primary outcome in the intention-to-treat population, with missing data being multiply imputed. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN06180958. FINDINGS Between May 20, 2015, and Dec 31, 2015, we recruited 1546 patients from 33 practices and randomly assigned them to receive the intervention (n=797) or usual care (n=749). In our intention-to-treat analysis, there was no difference between trial groups in the primary outcome of quality of life (adjusted difference in mean EQ-5D-5L 0·00, 95% CI -0·02 to 0·02; p=0·93). 78 patients died, and the deaths were not considered as related to the intervention. INTERPRETATION To our knowledge, this trial is the largest investigation of the international consensus about optimal management of multimorbidity. The 3D intervention did not improve patients' quality of life. FUNDING National Institute for Health Research.
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Affiliation(s)
- Chris Salisbury
- Centre for Academic Primary Care, NIHR School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Mei-See Man
- Centre for Academic Primary Care, NIHR School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population of Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Bruce Guthrie
- Population Health Sciences Division, School of Medicine, University of Dundee, Dundee, UK
| | - Katherine Chaplin
- Centre for Academic Primary Care, NIHR School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Daisy M Gaunt
- Bristol Randomised Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sara Brookes
- Bristol Randomised Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Caroline Gardner
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population of Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Sandra Hollinghurst
- Centre for Academic Primary Care, NIHR School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Victoria Lee
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population of Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, UK
| | - John McLeod
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Cindy Mann
- Centre for Academic Primary Care, NIHR School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Keith R Moffat
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Stewart W Mercer
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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9
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Mercer SW, Zhou Y, Humphris GM, McConnachie A, Bakhshi A, Bikker A, Higgins M, Little P, Fitzpatrick B, Watt GCM. Multimorbidity and Socioeconomic Deprivation in Primary Care Consultations. Ann Fam Med 2018; 16. [PMID: 29531103 PMCID: PMC5847350 DOI: 10.1370/afm.2202] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The influence of multimorbidity on the clinical encounter is poorly understood, especially in areas of high socioeconomic deprivation where burdensome multimorbidity is concentrated. The aim of the current study was to examine the effect of multimorbidity on general practice consultations, in areas of high and low deprivation. METHODS We conducted secondary analyses of 659 video-recorded routine consultations involving 25 general practitioners (GPs) in deprived areas and 22 in affluent areas of Scotland. Patients rated the GP's empathy using the Consultation and Relational Empathy (CARE) measure immediately after the consultation. Videos were analyzed using the Measure of Patient-Centered Communication. Multilevel, multi-regression analysis identified differences between the groups. RESULTS In affluent areas, patients with multimorbidity received longer consultations than patients without multimorbidity (mean 12.8 minutes vs 9.3, respectively; P = .015), but this was not so in deprived areas (mean 9.9 minutes vs 10.0 respectively; P = .774). In affluent areas, patients with multimorbidity perceived their GP as more empathic (P = .009) than patients without multimorbidity; this difference was not found in deprived areas (P = .344). Video analysis showed that GPs in affluent areas were more attentive to the disease and illness experience in patients with multimorbidity (P < .031) compared with patients without multimorbidity. This was not the case in deprived areas (P = .727). CONCLUSIONS In deprived areas, the greater need of patients with multimorbidity is not reflected in the longer consultation length, higher GP patient centeredness, and higher perceived GP empathy found in affluent areas. Action is required to redress this mismatch of need and service provision for patients with multimorbidity if health inequalities are to be narrowed rather than widened by primary care.
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Affiliation(s)
- Stewart W Mercer
- Academic Unit of General Practice and Primary Care, Institute of Health and Well-being, University of Glasgow, Scotland, United Kingdom
| | - Yuefang Zhou
- School of Medicine, University of St Andrews, Scotland, United Kingdom
| | - Gerry M Humphris
- School of Medicine, University of St Andrews, Scotland, United Kingdom
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Boyd Orr Building, University of Glasgow, Scotland, United Kingdom
| | - Andisheh Bakhshi
- Robertson Centre for Biostatistics, Boyd Orr Building, University of Glasgow, Scotland, United Kingdom
| | - Annemieke Bikker
- Academic Unit of General Practice and Primary Care, Institute of Health and Well-being, University of Glasgow, Scotland, United Kingdom
| | - Maria Higgins
- Academic Unit of General Practice and Primary Care, Institute of Health and Well-being, University of Glasgow, Scotland, United Kingdom
| | - Paul Little
- Primary Medical Care, Aldermoor Health Centre, Aldermoor close, University of Southampton, Southampton, United Kingdom
| | - Bridie Fitzpatrick
- Academic Unit of General Practice and Primary Care, Institute of Health and Well-being, University of Glasgow, Scotland, United Kingdom
| | - Graham C M Watt
- Academic Unit of General Practice and Primary Care, Institute of Health and Well-being, University of Glasgow, Scotland, United Kingdom
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Fitzpatrick S, Kerr D, Fitzpatrick B. P424Exploring the relationship between pacemaker dependency, cardiac symptoms and perceived quality of life in patients with implanted dual chamber pacemakers. Europace 2018. [DOI: 10.1093/europace/euy015.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- S Fitzpatrick
- Altnagelvin Area Hospital, Cardiac Investigations Unit, Londonderry, United Kingdom
| | - D Kerr
- Ulster University, Institute of Nursing and Health Research, Jordanstown, United Kingdom
| | - B Fitzpatrick
- Ulster University, Sport and Exercise Sciences Research Institute, Derry, United Kingdom
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Bikker AP, Fitzpatrick B, Murphy D, Forster L, Mercer SW. Assessing the Consultation and Relational Empathy (CARE) Measure in sexual health nurses' consultations. BMC Nurs 2017; 16:71. [PMID: 29204104 PMCID: PMC5702142 DOI: 10.1186/s12912-017-0265-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 11/13/2017] [Indexed: 12/30/2022] Open
Abstract
Background Increasingly healthcare policies emphasise the importance of person-centred, empathic care. Consequently, healthcare professionals are expected to demonstrate the ‘human’ aspects of care in training and in practice. The Consultation and Relational Empathy (CARE) Measure is a patient-rated measure of the interpersonal skills of healthcare practitioners. It has been widely validated for use by healthcare professionals in both primary and secondary care. This paper reports on the validity and reliability of the CARE Measure with sexual health nurses. Methods Patient questionnaires were collected for 943 consultations with 20 sexual health nurses. Participating patients self-completed the questionnaire immediately after the encounter with the nurse. The questionnaire included the ten item CARE Measure, the Patient Enablement Index, and overall satisfaction instruments. Construct validity was assessed through Spearman’s correlation and principal component analysis. Internal consistence was assessed through Cronbach’s alpha and the inter-rater reliability through Generalisability Theory. Data were collected in 2013 in Scotland. Results Female patients completed 68% of the questionnaires. The mean patient age was 28.8 years (standard deviation 9.8 years). Two of the 20 participating nurses withdrew from the study. Most patients (71.7%) regarded the CARE Measure items as very important to their consultation and the number of ‘not applicable’ and missing responses’ were low (2.6% and 0.1% respectively). The participating nurses had high CARE Measure scores; out of a maximum possible score of 50, the overall mean CARE measure score was 47.8 (standard deviation 4.4). The scores were moderately correlated with patient enablement (rho = 0.232, p = 0.001) and overall satisfaction (rho = 0.377, p = 0.001. Cronbach’s alpha showed the measure’s high internal consistency (Cronbach’s alpha coefficient = 0.95), but the inter-rater reliability could not be calculated due to the high achieved CARE Measure scores that varied little between nurses. Conclusions Within this clinical context the CARE Measure has high perceived relevance and face validity. The findings support construct validity and some evidence of reliability. The high CARE Measure scores may have been due to sample bias. A future study which ensures a representative sample of patients on a larger group of nurses is required to determine whether the measure can discriminate between nurses.
