A RCT to explore the effectiveness of supporting adherence to nebuliser medication in adults with cystic fibrosis: fidelity assessment of study interventions

BACKGROUND

A multi-component self-management intervention 'CFHealthHub' was developed to reduce pulmonary exacerbations in adults with Cystic Fibrosis (CF) by supporting adherence to nebuliser medication. It was evaluated in a randomized controlled trial (RCT) involving 19 CF centres, with 32 interventionists, 305 participants in the intervention group, and 303 participants in the standard care arm. Ensuring treatment fidelity of intervention delivery was crucial to ensure that the intervention produced the expected outcomes.

METHODS

Fidelity of the CFHealthHub intervention and standard care was assessed using different methods for each of the five fidelity domains defined by the Borrelli framework: study design, training, treatment delivery, receipt, and enactment. Study design ensured that the groups received the intended intervention or standard care. Interventionists underwent training and competency assessments to be deemed certified to deliver the intervention. Audio-recorded intervention sessions were assessed for fidelity drift. Receipt was assessed by identifying whether participants set Action and Coping Plans, while enactment was assessed using click analytics on the CFHealthHub digital platform.

RESULTS

Design: There was reasonable agreement (74%, 226/305) between the expected versus actual intervention dose received by participants in the CFHealthHub intervention group. The standard care group did not include focused adherence support for most centres and participants. Training: All interventionists were trained. Treatment delivery: The trial demonstrated good fidelity (overall fidelity by centre ranged from 79 to 97%), with only one centre falling below the mean threshold (> 80%) on fidelity drift assessments. Receipt: Among participants who completed the 12-month intervention, 77% (205/265) completed at least one action plan, and 60% (160/265) completed at least one coping plan. Enactment: 88% (268/305) of participants used web/app click analytics outside the intervention sessions. The mean (SD) number of web/app click analytics per participant was 31.2 (58.9). Additionally, 64% (195/305) of participants agreed to receive notifications via the mobile application, with an average of 53.6 (14.9) notifications per participant.

CONCLUSIONS

The study demonstrates high fidelity throughout the RCT, and the CFHealthHub intervention was delivered as intended. This provides confidence that the results of the RCT are a valid reflection of the effectiveness of the CFHealthHub intervention compared to standard care.

TRIAL REGISTRATION

ISRCTN registry: ISRCTN55504164 (date of registration: 12/10/2017).

Development of an intervention to increase adherence to nebuliser treatment in adults with cystic fibrosis: CFHealthHub

BACKGROUND

Cystic fibrosis (CF) is a life-limiting genetic condition in which daily therapies to maintain lung health are critical, yet treatment adherence is low. Previous interventions to increase adherence have been largely unsuccessful and this is likely due to a lack of focus on behavioural evidence and theory alongside input from people with CF. This intervention is based on a digital platform that collects and displays objective nebuliser adherence data. The purpose of this paper is to identify the specific components of an intervention to increase and maintain adherence to nebuliser treatments in adults with CF with a focus on reducing effort and treatment burden.

METHODS

Intervention development was informed by the Behaviour Change Wheel (BCW) and person-based approach (PBA). A multidisciplinary team conducted qualitative research to inform a needs analysis, selected, and refined intervention components and methods of delivery, mapped adherence-related barriers and facilitators, associated intervention functions and behaviour change techniques, and utilised iterative feedback to develop and refine content and processes.

RESULTS

Results indicated that people with CF need to understand their treatment, be able to monitor adherence, have treatment goals and feedback and confidence in their ability to adhere, have a treatment plan to develop habits for treatment, and be able to solve problems around treatment adherence. Behaviour change techniques were selected to address each of these needs and were incorporated into the digital intervention developed iteratively, alongside a manual and training for health professionals. Feedback from people with CF and clinicians helped to refine the intervention which could be tailored to individual patient needs.

CONCLUSIONS

The intervention development process is underpinned by a strong theoretical framework and evidence base and was developed by a multidisciplinary team with a range of skills and expertise integrated with substantial input from patients and clinicians. This multifaceted development strategy has ensured that the intervention is usable and acceptable to people with CF and clinicians, providing the best chance of success in supporting people with CF with different needs to increase and maintain their adherence. The intervention is being tested in a randomised controlled trial across 19 UK sites.

Effect of a national urgent care telephone triage service on population perceptions of urgent care provision: controlled before and after study

OBJECTIVE

To measure the effect of an urgent care telephone service NHS 111 on population perceptions of urgent care.