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Affiliation(s)
- Annemieke P Bikker
- Usher Institute for Population Sciences and Informatics, The University of Edinburgh, 9 BioQuarter, Little France Road, Edinburgh, EH16 4UX UK
| | - Bridie Fitzpatrick
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX UK
| | - Douglas Murphy
- School of Medicine, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF UK
| | - Lorraine Forster
- Sandyford Sexual Health Services, 2-6 Sandyford Place, Glasgow, G3 7NB UK
| | - Stewart W Mercer
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX UK
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Mercer SW, O'Brien R, Fitzpatrick B, Higgins M, Guthrie B, Watt G, Wyke S. The development and optimisation of a primary care-based whole system complex intervention (CARE Plus) for patients with multimorbidity living in areas of high socioeconomic deprivation. Chronic Illn 2016; 12:165-81. [PMID: 27068113 PMCID: PMC4995497 DOI: 10.1177/1742395316644304] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 02/01/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To develop and optimise a primary care-based complex intervention (CARE Plus) to enhance the quality of life of patients with multimorbidity in the deprived areas. METHODS Six co-design discussion groups involving 32 participants were held separately with multimorbid patients from the deprived areas, voluntary organisations, general practitioners and practice nurses working in the deprived areas. This was followed by piloting in two practices and further optimisation based on interviews with 11 general practitioners, 2 practice nurses and 6 participating multimorbid patients. RESULTS Participants endorsed the need for longer consultations, relational continuity and a holistic approach. All felt that training and support of the health care staff was important. Most participants welcomed the idea of additional self-management support, though some practitioners were dubious about whether patients would use it. The pilot study led to changes including a revised care plan, the inclusion of mindfulness-based stress reduction techniques in the support of practitioners and patients, and the stream-lining of the written self-management support material for patients. DISCUSSION We have co-designed and optimised an augmented primary care intervention involving a whole-system approach to enhance quality of life in multimorbid patients living in the deprived areas. CARE Plus will next be tested in a phase 2 cluster randomised controlled trial.
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Affiliation(s)
- Stewart William Mercer
- General Practice and Primary Care, University of Glasgow, United Kingdom of Great Britain and Northern Ireland
| | - Rosaleen O'Brien
- General Practice and Primary Care, University of Glasgow, United Kingdom of Great Britain and Northern Ireland
| | - Bridie Fitzpatrick
- General Practice and Primary Care, University of Glasgow, United Kingdom of Great Britain and Northern Ireland
| | - Maria Higgins
- General Practice and Primary Care, University of Glasgow, United Kingdom of Great Britain and Northern Ireland
| | - Bruce Guthrie
- General Practice and Primary Care, University of Glasgow, United Kingdom of Great Britain and Northern Ireland
| | - Graham Watt
- General Practice and Primary Care, University of Glasgow, United Kingdom of Great Britain and Northern Ireland
| | - Sally Wyke
- General Practice and Primary Care, University of Glasgow, United Kingdom of Great Britain and Northern Ireland
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Mercer SW, Fitzpatrick B, Guthrie B, Fenwick E, Grieve E, Lawson K, Boyer N, McConnachie A, Lloyd SM, O'Brien R, Watt GCM, Wyke S. The CARE Plus study - a whole-system intervention to improve quality of life of primary care patients with multimorbidity in areas of high socioeconomic deprivation: exploratory cluster randomised controlled trial and cost-utility analysis. BMC Med 2016; 14:88. [PMID: 27328975 PMCID: PMC4916534 DOI: 10.1186/s12916-016-0634-2] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 06/02/2016] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Multimorbidity is common in deprived communities and reduces quality of life. Our aim was to evaluate a whole-system primary care-based complex intervention, called CARE Plus, to improve quality of life in multimorbid patients living in areas of very high deprivation. METHODS We used a phase 2 exploratory cluster randomised controlled trial with eight general practices in Glasgow in very deprived areas that involved multimorbid patients aged 30-65 years. The intervention comprised structured longer consultations, relationship continuity, practitioner support, and self-management support. Control practices continued treatment as usual. Primary outcomes were quality of life (EQ-5D-5L utility scores) and well-being (W-BQ12; 3 domains). Cost-effectiveness from a health service perspective, engagement, and retention were assessed. Recruitment and baseline measurements occurred prior to randomisation. Blinding post-randomisation was not possible but outcome measurement and analysis were masked. Analyses were by intention to treat. RESULTS Of 76 eligible practices contacted, 12 accepted, and eight were selected, randomised and participated for the duration of the trial. Of 225 eligible patients, 152 (68 %) participated and 67/76 (88 %) in each arm completed the 12-month assessment. Two patients died in the control group. CARE Plus significantly improved one domain of well-being (negative well-being), with an effect size of 0.33 (95 % confidence interval [CI] 0.11-0.55) at 12 months (p = 0.0036). Positive well-being, energy, and general well-being (the combined score of the three components) were not significantly influenced by the intervention at 12 months. EQ-5D-5L area under the curve over the 12 months was higher in the CARE Plus group (p = 0.002). The incremental cost in the CARE Plus group was £929 (95 % CI: £86-£1788) per participant with a gain in quality-adjusted life years of 0.076 (95 % CI: 0.028-0.124) over the 12 months of the trial, resulting in a cost-effectiveness ratio of £12,224 per quality-adjusted life year gained. Modelling suggested that cost-effectiveness would continue. CONCLUSIONS It is feasible to conduct a high-quality cluster randomised control trial of a complex intervention with multimorbid patients in primary care in areas of very high deprivation. Enhancing primary care through a whole-system approach may be a cost-effective way to protect quality of life for multimorbid patients in deprived areas. TRIAL REGISTRATION TRIAL REGISTRATION ISRCTN 34092919 , assigned 14/1/2013.
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Affiliation(s)
- Stewart W Mercer
- Institute of Health and Wellbeing, General Practice and Primary Care, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK.
| | - Bridie Fitzpatrick
- Institute of Health and Wellbeing, General Practice and Primary Care, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK
| | - Bruce Guthrie
- Population Health Sciences Division, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK
| | - Elisabeth Fenwick
- Health Economics and Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Eleanor Grieve
- Health Economics and Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Kenny Lawson
- Health Economics and Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Nicki Boyer
- Health Economics and Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8QQ, UK
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8QQ, UK
| | - Rosaleen O'Brien
- Institute of Applied Health, Glasgow Caledonian University, 4th Floor George Moore Building, Cowcaddens Road, Glasgow, Lanarkshire, G4 0BA, UK
| | - Graham C M Watt
- Institute of Health and Wellbeing, General Practice and Primary Care, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK
| | - Sally Wyke
- Institute of Health and Wellbeing, University of Glasgow, 27 Bute Gardens, Glasgow, G12 8RS, UK
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Scheinberg M, Castaneda Hernandez G, Li M, Rao U, Singh E, Mahgoub E, Coindreau J, O'Brien J, Vicik S, Fitzpatrick B, Hassett B. THU0124 Variability of Intended Copies for Etanercept in Five Countries:. Ann Rheum Dis 2016. [DOI: 10.1136/annrheumdis-2016-eular.1449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Man MS, Chaplin K, Mann C, Bower P, Brookes S, Fitzpatrick B, Guthrie B, Shaw A, Hollinghurst S, Mercer S, Rafi I, Thorn J, Salisbury C. Improving the management of multimorbidity in general practice: protocol of a cluster randomised controlled trial (The 3D Study). BMJ Open 2016; 6:e011261. [PMID: 27113241 PMCID: PMC4854003 DOI: 10.1136/bmjopen-2016-011261] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION An increasing number of people are living with multimorbidity. The evidence base for how best to manage these patients is weak. Current clinical guidelines generally focus on single conditions, which may not reflect the needs of patients with multimorbidity. The aim of the 3D study is to develop, implement and evaluate an intervention to improve the management of patients with multimorbidity in general practice. METHODS AND ANALYSIS This is a pragmatic two-arm cluster randomised controlled trial. 32 general practices around Bristol, Greater Manchester and Glasgow will be randomised to receive either the '3D intervention' or usual care. 3D is a complex intervention including components affecting practice organisation, the conduct of patient reviews, integration with secondary care and measures to promote change in practice organisation. Changes include improving continuity of care and replacing reviews of each disease with patient-centred reviews with a focus on patients' quality of life, mental health and polypharmacy. We aim to recruit 1383 patients who have 3 or more chronic conditions. This provides 90% power at 5% significance level to detect an effect size of 0.27 SDs in the primary outcome, which is health-related quality of life at 15 months using the EQ-5D-5L. Secondary outcome measures assess patient centredness, illness burden and treatment burden. The primary analysis will be a multilevel regression model adjusted for baseline, stratification/minimisation, clustering and important co-variables. Nested process evaluation will assess implementation, mechanisms of effectiveness and interaction of the intervention with local context. Economic analysis of cost-consequences and cost-effectiveness will be based on quality-adjusted life years. ETHICS AND DISSEMINATION This study has approval from South-West (Frenchay) National Health Service (NHS) Research Ethics Committee (14/SW/0011). Findings will be disseminated via final report, peer-reviewed publications and guidance to healthcare professionals, commissioners and policymakers. TRIAL REGISTRATION NUMBER ISRCTN06180958; Pre-results.
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Affiliation(s)
- Mei-See Man
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Katherine Chaplin
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Cindy Mann
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Peter Bower
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Sara Brookes
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Bridie Fitzpatrick
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Bruce Guthrie
- Quality, Safety and Informatics Research Group, University of Dundee, Dundee, UK
| | - Alison Shaw
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sandra Hollinghurst
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Stewart Mercer
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Imran Rafi
- Clinical Innovation and Research, Royal College of General Practitioners, London, UK
| | - Joanna Thorn
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
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Mercer SW, Higgins M, Bikker AM, Fitzpatrick B, McConnachie A, Lloyd SM, Little P, Watt GCM. General Practitioners' Empathy and Health Outcomes: A Prospective Observational Study of Consultations in Areas of High and Low Deprivation. Ann Fam Med 2016; 14:117-24. [PMID: 26951586 PMCID: PMC4781514 DOI: 10.1370/afm.1910] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE We set out to compare patients' expectations, consultation characteristics, and outcomes in areas of high and low socioeconomic deprivation, and to examine whether the same factors predict better outcomes in both settings. METHODS Six hundred fifty-nine patients attending 47 general practitioners in high- and low-deprivation areas of Scotland participated. We assessed patients' expectations of involvement in decision making immediately before the consultation and patients' perceptions of their general practitioners' empathy immediately after. Consultations were video recorded and analyzed for verbal and non-verbal physician behaviors. Symptom severity and related well-being were measured at baseline and 1 month post-consultation. Consultation factors predicting better outcomes at 1 month were identified using backward selection methods. RESULTS Patients in deprived areas had less desire for shared decision-making (P <.001). They had more problems to discuss (P = .01) within the same consultation time. Patients in deprived areas perceived their general practitioners (GPs) as less empathic (P = .02), and the physicians displayed verbal and nonverbal behaviors that were less patient centered. Outcomes were worse at 1 month in deprived than in affluent groups (70% response rate; P <.001). Perceived physician empathy predicted better outcomes in both groups. CONCLUSIONS Patients' expectations, GPs' behaviors within the consultation, and health outcomes differ substantially between high- and low-deprivation areas. In both settings, patients' perceptions of the physicians' empathy predict health outcomes. These findings are discussed in the context of inequalities and the "inverse care law."
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Affiliation(s)
- Stewart W Mercer
- Academic Unit of General Practice and Primary Care, Institute of Health and Well-Being, University of Glasgow, Glasgow, Scotland
| | - Maria Higgins
- Academic Unit of General Practice and Primary Care, Institute of Health and Well-Being, University of Glasgow, Glasgow, Scotland
| | - Annemieke M Bikker
- Academic Unit of General Practice and Primary Care, Institute of Health and Well-Being, University of Glasgow, Glasgow, Scotland
| | - Bridie Fitzpatrick
- Academic Unit of General Practice and Primary Care, Institute of Health and Well-Being, University of Glasgow, Glasgow, Scotland
| | - Alex McConnachie
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland
| | - Paul Little
- Primary Medical Care, Aldermoor Health Centre, University of Southampton, Southampton, England
| | - Graham C M Watt
- Academic Unit of General Practice and Primary Care, Institute of Health and Well-Being, University of Glasgow, Glasgow, Scotland
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Bikker AP, Fitzpatrick B, Murphy D, Mercer SW. Measuring empathic, person-centred communication in primary care nurses: validity and reliability of the Consultation and Relational Empathy (CARE) Measure. BMC Fam Pract 2015; 16:149. [PMID: 26493072 PMCID: PMC4619021 DOI: 10.1186/s12875-015-0374-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 10/16/2015] [Indexed: 12/30/2022]
Abstract
Background Empathic patient-centred care is central to high quality health encounters. The Consultation and Relational Empathy (CARE) Measure is a patient-rated experience measure of the interpersonal quality of healthcare encounters. The measure has been extensively validated and is widely used by doctors in primary care but has not been validated in nursing. This study assessed the validity and reliability of the CARE Measure in routine nurse consultations in primary care. Methods Seventeen nurses from nine general medical practices located in three Scottish Health Boards participated in the study. Consecutive patients (aged 16 years or older) were asked to self-complete a questionnaire containing the CARE Measure immediately after their clinical encounter with the nurse. Statistical analysis included Spearman’s correlation and principal component analysis (construct validity), Cronbach’s alpha (internal consistency), and Generalisability theory (inter-rater reliability). Results A total of 774 patients (327 male and 447 female) completed the questionnaire. Almost three out of four patients (73 %) felt that the CARE Measure items were very important to their current consultation. The number of ‘not applicable’ responses and missing values were low overall (5.7 and 1.6 % respectively). The mean CARE Measure score in the consultations was 45.9 and 48 % achieved the maximum possible score of 50. CARE Measure scores correlated in predicted ways with overall satisfaction and patient enablement in support of convergent and divergent validity. Factor analysis found that the CARE Measure items loaded highly onto a single factor. The measure showed high internal consistency (Cronbach’s alpha coefficient = 0.97) and acceptable inter-rater reliability (G = 0.6 with 60 patients ratings per nurse). The scores were not affected by patients’ age, gender, self-perceived overall health, living arrangements, employment status or language spoken at home. Conclusions The CARE Measure has high face and construct validity, and internal reliability in nurse consultations in primary care. Its ability to discriminate between nurses is sufficient for educational and quality improvement purposes.
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Affiliation(s)
- Annemieke P Bikker
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK.
| | - Bridie Fitzpatrick
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK.
| | - Douglas Murphy
- School of Medicine, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK.
| | - Stewart W Mercer
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK.
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Abstract
College drinking is a problem with severe academic, health, and safety consequences. The underlying social processes that lead to increased drinking activity are not well understood. Social Norms Theory is an approach to analysis and intervention based on the notion that students' misperceptions about the drinking culture on campus lead to increases in alcohol use. In this paper we develop an agent-based simulation model, implemented in MATLAB, to examine college drinking. Students' drinking behaviors are governed by their identity (and how others perceive it) as well as peer influences, as they interact in small groups over the course of a drinking event. Our simulation results provide some insight into the potential effectiveness of interventions such as social norms marketing campaigns.