DESIGN

Controlled before and after population survey, using quota sampling to identify 2000 respondents reflective of the age/sex profile of the general population.

SETTING

England. 4 areas where NHS 111 was introduced, and 3 control areas where NHS 111 had yet to be introduced.

PARTICIPANTS

28 071 members of the general population, including 2237 recent users of urgent care.

INTERVENTION

NHS 111 offers advice to members of the general population seeking urgent care, recommending the best service to use or self-management. Policymakers introduced NHS 111 to improve access to urgent care.

OUTCOMES MEASURES

The primary outcome was change in satisfaction with recent urgent care use 9 months after the launch of NHS 111. Secondary outcomes were change in satisfaction with urgent care generally and with the national health service.

RESULTS

The overall response rate was 28% (28 071/100 408). 8% (2237/28 071) had used urgent care in the previous 3 months. Of the 652 recent users of urgent care in the NHS 111 intervention areas, 9% (60/652) reported calling NHS 111 in the 'after' period. There was no evidence that the introduction of NHS 111 was associated with a changed perception of recent urgent care. For example, the percentage rating their experience as excellent remained at 43% (OR 0.97, 95% CI 0.69 to 1.37). Similarly, there was no change in population perceptions of urgent care generally (1.06, 95% CI 0.95 to 1.17) or the NHS (0.94, 95% CI 0.85 to 1.05) following the introduction of NHS 111.

CONCLUSIONS

A new telephone triage service did not improve perceptions of urgent care or the health service. This could be explained by the small amount of NHS 111 activity in a large emergency and urgent care system.

Hospital characteristics affecting potentially avoidable emergency admissions: national ecological study

Some emergency admissions can be avoided if acute exacerbations of health problems are managed by emergency and urgent care services without resorting to admission to a hospital bed. In England, these services include hospitals, emergency ambulance, and a range of primary and community services. The aim was to identify whether characteristics of hospitals affect potentially avoidable emergency admission rates. An age-sex adjusted rate of admission for 14 conditions rich in avoidable emergency admissions was calculated for 129 hospitals in England for 2008-2011. Twenty-two per cent (3,273,395/14,998,773) of emergency admissions were classed as potentially avoidable, with threefold variation between hospitals. Explanatory factors of this variation included those which hospital managers could not control (demand for hospital emergency departments) and those which they could control (supply in terms of numbers of acute beds in the hospital, and management of non-emergency and emergency patients within the hospital). Avoidable admission rates were higher for hospitals with higher emergency department attendance rates, higher numbers of acute beds per 1000 catchment population and higher conversion rates from emergency department attendance to admission. Hospital managers may be able to reduce avoidable emergency admissions by reducing supply of acute beds and conversion rates from emergency department attendance.

Impact of the urgent care telephone service NHS 111 pilot sites: a controlled before and after study

OBJECTIVES

To measure the impact of the urgent care telephone service NHS 111 on the emergency and urgent care system.

DESIGN

Controlled before and after study using routine data.

SETTING

Four pilot sites and three control sites covering a total population of 3.6 million in England, UK.

PARTICIPANTS AND DATA

Routine data on 36 months of use of emergency ambulance service calls and incidents, emergency department attendances, urgent care contacts (general practice (GP) out of hours, walk in and urgent care centres) and calls to the telephone triage service NHS direct.

INTERVENTION

NHS 111, a new 24 h 7 day a week telephone service for non-emergency health problems, operated by trained non-clinical call handlers with clinical support from nurse advisors, using NHS Pathways software to triage calls to different services and home care.

MAIN OUTCOMES

Changes in use of emergency and urgent care services.

RESULTS

NHS 111 triaged 277 163 calls in the first year of operation for a population of 1.8 million. There was no change overall in emergency ambulance calls, emergency department attendances or urgent care use. There was a 19.3% reduction in calls to NHS Direct (95% CI -24.6% to -14.0%) and a 2.9% increase in emergency ambulance incidents (95% CI 1.0% to 4.8%). There was an increase in activity overall in the emergency and urgent care system in each site ranging 4.7-12%/month and this remained when assuming that NHS 111 will eventually take all NHS Direct and GP out of hours calls.