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Affiliation(s)
- B Fitzpatrick
- Tempest Technologies, 8939 S. Sepulveda Blvd. Suite 506, Los Angeles, CA 90045 USA ; Loyola Marymount University, UH 2700, 1 LMU Drive, Los Angeles, CA 90045 USA
| | - J Martinez
- Tempest Technologies, 8939 S. Sepulveda Blvd. Suite 506, Los Angeles, CA 90045 USA
| | - E Polidan
- Tempest Technologies, 8939 S. Sepulveda Blvd. Suite 506, Los Angeles, CA 90045 USA ; Loyola Marymount University, UH 2700, 1 LMU Drive, Los Angeles, CA 90045 USA
| | - E Angelis
- Tempest Technologies, 8939 S. Sepulveda Blvd. Suite 506, Los Angeles, CA 90045 USA
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Ho TP, Zhao X, Courville AB, Linderman JD, Smith S, Sebring N, Della Valle DM, Fitzpatrick B, Simchowitz L, Celi FS. Effects of a 12-month moderate weight loss intervention on insulin sensitivity and inflammation status in nondiabetic overweight and obese subjects. Horm Metab Res 2015; 47:289-96. [PMID: 24977656 DOI: 10.1055/s-0034-1382011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Weight loss intervention is the principal non-pharmacological method for prevention and treatment of type 2 diabetes. However, little is known whether it influences insulin sensitivity directly or via its anti-inflammatory effect. The aim of this study was to assess the independent role of changes in inflammation status and weight loss on insulin sensitivity in this population.Overweight and obese nondiabetic participants without co-morbidities underwent a one-year weight loss intervention focused on caloric restriction and behavioral support. Markers of inflammation, body composition, anthropometric para-meters, and insulin sensitivity were recorded at baseline, 6, and 12 months. Insulin sensitivity was assessed with frequently sampled intravenous glucose tolerance test and Minimal Model. Twenty-eight participants (F: 15, M: 13, age 39±5 years, BMI 33.2±4.6 kg/m(2)) completed the study, achieving 9.4±6.9% weight loss, which was predominantly fat mass (7.7±5.6 kg, p<0.0001). Dietary intervention resulted in significant decrease in leptin, leptin-to-adiponectin ratio, hs-CRP, and IL-6 (all p<0.02), and improvement in HOMA-IR and Insulin Sensitivity Index (SI) (both p<0.001). In response to weight loss IL-1β, IL-2, leptin, and resistin were significantly associated with insulin, sensitivity, whereas sICAM-1 had only marginal additive effect. Moderate weight loss in otherwise healthy overweight and obese individuals resulted in an improvement in insulin sensitivity and in the overall inflammation state; the latter played only a minimal independent role in modulating insulin sensitivity.
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Affiliation(s)
- T P Ho
- National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD, USA
| | - X Zhao
- National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD, USA
| | - A B Courville
- Nutrition Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - J D Linderman
- National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD, USA
| | - S Smith
- National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD, USA
| | - N Sebring
- Nutrition Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - D M Della Valle
- Nutrition Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - B Fitzpatrick
- Nutrition Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - L Simchowitz
- National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD, USA
| | - F S Celi
- National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD, USA
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Abstract
The aim of this study was to develop a patient self-report tool to detect symptoms of genital and lower limb lymphoedema in male survivors of genitourinary cancer. The study incorporated the views of patients and subject specialists (lymphoedema and urology) in the design of a patient questionnaire based on the literature. Views on comprehensiveness, relevance of content, ease of understanding and perceived acceptability to patients were collated. The findings informed the development of the next iteration of the questionnaire. The overall view of participants was that the development and application of such a tool was of great clinical value and the Lymphoedema Genito-Urinary Cancer Questionnaire (LGUCQ) has significant potential for further development as a research tool to inform prevalence of this under-reported condition.
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Affiliation(s)
- Rhian Noble-Jones
- University Teacher, University of Glasgow and Oncology Physiotherapist, Western General Hospital, Edinburgh
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Pritchett R, Fitzpatrick B, Watson N, Cotmore R, Wilson P, Bryce G, Donaldson J, Boyd K, Zeanah C, Norrie J, Taylor J, Larrieu J, Messow M, Forde M, Turner F, Irving S, Minnis H. A feasibility randomised controlled trial of the New Orleans intervention for infant mental health: a study protocol. ScientificWorldJournal 2013; 2013:838042. [PMID: 24023537 PMCID: PMC3655679 DOI: 10.1155/2013/838042] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 03/31/2013] [Indexed: 11/29/2022] Open
Abstract
Child maltreatment is associated with life-long social, physical, and mental health problems. Intervening early to provide maltreated children with safe, nurturing care can improve outcomes. The need for prompt decisions about permanent placement (i.e., regarding adoption or return home) is internationally recognised. However, a recent Glasgow audit showed that many maltreated children "revolve" between birth families and foster carers. This paper describes the protocol of the first exploratory randomised controlled trial of a mental health intervention aimed at improving placement permanency decisions for maltreated children. This trial compares an infant's mental health intervention with the new enhanced service as usual for maltreated children entering care in Glasgow. As both are new services, the trial is being conducted from a position of equipoise. The outcome assessment covers various fields of a child's neurodevelopment to identify problems in any ESSENCE domain. The feasibility, reliability, and developmental appropriateness of all outcome measures are examined. Additionally, the potential for linkage with routinely collected data on health and social care and, in the future, education is explored. The results will inform a definitive randomised controlled trial that could potentially lead to long lasting benefits for the Scottish population and which may be applicable to other areas of the world. This trial is registered with ClinicalTrials.gov (NC01485510).
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Affiliation(s)
- Rachel Pritchett
- Academic Unit of Mental Health & Wellbeing, University of Glasgow, Caledonia House, Royal Hospital for Sick Children, Glasgow G3 8SJ, UK
| | - Bridie Fitzpatrick
- College of Medical, Veterinary and Life Sciences, University of Glasgow, General Practice and Primary Care, 1 Horselethill Road, Glasgow G12 9LX, UK
| | - Nicholas Watson
- Strathclyde Centre for Disability Research, Institute for Health and Wellbeing, School of Social and Political Sciences, University of Glasgow, Adam Smith Building, 40 Bute Gardens, Glasgow G12 8RT, UK
| | | | - Philip Wilson
- Centre for Rural Health, University of Aberdeen, Centre for Health Science, Old Perth Road, Inverness IV2 3JH, UK
| | - Graham Bryce
- Glasgow Infant and Family Team, NSPCC Scotland, Rowanpark, Ardlaw Street, Glasgow G51 3RR, UK
| | - Julia Donaldson
- Glasgow Infant and Family Team, NSPCC Scotland, Rowanpark, Ardlaw Street, Glasgow G51 3RR, UK
| | - Kathleen Boyd
- Health Economics & Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ, UK
| | - Charles Zeanah
- Tulane University School of Medicine, 1430 Tulane Avenue, No. 8055, New Orleans, LA 70112, USA
| | - John Norrie
- Health Services Research Unit, 3rd Floor Health Sciences Building, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Julie Taylor
- Child Protection Research Centre, University of Edinburgh, St Leonard's Land, Holyrood Road, Edinburgh EH8 8AQ, UK
| | - Julie Larrieu
- Tulane University School of Medicine, 1430 Tulane Avenue, No. 8055, New Orleans, LA 70112, USA
| | - Martina Messow
- Robertson Centre for Biostatistics, University of Glasgow, Level 11, Boyd Orr Building, University Avenue, Glasgow G12 8QQ, UK
| | - Matt Forde
- NSPCC Scotland, 2nd Floor, Tara House, 46 Bath Street, Glasgow G2 1HG, UK
| | - Fiona Turner
- Academic Unit of Mental Health & Wellbeing, University of Glasgow, Caledonia House, Royal Hospital for Sick Children, Glasgow G3 8SJ, UK
| | - Susan Irving