CONCLUSIONS

In its first year of operation in four pilot sites NHS 111 did not deliver the expected system benefits of reducing calls to the 999 ambulance service or shifting patients to urgent rather than emergency care. There is potential that this type of service increases overall demand for urgent care.

What can qualitative research do for randomised controlled trials? A systematic mapping review

OBJECTIVE

To develop an empirically based framework of the aspects of randomised controlled trials addressed by qualitative research.

DESIGN

Systematic mapping review of qualitative research undertaken with randomised controlled trials and published in peer-reviewed journals.

DATA SOURCES

MEDLINE, PreMEDLINE, EMBASE, the Cochrane Library, Health Technology Assessment, PsycINFO, CINAHL, British Nursing Index, Social Sciences Citation Index and ASSIA.

ELIGIBILITY CRITERIA

Articles reporting qualitative research undertaken with trials published between 2008 and September 2010; health research, reported in English.

RESULTS

296 articles met the inclusion criteria. Articles focused on 22 aspects of the trial within five broad categories. Some articles focused on more than one aspect of the trial, totalling 356 examples. The qualitative research focused on the intervention being trialled (71%, 254/356); the design, process and conduct of the trial (15%, 54/356); the outcomes of the trial (1%, 5/356); the measures used in the trial (3%, 10/356); and the target condition for the trial (9%, 33/356). A minority of the qualitative research was undertaken at the pretrial stage (28%, 82/296). The value of the qualitative research to the trial itself was not always made explicit within the articles. The potential value included optimising the intervention and trial conduct, facilitating interpretation of the trial findings, helping trialists to be sensitive to the human beings involved in trials, and saving money by steering researchers towards interventions more likely to be effective in future trials.

CONCLUSIONS

A large amount of qualitative research undertaken with specific trials has been published, addressing a wide range of aspects of trials, with the potential to improve the endeavour of generating evidence of effectiveness of health interventions. Researchers can increase the impact of this work on trials by undertaking more of it at the pretrial stage and being explicit within their articles about the learning for trials and evidence-based practice.

A pilot 'cohort multiple randomised controlled trial' of treatment by a homeopath for women with menopausal hot flushes

INTRODUCTION

In order to address the limitations of the standard pragmatic RCT design, the innovative 'cohort multiple RCT' design was developed. The design was first piloted by addressing a clinical question " What is the clinical and cost effectiveness of treatment by a homeopath for women with menopausal hot flushes?".

METHODS

A cohort with the condition of interest (hot flushes) was recruited through an observational study of women's midlife health and consented to provide observational data and have their data used comparatively. The 'Hot Flush' Cohort were then screened in order to identify patients eligible for a trial of the offer of treatment by a homeopath (Eligible Trial Group). A proportion of the Eligible Trial Group was then randomly selected to the Offer Group and offered treatment. A "patient centred" approach to information and consent was adopted. Patients were not (i) told about treatments that they would not be offered, and trial intervention information was only given to the Offer Group after random selection. Patients were not (ii) given prior information that their treatment would be decided by chance.

RESULTS

The 'cohort multiple RCT' design was acceptable to the NHS Research Ethics Committee. The majority of patients completed multiple questionnaires. Acceptance of the offer was high (17/24).

DISCUSSION

This pilot identified the feasibility of an innovative design in practice. Further research is required to test the concept of undertaking multiple trials within a cohort of patients and to assess the acceptability of the "patient centred" approach to information and consent.

Telephone triage, expert systems and clinical expertise

This paper reports on a qualitative study of the use of an expert system developed for the British telephone triage service NHS Direct. This system, known as CAS, is designed to standardise and control the interaction between NHS Direct nurses and callers. The paper shows, however, that in practice the nurses use CAS in a range of ways and, in so doing, privilege their own expertise and deliver an individualised service. The paper concludes by arguing that NHS Direct management's policy of using CAS as a means of standardising service delivery will achieve only limited success due not only to the professional ideology of nursing but also to the fact that rule-based expert systems capture only part of what 'experts' do.

Rationing in the emergency department: the good, the bad, and the unacceptable

OBJECTIVES

Waiting times in emergency departments (EDs) are an important government priority. Although substantial efforts are currently being made to reduce waiting times, little attention has been paid to the patients' view. We used qualitative methods to explore patients' perspectives on waiting times and other approaches to rationing and prioritisation.

METHODS

Face to face, in depth, qualitative interviews (n = 11) explored how patients valued waiting times for non-urgent ED care. The framework approach (identifying a thematic framework through repeated re-reading) was used to analyse transcripts.