- Academic Unit of Mental Health and Wellbeing, Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow G12 0XH, UK
| | - Helen Minnis
- Academic Unit of Mental Health & Wellbeing, University of Glasgow, Caledonia House, Royal Hospital for Sick Children, Glasgow G3 8SJ, UK
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22
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Murie J, Messow CM, Fitzpatrick B. Feasibility of screening for and treating vitamin D deficiency in forensic psychiatric inpatients. J Forensic Leg Med 2012; 19:457-64. [DOI: 10.1016/j.jflm.2012.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Revised: 02/14/2012] [Accepted: 04/08/2012] [Indexed: 12/01/2022]
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23
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Smith BH, Campbell A, Linksted P, Fitzpatrick B, Jackson C, Kerr SM, Deary IJ, MacIntyre DJ, Campbell H, McGilchrist M, Hocking LJ, Wisely L, Ford I, Lindsay RS, Morton R, Palmer CNA, Dominiczak AF, Porteous DJ, Morris AD. Cohort Profile: Generation Scotland: Scottish Family Health Study (GS:SFHS). The study, its participants and their potential for genetic research on health and illness. Int J Epidemiol 2012; 42:689-700. [DOI: 10.1093/ije/dys084] [Citation(s) in RCA: 288] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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24
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Luciano M, Batty GD, McGilchrist M, Linksted P, Fitzpatrick B, Jackson C, Pattie A, Dominiczak AF, Morris AD, Smith BH, Porteous D, Deary IJ. Shared genetic aetiology between cognitive ability and cardiovascular disease risk factors: Generation Scotland's Scottish family health study. Intelligence 2010. [DOI: 10.1016/j.intell.2010.03.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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25
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Mercer SW, Neumann M, Wirtz M, Fitzpatrick B, Vojt G. General practitioner empathy, patient enablement, and patient-reported outcomes in primary care in an area of high socio-economic deprivation in Scotland--a pilot prospective study using structural equation modeling. Patient Educ Couns 2008; 73:240-5. [PMID: 18752916 DOI: 10.1016/j.pec.2008.07.022] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2007] [Revised: 07/03/2008] [Accepted: 07/08/2008] [Indexed: 05/05/2023]
Abstract
OBJECTIVE The aim of this pilot prospective study was to investigate the relationships between general practitioners (GPs) empathy, patient enablement, and patient-assessed outcomes in primary care consultations in an area of high socio-economic deprivation in Scotland. METHODS This prospective study was carried out in a five-doctor practice in an area of high socioeconomic deprivation in Scotland. Patients' views on the consultation were gathered using the Consultation and Relational Empathy (CARE) Measure and the Patient Enablement Instrument (PEI). Changes in main complaint and well-being 1 month after the contact consultation were gathered from patients by postal questionnaire. The effect of GP empathy on patient enablement and prospective change in outcome was investigated using structural equation modelling. RESULTS 323 patients completed the initial questionnaire at the contact consultation and of these 136 (42%) completed and returned the follow-up questionnaire at 1 month. Confirmatory factor analysis confirmed the construct validity ofthe CARE Measure, though omission of two ofthe six PEI items was required in order to reach an acceptable global data fit. The structural equation model revealed a direct positive relationship between GP empathy and patient enablement at contact consultation and a prospective relationship between patient enablement and changes in main complaint and well-being at 1 month. CONCLUSION In a high deprivation setting, GP empathy is associated with patient enablement at consultation, and enablement predicts patient-rated changes 1 month later. Further larger studies are desirable to confirm or refute these findings. PRACTICE IMPLICATIONS Ways of increasing GP empathy and patient enablement need to be established in order to maximise patient outcomes. Consultation length and relational continuity of care are known factors: the benefit of training and support for GPs needs to be further investigated.
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Affiliation(s)
- Stewart W Mercer
- Section of General Practice and Primary Care, Division of Community-based Sciences, Faculty of Medicine, University of Glasgow, United Kingdom.
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26
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Cowen RL, Garside EJ, Fitzpatrick B, Papadopoulou MV, Williams KJ. Gene therapy approaches to enhance bioreductive drug treatment. Br J Radiol 2008; 81 Spec No 1:S45-56. [DOI: 10.1259/bjr/55070206] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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27
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Mehibel M, Chinje E, Eustace A, Fitzpatrick B, Cowen R, Stratford I. C22. The effect of cytokine-induced macrophages on the tumour response to AQ4N and radiation. Nitric Oxide 2007. [DOI: 10.1016/j.niox.2007.09.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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28
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Fitzpatrick B, Babur M, Telfer B, Chinje E, Cowen R, Stratford I. B3. A study to determine the role of iNOS as a radiosensitizer and potentiator of bioreductive drugs in human tumours. Nitric Oxide 2007. [DOI: 10.1016/j.niox.2007.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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29
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Smith BH, Campbell H, Blackwood D, Connell J, Connor M, Deary IJ, Dominiczak AF, Fitzpatrick B, Ford I, Jackson C, Haddow G, Kerr S, Lindsay R, McGilchrist M, Morton R, Murray G, Palmer CNA, Pell JP, Ralston SH, St Clair D, Sullivan F, Watt G, Wolf R, Wright A, Porteous D, Morris AD. Generation Scotland: the Scottish Family Health Study; a new resource for researching genes and heritability. BMC Med Genet 2006; 7:74. [PMID: 17014726 PMCID: PMC1592477 DOI: 10.1186/1471-2350-7-74] [Citation(s) in RCA: 163] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/17/2006] [Accepted: 10/02/2006] [Indexed: 11/24/2022]
Abstract
Background Generation Scotland: the Scottish Family Health Study aims to identify genetic variants accounting for variation in levels of quantitative traits underlying the major common complex diseases (such as cardiovascular disease, cognitive decline, mental illness) in Scotland. Methods/Design Generation Scotland will recruit a family-based cohort of up to 50,000 individuals (comprising siblings and parent-offspring groups) across Scotland. It will be a six-year programme, beginning in Glasgow and Tayside in the first two years (Phase 1) before extending to other parts of Scotland in the remaining four years (Phase 2). In Phase 1, individuals aged between 35 and 55 years, living in the East and West of Scotland will be invited to participate, along with at least one (and preferably more) siblings and any other first degree relatives aged 18 or over. The total initial sample size will be 15,000 and it is planned that this will increase to 50,000 in Phase 2. All participants will be asked to contribute blood samples from which DNA will be extracted and stored for future investigation. The information from the DNA, along with answers to a life-style and medical history questionnaire, clinical and biochemical measurements taken at the time of donation, and subsequent health developments over the life course (traced through electronic health records) will be stored and used for research purposes. In addition, a detailed public consultation process will begin that will allow respondents' views to shape and develop the study. This is an important aspect to the research, and forms the continuation of a long-term parallel engagement process. Discussion As well as gene identification, the family-based study design will allow measurement of the heritability and familial aggregation of relevant quantitative traits, and the study of how genetic effects may vary by parent-of-origin. Long-term potential outcomes of this research include the targeting of disease prevention and treatment, and the development of screening tools based on the new genetic information. This study approach is complementary to other population-based genetic epidemiology studies, such as UK Biobank, which are established primarily to characterise genes and genetic risk in the population.
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Affiliation(s)
- Blair H Smith
- University of Aberdeen, Department of General Practice and Primary Care, Foresterhill Health Centre, Westburn Road, Aberdeen, UK
| | - Harry Campbell
- University of Edinburgh, Division of Community Health Sciences, Medical School, Teviot Place, Edinburgh, UK
| | - Douglas Blackwood
- University of Edinburgh, Department of Psychiatry, The Royal Edinburgh Hospital, Morningside Park, Edinburgh, UK
| | - John Connell
- University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow, UK
| | - Mike Connor
- University of Glasgow, Institute of Medical Genetics, Yorkhill, Glasgow, UK
| | - Ian J Deary
- University of Edinburgh, Department of Psychology, 7 George Square, Edinburgh, UK
| | - Anna F Dominiczak
- University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow, UK
| | - Bridie Fitzpatrick
- University of Glasgow, Division of Community-Based Sciences, Glasgow, UK
| | - Ian Ford
- University of Glasgow, Robertson Centre for Biostatistics, 15 University Gardens, Glasgow, UK
| | - Cathy Jackson
- University of Dundee, Tayside Centre for General Practice, Kirsty Semple Way, Dundee, UK
| | - Gillian Haddow
- University of Edinburgh, Old Surgeons Halls, High School Yards, Edinburgh, UK
| | - Shona Kerr
- University of Edinburgh, Molecular Medicine Centre, Western General Hospital, Crewe Road, Edinburgh, UK
| | - Robert Lindsay
- University of Glasgow, Division of Cardiovascular & Medical Sciences, Glasgow, UK
| | - Mark McGilchrist
- University of Dundee, Health Informatics Centre, MacKenzie Building, Kirsty Semple Way, Dundee, UK
| | - Robin Morton
- University of Edinburgh, Molecular Medicine Centre, Western General Hospital, Crewe Road, Edinburgh, UK
| | - Graeme Murray
- University of Aberdeen, Department of Pathology, University Medical Buildings, Foresterhill, Aberdeen, UK
| | - Colin NA Palmer
- University of Dundee, Biomedical Research Centre, Level 5, Ninwells Hospital, Dundee, UK
| | - Jill P Pell
- University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow, UK
| | - Stuart H Ralston
- University of Edinburgh, Western General Hospital, Rheumatic Diseases Unit, Edinburgh, UK
| | - David St Clair
- University of Aberdeen, College of Life Sciences and Medicine, Polworth Building, Aberdeen, UK
| | - Frank Sullivan
- University of Dundee, Community Health Sciences Division, MacKenzie Building, Kirsty Semple Way, Dundee, UK
| | - Graham Watt
- University of Glasgow, Division of Community-Based Sciences, Glasgow, UK
| | - Roland Wolf
- University of Dundee, Biomedical Research Centre, Level 5, Ninwells Hospital, Dundee, UK
| | - Alan Wright
- University of Edinburgh, MRC Human Genetics Unit, Western General Hospital, Crewe Road, Edinburgh, UK
| | - David Porteous
- University of Edinburgh, Molecular Medicine Centre, Western General Hospital, Crewe Road, Edinburgh, UK
| | - Andrew D Morris
- University of Dundee, Division of Medicine and Therapeutics, Level 7, Ninewells Hospital and Medical School, Dundee, UK
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Senok A, Wilson P, Reid M, Scoular A, Craig N, McConnachie A, Fitzpatrick B, MacDonald A. Can we evaluate population screening strategies in UK general practice? A pilot randomised controlled trial comparing postal and opportunistic screening for genital chlamydial infection. J Epidemiol Community Health 2005; 59:198-204. [PMID: 15709078 PMCID: PMC1733025 DOI: 10.1136/jech.2004.021584] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
STUDY OBJECTIVE To assess whether opportunistic and postal screening strategies for Chlamydia trachomatis can be compared with usual care in a randomised trial in general practice. DESIGN Feasibility study for a randomised controlled trial. SETTING Three West of Scotland general medical practices: one rural, one urban/deprived, and one urban/affluent. PARTICIPANTS 600 women aged 16-30 years, 200 from each of three participating practices selected at random from a sample of West of Scotland practices that had expressed interest in the study. The women could opt out of the study. Those who did not were randomly assigned to one of three groups: postal screening, opportunistic screening, or usual care. RESULTS 38% (85 of 221) of the approached practices expressed interest in the study. Data were collected successfully from the three participating practices. There were considerable workload implications for staff. Altogether 124 of the 600 women opted out of the study. During the four month study period, 55% (81 of 146) of the control group attended their practice but none was offered screening. Some 59% (80 of 136) women in the opportunistic group attended their practice of whom 55% (44 of 80) were offered screening. Of those, 64% (28 of 44) accepted, representing 21% of the opportunistic group. Forty eight per cent (59 of 124) of the postal group returned samples. CONCLUSION A randomised controlled trial comparing postal and opportunistic screening for chlamydial infection in general practice is feasible, although resource intensive. There may be problems with generalizing from screening trials in which patients may opt out from the offer of screening.
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Affiliation(s)
- Abiola Senok
- General Practice and Primary Care, Division of Community Based Sciences, University of Glasgow, Glasgow, UK
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31
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Lynch J, Kelly N, Fitzpatrick B, Regan P. A sacrococcygeal extraspinal ependymoma in a 67-year-old man: a case report and review of the literature. Br J Plast Surg 2002; 55:80-2. [PMID: 11783977 DOI: 10.1054/bjps.2001.3724] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Extraspinal ependymomas are extremely uncommon tumours of glial origin. They occur predominantly in children and adolescents. We report a case of a subcutaneous extraspinal ependymoma in a 67-year-old man. This was excised, and the defect reconstructed with a V-Y advancement flap.
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Affiliation(s)
- J Lynch
- Department of Plastic, Reconstructive and Hand Surgery, University College Hospital, Galway, Ireland
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Nolan B, White B, Smith J, O'Reily C, Fitzpatrick B, Smith OP. Desmopressin: therapeutic limitations in children and adults with inherited coagulation disorders. Br J Haematol 2000; 109:865-9. [PMID: 10929043 DOI: 10.1046/j.1365-2141.2000.02067.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Desmopressin (DDAVP), a synthetic analogue of vasopressin has been successfully used in the treatment of type I von Willebrand's disease (VWD), mild factor VIII (FVIII) deficiency and intrinsic platelet function defects (PFDs) for almost three decades. However, there is limited published data documenting its efficacy and the reliability of circulating plasma FVIII:C as a surrogate marker of response to therapy in VWD. We report the haemostatic response to DDAVP in 133 consecutive patients (91 type I VWD, 20 mild FVIII deficiency and 22 PFDs). Minimal therapeutic response to DDAVP (0.3 microg/kg) was defined by normalization 30 min post- infusion of bleeding time for PFDs, factor VIII:C (FVIII:C) for mild haemophilia A, and von Willebrand factor antigen (VWF:Ag), von Willebrand factor functional activity (VWF:Ac) and FVIII:C for VWD. Nine out of 91 (10%) VWD patients failed to achieve minimal therapeutic response to DDAVP; plasma FVIII:C levels were an unreliable surrogate marker of DDAVP response as 6 out of 9 (67%) of these patients had normal post-infusion FVIII:C levels. Five out of the 20 (25%) patients with mild FVIII deficiency and 5 out of 22 (23%) patients with PFDs failed to achieve a minimal therapeutic response to DDAVP. DDAVP is an effective therapy in the majority of patients with type I VWD, PFDs and mild FVIII deficiency. The significant failure rate associated with this therapy supports the recent recommendations that response should be assessed in all patients at the time of diagnosis. FVIII:C is an unreliable guide of response to DDAVP in patients with VWD and therefore VWF:Ag and VWF:Ac should also be assessed. Failure to demonstrate the response of VWF:Ag, VWF:Ac and FVIII:C to DDAVP in patients with VWD is likely to increase the risk of haemorrhagic complications in patients with bleeding episodes or who are undergoing surgery.
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Affiliation(s)
- B Nolan
- National Centre for Inherited Coagulation Disorders, National Children's Hospital, Tallaght Hospital, St James's Hospital, Trinity College Dublin, Ireland
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Quinn J, Patel P, Fitzpatrick B, Manning B, Dillon P, Daly S, Okennedy R, Alcocer M, Lee H, Morgan M, Lang K. The use of regenerable, affinity ligand-based surfaces for immunosensor applications. Biosens Bioelectron 1999; 14:587-95. [PMID: 11459104 DOI: 10.1016/s0956-5663(99)00032-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The regeneration of antibody-binding surfaces is of major importance for re-usable sensor formats such as required for direct 'real-time' biosensing technologies and is often difficult to achieve. Antibodies commonly bind the antigen with high avidity and may themselves be sensitive to regeneration conditions. The interaction of polyclonal anti-chlorpyriphos antibody with an immobilised chlorpyriphos-ovalbumin (chlor-oval) conjugate and the interaction of soluble recombinant CD4 with covalently immobilised anti-CD4 IgG are presented in order to highlight these difficulties. Affinity-capture is suggested as an alternative format as it facilitates surface regeneration, directed immobilisation and the attainment of interaction progress curves that conform to the ideal pseudo-first-order kinetic interaction model. Protein A, protein G and polyclonal anti-mouse Fe-coated surfaces were used to observe the interaction of captured anti-GST monoclonal antibody with glutathione-s-transferase (GST). It was shown that a protein A affinity-capture surface produced ideal interaction progress curves while both protein G and polyclonal anti-mouse Fe resulted in systemic deviations.