RESULTS

Interviewees found some forms of rationing and prioritisation acceptable. They expected rationing by delay, but required explanations or information on the reason for their wait. They valued prioritisation by triage (rationing by selection) and thought that this role could be expanded for the re-direction of non-urgent patients elsewhere (rationing by deflection). Interviewees were mainly unwilling or unable to engage in prioritisation of different types of patients, openly prioritising only those with obvious clinical need, and children. However, some interviewees were willing to ration implicitly, labelling some attenders as inappropriate, such as those causing a nuisance. Others felt it was unacceptable to blame "inappropriate" attenders, as their attendance may relate to lack of information or awareness of service use. Explicit rationing between services was not acceptable, although some believed there were more important priorities for NHS resources than ED waiting times. Interviewees disagreed with the hypothetical notion of paying to be seen more quickly in the ED (rationing by charging).

CONCLUSIONS

Interviewees expected to wait and accepted the need for prioritisation, although they were reluctant to engage in judgements regarding prioritisation. They supported the re-direction of patients with certain non-urgent complaints. However, they perceived a need for more explanation and information about their wait, the system, and alternative services.

The impact of a general practice co-operative on accident and emergency services, patient satisfaction and GP satisfaction

BACKGROUND

The advent of general practice co-operatives represented a fundamental change in the delivery and organization of out-of-hours services. Concerns have been voiced that co-operatives might impact adversely on workload in accident and emergency (A&E) departments.

OBJECTIVE

The purpose of this study was to assess the impact of establishing a general practice co-operative on use of A&E services, patient satisfaction and GP satisfaction.

METHODS

A controlled before and after study of a GP co-operative in Sheffield, UK was carried out. A postal questionnaire was sent to 26 911 people, 13 442 before and 13 469 after the opening of the co-operative, to determine service use, in particular A&E attendance, in the previous 4 weeks. Patient satisfaction was assessed through structured interviews with 653 patients. GP satisfaction was assessed using a postal survey of all 98 Sheffield practices 2 years after the opening of the co-operative.

RESULTS

There was no change in the use of A&E services, odds ratio = 1.08 (95% confidence interval 0.60-1.94). There was no change in patient satisfaction overall, mean difference 0.02 (-0.32 to 0.36). Sixty-seven per cent of doctors in member practices were much more satisfied with out-of-hours duty compared with 10% in non-member practices (P < 0.001).

CONCLUSIONS

General practice co-operatives have been successful in achieving their policy objectives, improving GP morale without jeopardizing patient satisfaction or impacting adversely on A&E services.

NHS Direct: consistency of triage outcomes

OBJECTIVES

To examine the consistency of triage outcomes by nurses using four types of computerised decision support software in NHS Direct.

METHODS

119 scenarios were constructed based on calls to ambulance services that had been assigned the lowest priority category by the emergency medical dispatch systems in use. These scenarios were presented to nurses working in four NHS Direct call centres using different computerised decision support software, including the NHS Clinical Assessment System.

RESULTS

The overall level of agreement between the nurses using the four systems was "fair" rather than "moderate" or "good" (kappa=0.375, 95% CI: 0.34 to 0.41). For example, the proportion of calls triaged to accident and emergency departments varied from 22% (26 of 119) to 44% (53 of 119). Between 21% (25 of 119) and 31% (37 of 119) of these low priority ambulance calls were triaged back to the 999 ambulance service. No system had both high sensitivity and specificity for referral to accident and emergency services.

CONCLUSIONS

There were large differences in outcome between nurses using different software systems to triage the same calls. If the variation is primarily attributable to the software then standardising on a single system will obviously eliminate this. As the calls were originally made to ambulance services and given the lowest priority, this study also suggests that if, in the future, ambulance services pass such calls to NHS Direct then at least a fifth of these may be passed back unless greater sensitivity in the selection of calls can be achieved.

NHS Direct and nurses--opportunity or monotony?

NHS Direct, the 24-hour telephone helpline providing information and advice about health problems, is available throughout England and Wales. It was envisaged as a nurse-led service presenting a new opportunity for the nursing profession. Free text comments from a postal survey of NHS Direct nurses revealed that a large proportion of nurses were happy with working in NHS Direct, and that it presented some nurses with the opportunity of a new and challenging role. However, a minority found the work monotonous and felt that NHS Direct is likely to face the challenge of staff retention.