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Affiliation(s)
- J Quinn
- School of Biotechnology, Dublin City University, Glasnevin, Ireland
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Wolf DC, Goldsworthy TL, Donner EM, Harden R, Fitzpatrick B, Everitt JI. Estrogen treatment enhances hereditary renal tumor development in Eker rats. Carcinogenesis 1998; 19:2043-7. [PMID: 9855022 DOI: 10.1093/carcin/19.11.2043] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Hormonal influences are known to affect the development of renal cell carcinoma in man and laboratory animal models. We tested the hypothesis that estrogen treatment or ovariectomy of rats modulates renal tumor development using tuberous sclerosis 2 (Tsc2) heterozygous mutant (Eker) rats in which a germline mutation predisposes the animals to renal cell tumor development. Two-month-old female wild-type and Eker rats were ovariectomized or sham-operated and treated with placebo or 5 mg 17beta-estradiol in s.c. pellets for 6 or 10 months. Rats were examined at 8 or 12 months of age, at which time the numbers of renal tumors and preneoplastic foci were quantitated and the severity of nephropathy was assessed. In contrast to what may have been expected, prolonged estrogen treatment enhanced the development of hereditary renal cell tumors, with a 2-fold greater number of preneoplastic and neoplastic renal lesions compared with untreated Eker rats. Ovariectomized Eker rats had 33% fewer renal lesions than the unmanipulated control group. No tumors or preneoplastic lesions were present in wild-type rats at either time point. Estrogen treatment increased the severity of nephropathy in both wild-type and Eker rats, whereas ovariectomy was protective against nephropathic changes. Although estrogen is not a rat renal carcinogen, it enhanced the development of hereditary renal cell tumors when administered to Eker rats. Eker rats heterozygous for a mutation in the Tsc2 locus provide a good model in which to study how genetic and hormonal factors contribute to the development of renal cell tumors and to understand the influence genetic susceptibility has on the development of renal cell carcinoma.
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Affiliation(s)
- D C Wolf
- Chemical Industry Institute of Toxicology, Research Triangle Park, NC 27709, USA
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Abstract
Temporalis muscle transfer is a versatile technique frequently used for reconstructive procedures in the maxillofacial region. However the thickness of the pedicle may interfere with masticatory function when used anteriorly in the oral cavity. To repair full-length mid-palatal defects in fully dentate patients the flap can be passed through the maxillary sinus and combined with local repair of the soft palate, thus avoiding any occlusal trauma from the posterior teeth. The operation is a single stage procedure with low morbidity and few complications, and is a useful technique for repairing the large untreated clefts frequently encountered in developing countries. The procedure is used by members of the Australian and New Zealand Association of Oral and Maxillofacial Surgeons Bangladesh Project who have operated in Dhaka teaching hospitals on a regular basis since 1991.
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Affiliation(s)
- J F Arvier
- Maxillofacial Surgery Unit, Dhaka Dental College, Bangladesh
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Mahler HI, Fitzpatrick B, Parker P, Lapin A. The relative effects of a health-based versus an appearance-based intervention designed to increase sunscreen use. Am J Health Promot 1997; 11:426-9. [PMID: 10168263 DOI: 10.4278/0890-1171-11.6.426] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- H I Mahler
- California State University, San Marcos 92096-0001, USA
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37
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Leslie WS, Fitzpatrick B, Morrison CE, Watt GCM, Tunstall-Pedoe H. Out-of-hospital cardiac arrest due to coronary heart disease: A comparison of survival before and after the introduction of defribrillators in ambulances. Resuscitation 1996. [DOI: 10.1016/0300-9572(96)89036-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Tunstall-Pedoe H, Morrison C, Woodward M, Fitzpatrick B, Watt G. Sex differences in myocardial infarction and coronary deaths in the Scottish MONICA population of Glasgow 1985 to 1991. Presentation, diagnosis, treatment, and 28-day case fatality of 3991 events in men and 1551 events in women. Circulation 1996; 93:1981-92. [PMID: 8640972 DOI: 10.1161/01.cir.93.11.1981] [Citation(s) in RCA: 169] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Scottish MONICA used medical and medico-legal records and World Health Organization MONICA Project criteria to register coronary events in 25- to 64-year-old residents of the high-incidence area of north Glasgow from 1985 to 1991. METHODS AND RESULTS Age-standardized data from 3991 episodes of nonfatal definite myocardial infarction and coronary deaths in men (mean age, 55.5 years) were compared with 1551 in women (57.0 years). Many results, such as the overall 28-day fatality rates of 49.8% in men and 48.5% in women, showed insignificant differences. However, 74.3% of deaths in men occurred out of hospital versus 67.8% in women (P = .0004). After admission to hospital, fatality rates in women were 14% higher (P = .07) and after admission to coronary care, 22% higher (P = .04). Women were more often widowed. Fewer had a history of previous myocardial infarction, but the prevalence of angina pectoris, of smoking, and of chest pain in the attack was the same as in men; more had shock, syncope, and breathlessness. More consulted a doctor before admission to hospital, which delayed their coming under care. More men had ECG Q-wave progression, and more women had smaller ECG changes. This, and marginally reduced chances of direct admission to coronary care, of thrombolysis, of aspirin, and of beta-blockers, did not explain women's excess hospital fatality. CONCLUSIONS Acute coronary events appear to be recognized and treated fairly equally in men and women 25 to 64 years old in Glasgow, so differences are small but subtle. More men die suddenly out of hospital; the reason why more women die after arrival may be because the equivalent number of men have already died outside.
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Affiliation(s)
- H Tunstall-Pedoe
- Scottish MONICA Project: Cardiovascular Epidemiology Unit, University of Dundee, Ninewells Hospital, Glasgow, Scotland, UK
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Leslie WS, Fitzpatrick B, Morrison CE, Watt GC, Tunstall-Pedoe H. Out-of-hospital cardiac arrest due to coronary heart disease: a comparison of survival before and after the introduction of defribrillators in ambulances. Heart 1996; 75:195-9. [PMID: 8673761 PMCID: PMC484260 DOI: 10.1136/hrt.75.2.195] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To assess the actual impact on coronary mortality of equipping ambulances with defibrillators. DESIGN Retrospective analysis of routine medical and legal records of all those who had a cardiac arrest attributed to coronary heart disease occurring outside hospital in a defined population before and after the introduction of Heartstart. SETTING City of Glasgow, North of the River Clyde, 1984 and 1990. PATIENTS 296 and 267 men and women aged 25-64 inclusive in 1984 and 1990 respectively who had a cardiac arrest outside hospital which was attributed to coronary heart disease (International Classification of Diseases codes 410-414, ninth revision). RESULTS The impact on coronary mortality in 1990 of equipping ambulances with defibrillators concurred with the earlier prediction of less than 1% of all coronary deaths. The circumstances of cardiac arrest were largely unchanged; most occurred outside hospital in the victim's home and the principal witnesses were members of the victim's family. A call for help before cardiac arrest was made in very few cases and cardiopulmonary resuscitation was attempted by laypersons in less than a third of the deaths they witnessed. There was a significant increase in the number of cardiopulmonary resuscitation attempts made by ambulance crews (16% v 32%, P < 0.01). Ambulance crews, however, still attended less than half of all cases (44% and 47%). CONCLUSION The impact of equipping ambulances with defibrillators will remain small unless strategies are introduced that focus on improving the public's response to coronary emergencies by calling for help promptly and initiating cardiopulmonary resuscitation before the arrival of the emergency services.