Impact of NHS Direct on other services: the characteristics and origins of its nurses

OBJECTIVE

To characterise the NHS Direct nurse workforce and estimate the impact of NHS Direct on the staffing of other NHS nursing specialties.

METHOD

A postal survey of NHS Direct nurses in all 17 NHS Direct call centres operating in June 2000.

RESULTS

The response rate was 74% (682 of 920). In the three months immediately before joining NHS Direct, 20% (134 of 682, 95% confidence intervals 17% to 23%) of respondents had not been working in the NHS. Of the 540 who came from NHS nursing posts, one fifth had come from an accident and emergency department or minor injury unit (110 of 540), and one in seven from practice nursing (75 of 540). One in ten (65 of 681) nurses said that previous illness, injury, or disability had been an important reason for deciding to join NHS Direct. Sixty two per cent (404 of 649) of nurses felt their job satisfaction and work environment had improved since joining NHS Direct.

CONCLUSION

The NHS Direct nurse workforce currently constitutes a small proportion (about 0.5%) of all qualified nurses in the NHS, although it recruits relatively experienced and well qualified nurses more heavily from some specialties, such as accident and emergency nursing, than others. However, its overall impact on staffing in any one specialty is likely to be small. NHS Direct has succeeded in providing employment for some nurses who might otherwise be unable to continue in nursing because of disability.

Use of evidence based leaflets to promote informed choice in maternity care: randomised controlled trial in everyday practice

OBJECTIVE

To assess the effect of leaflets on promoting informed choice in women using maternity services.

DESIGN

Cluster trial, with maternity units randomised to use leaflets (intervention units) or offer usual care (control units). Data collected through postal questionnaires.

SETTING

13 maternity units in Wales.

PARTICIPANTS

Four separate samples of women using maternity services. Antenatal samples: women reaching 28 weeks' gestation before (n=1386) and after (n=1778) the intervention. Postnatal samples: women at eight weeks after delivery before (n=1741) and after (n=1547) the intervention.

INTERVENTION

Provision of 10 pairs of Informed Choice leaflets for service users and midwives and a training session for staff in their use.

MAIN OUTCOME MEASURES

Change in the proportion of women who reported exercising informed choice.

SECONDARY OUTCOMES

changes in women's knowledge; satisfaction with information, choice, and discussion; and possible consequences of informed choice.

RESULTS

There was no change in the proportion of women who reported that they exercised informed choice in the intervention units compared with the control units for either antenatal or postnatal women. There was a small increase in satisfaction with information in the antenatal samples in the intervention units compared with the control units (odds ratio 1.40, 95% confidence interval 1.05 to 1.88). Only three quarters of women in the intervention units reported being given at least one of the leaflets, indicating problems with the implementation of the intervention.

CONCLUSION

In everyday practice, evidence based leaflets were not effective in promoting informed choice in women using maternity services.

The acceptability of an emergency medical dispatch system to people who call 999 to request an ambulance

OBJECTIVE

To determine the acceptability of an emergency medical dispatch (EMD) system to people who call 999 to request an ambulance.

METHODS

Postal questionnaires to two systematic random samples of approximately 500 named callers to one ambulance service before, and one year after, the introduction of EMD.

RESULTS

The response rate was 72% (355 of 493) before, and 63% (297 of 466) after, EMD. There was a reduction, from 81% (284 of 349) to 70% (200 of 286), in the proportion of callers who found all the questions asked by the call taker relevant, although this did not adversely affect the proportion of callers who were very satisfied with the 999 call, which increased from 78% (268 of 345) to 86% (247 of 287). The proportion of callers who reported receiving first aid advice increased from 7% (23 of 323) to 43% (117 of 272) and general information from 13% (41 of 315) to 58% (157 of 269). Satisfaction levels with the amount of advice given increased, while satisfaction with response times remained stable at 76% (254 of 320) very satisfied before and 78% (217 of 279) after EMD. The proportion of respondents very satisfied with the service in general increased from 71% (238 of 336) to 79% (220 of 277). There was evidence in respondents' written comments of two potential problems with EMD from the caller's viewpoint. Firstly, some callers were advised to take actions that were subsequently not needed; secondly, a small number of callers felt that the ambulance crew did not treat the situation as seriously as they would have liked.