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Affiliation(s)
- W S Leslie
- MONICA Project Centre, Royal Infirmary, Glasgow
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Fitzpatrick B, Minimo C, Bibbo M. Organotypic thymic carcinoma; case report with histological and cytological correlates. Cytopathology 1995; 6:110-4. [PMID: 7795160 DOI: 10.1111/j.1365-2303.1995.tb00456.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- B Fitzpatrick
- Cytopathology Department, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA
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Minimo C, Galera-Davidson H, Xiao J, Christen R, Fitzpatrick B, Bartels PH, Bibbo M. Importance of different nuclear morphologic patterns in grading prostatic adenocarcinoma. An expanded model for computer graphic filters. Anal Quant Cytol Histol 1994; 16:307-14. [PMID: 7840836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The aim of this work was to continue the development of an interactive workstation for the nuclear grading of prostatic lesions by including a large range of nuclear patterns. A previous model was based on four groups: hyperplasia, Mostofi grade 1, Mostofi grade 2 and Mostofi grade 3. Each group included the most common nuclear patterns of the lesions. One set used to test the model included cases showing patterns different from the typical ones of the model. Poor results were obtained for low and medium grades. A review of all the cases in our database led to the conclusion that different nuclear patterns can belong to the same "nuclear grade." Thus, in this work the model was expanded to include six groups: hyperplasia, two subgroups for Mostofi grade 1, two subgroups for Mostofi grade 2 and Mostofi grade 3. A set of 900 nuclei, 150 in each group, was selected to test the model. An additional 300 nuclei, 50 in each group, were used for a test set. The overall success rate for classifying the nuclei in the test set using the new model was 93% as compared to a rate of 71% obtained for the similar test set, described above, using the previous model. Moreover, correlating karyometric features with nuclear morphology indicated a role for nucleoli in nuclear grading. The good results obtained with large and heterogeneous sets of cases indicate that the procedures used to develop this model may be adapted for the development of models for the nuclear grading of other tumors.
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Affiliation(s)
- C Minimo
- Department of Pathology and Cell Biology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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Bibbo M, Xiao J, Christen R, Fitzpatrick B, Galera-Davidson H, Bartels PH, Minimo C. Use of computer graphic filters for the nuclear grading of hematoxylin and eosin-stained specimens from prostatic lesions. Anal Quant Cytol Histol 1994; 16:183-8. [PMID: 7522452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
An inexpensive workstation is being developed to assist pathologists in diagnosing routine hematoxylin and eosin-stained slides. A linear discriminant model was applied to karyometric features of prostate lesions, and a grade according to Mostofi was determined from the discriminant values. Twenty cases, five of hyperplasia and five each of carcinoma Mostofi grades I, II and III, for a total of 600 nuclei, were selected to train the model. Computer graphic filters were constructed from the discriminant values. Each segmented nucleus has a colored frame (the graphic filter) displayed around it. The color, determined from discriminant values and correlated with the grades, ranges from green for hyperplasia, yellow for low grade, orange for medium grade and red for high grade. An additional 20 cases, 5 of hyperplasia and 5 each of the Mostofi grades, for a total of 538 nuclei, were selected to test the graphic filter. Ninety-six percent of the hyperplasia nuclei were framed in green, 84% of low grade nuclei were framed in yellow, 90% of medium grade nuclei were framed in orange, and 89% of high grade nuclei were framed in red. These results indicate the potential of the color graphic filter to show the pathologist immediate and accurate visual information about the grade of a nucleus. This method may help with the difficult diagnosis of borderline lesions and may help in making the diagnosis from scanty biopsy material.
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Affiliation(s)
- M Bibbo
- Department of Pathology and Cell Biology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania 19107-5244
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Flaherty P, Fitzpatrick B, Liljestrand J, O'Brien T. Antibiotic usage and resistance trends in a rehabilitation hospital. Am J Infect Control 1994. [DOI: 10.1016/0196-6553(94)90151-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
OBJECTIVE To determine the potential impact of emergency intervention strategies to prevent deaths from coronary heart disease outside hospital. DESIGN Analysis of routine medical and legal records of all persons dying of coronary heart disease in a defined population. SETTING Glasgow City, north of the river Clyde, 1984. SUBJECTS 420 people under 65 years for whom the underlying cause of death on the death certificate was coronary heart disease (ICD 410-414, 9th Revision). RESULTS Of the 296 deaths outside hospital, 73% occurred at home. The deaths of 40% of those who died outside hospital were not witnessed and these people could not have received prompt cardiopulmonary resuscitation. Only 16% of the witnesses of a death attempted cardiopulmonary resuscitation before the arrival of a doctor or an ambulance crew. Over half (53%) of the cases in which cardiopulmonary resuscitation could have been attempted by a witness, but was not attempted, death occurred in the presence of the spouse or other close relative. Death occurred in the presence of a duty doctor or the ambulance crew in a maximum of 5% of deaths outside hospital. Ninety one per cent of people were dead before a call for help was made. CONCLUSION Unless a greater proportion of patients receive cardiopulmonary resuscitation before emergency staff arrive at the scene the provision of emergency care staff with defibrillators is unlikely to have a significant impact on deaths outside hospital caused by coronary heart disease.
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Ballard JL, Bunt TJ, Fitzpatrick B, Malone JM. Bilateral traumatic internal carotid artery dissections: case report. J Vasc Surg 1992; 15:431-5. [PMID: 1735905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Bilateral internal carotid artery dissections after blunt cervicofacial trauma are rare, with 16 cases being previously published. Management is presumed to be an extension of the dominant therapy for unilateral dissection, that being anticoagulant therapy; however, bilateral stenoses engender questions of threat to total cerebral blood flow. We herein present a patient who suffered bilateral type B dissections and who then had progression of the process on anticoagulant therapy, resulting in an unusual carotid reconstruction.
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Affiliation(s)
- J L Ballard
- Maricopa Medical Center, Department of Surgery, Phoenix, AZ 85010
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Hofferber J, Fitzpatrick B. Clinical and financial aspects of shared/part-time practice. HMO Pract 1991; 5:160-4. [PMID: 10114295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Shared and part-time medical practices are popular with both the medical group and the clinicians who fill these positions at Group Health Cooperative. The medical group benefits from the flexibility provided by part-time practitioners. Part-time clinicians have the opportunity to devote time to their families or second careers. There are, however, additional costs and administrative problems associated with shared and part-time practices.
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Affiliation(s)
- J Hofferber
- Group Health Cooperative of Puget Sound, Seattle, WA 98121
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Abstract
A case of islet cell tumor occurring in a patient with the multiple endocrine neoplasia type I syndrome is reported. Immunostaining for insulin was strongly positive in the tumor cells. Numerous dense-core granules of endocrine caliber were identified ultrastructurally. Morphometric analysis of the secretory granules in 20 islet cell tumors gave a granule size of 182 +/- 52 nm (mean +/- standard deviation).
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Affiliation(s)
- B Fitzpatrick
- Department of Pathology, University of Texas M. D. Anderson Cancer Center, Houston 77030
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di Loreto C, Fitzpatrick B, Underhill S, Kim DH, Dytch HE, Galera-Davidson H, Bibbo M. Correlation between visual clues, objective architectural features, and interobserver agreement in prostate cancer. Am J Clin Pathol 1991; 96:70-5. [PMID: 2069137 DOI: 10.1093/ajcp/96.1.70] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Three pathologists evaluated a number of designated architectural features to assign grades to 41 cases of well- to moderately differentiated adenocarcinoma, and their opinions were compared. The consensus opinion was obtained and evaluated against objective measurements of glandular architecture that were obtained by morphometric techniques. The observers agreed on gland size, gland uniformity, and the number of glands per field in only 49%, 31%, and 39% of cases, respectively. There were significant differences in the Gleason grades assigned by observers. Paired matching of individual Gleason grades showed agreement among observers in 44% (18 of 41), 56% (23 of 41), and 75% (31 of 41) of cases, respectively. This level of interobserver disagreement occurred even though cases with predominant patterns were selected carefully and those with variable patterns were excluded. A direct relationship appears to exist between increasing Gleason grade and increasing glandular variability, and there is an inverse relationship between Gleason grade, gland lumen area, and the number of glandular nuclei, as assessed by a group of pathologists.
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Affiliation(s)
- C di Loreto
- Section of Cytopathology, University of Chicago, Illinois 60637
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