CONCLUSIONS

Introducing EMD increases the amount of first aid and general advice given to callers, and satisfaction with these aspects of the service, while maintaining satisfaction with response times. Overall satisfaction with the service increased. However, some changes may be needed to prevent a small amount of dissatisfaction directly associated with EMD.

Impact of NHS direct on demand for immediate care: observational study

OBJECTIVES

To quantify the impact of NHS Direct on the use of accident and emergency, ambulance, and general practitioner cooperative services.

DESIGN

Observational study of trends in use of NHS Direct and other immediate care services over 24 months spanning introduction of NHS Direct.

SETTING

Three areas in England in first wave of introduction of NHS Direct, and six nearby general practitioner cooperatives as controls.

SUBJECTS

All contacts with these immediate care services.

MAIN OUTCOME MEASURES

Changes in trends in use after introduction of NHS Direct.

RESULTS

NHS Direct received about 68 500 calls from a population of 1.3 million in its first year of operation, of which 72% were out of hours and 22% about a child aged under 5 years. Changes in trends in use of accident and emergency departments and ambulance services after introduction of NHS Direct were small and non-significant. Changes in trends in use of general practitioner cooperatives were also small but significant, from an increase of 2.0% a month before introduction of NHS Direct to -0.8% afterwards (relative change -2. 9% (95% confidence interval -4.2% to -1.5%)). This reduction in trend was significant both for calls handled by telephone advice alone and for those resulting in direct contact with a doctor. In contrast, the six control cooperatives showed no evidence of change in trend; an increase of 0.8% a month before NHS Direct and 0.9% after (relative change 0.1% (-0.9% to 1.1%)).

CONCLUSION

In its first year NHS Direct did not reduce the pressure on NHS immediate care services, although it may have restrained increasing demand on one important part-general practitioners' out of hours services.

Shifting services from secondary to primary care: stakeholders' views of the barriers

OBJECTIVES

To identify the barriers to shifting services from secondary to primary care perceived by the involved stakeholders.

METHODS

Forty-five semi-structured interviews with stakeholders from primary care, acute and community hospitals, purchasers (health authorities) and other agencies involved in two contrasting initiatives to shift services.

RESULTS

Stakeholders perceived similar barriers in the two initiatives: disinvesting from existing providers; lack of information on activity and costs; uncertainty over the quality of the proposed alternative service; concern about an increasing workload in primary care; diversity of views within primary care; difficulties in communication between the many agencies involved; and lack of leadership by purchasers.

CONCLUSIONS

Service shifts which involve disinvestment from existing providers and collaboration between agencies with different views and interests will inevitably face a range of barriers. Attempts to shift services by disinvesting from secondary care are likely to encounter the greatest difficulties. Attempts to shift without concomitant disinvestment may also be slow because of the difficulties of multi-agency collaboration. Frustration will be reduced if those involved have a realistic understanding of the difficulties rather than being surprised and overwhelmed by them.

General practice based physiotherapy: its use and effect on referrals to hospital orthopaedics and rheumatology outpatient departments

BACKGROUND

In November 1992, a pilot scheme was established in Doncaster to provide an on-site physiotherapy service in six non-fundholding general practices covering a population of approximately 44,000 people.

AIM

The aim of the pilot scheme was to transfer a hospital-based physiotherapy service, to which general practitioners had direct access, to a primary care setting and to reduce referrals to an orthopaedics outpatient department.

METHOD

Use of physiotherapy services and referrals to orthopaedics and rheumatology before and during the first year of the scheme were monitored. Comparisons were made with data over the same time periods for general practices that were not in the scheme. The location of management of patients referred to physiotherapy was monitored for an eight-month period during the scheme.

RESULTS

In the first year the scheme had a utilization rate of 31 per 1000 patients in the participating practices, representing a 164% increase over the hospital-based physiotherapy utilization rate for the year prior to the scheme. Eight per cent of physiotherapy patients received hospital-based treatment during the scheme. Changes in hospital outpatient referral rates attributable to the scheme were reductions of 8% to the orthopaedics department and 17% to the rheumatology department.

CONCLUSION

The increase in the use of the physiotherapy service was possibly caused, in part, by general practitioners sending patients to on-site physiotherapy who previously would have been referred to orthopaedics and, largely, by an increase in the treatment of patients who previously would not have been referred to hospital. Physiotherapy based in general practice can be a substitute for hospital-based physiotherapy and can contribute to a reduction in referrals to orthopaedics and rheumatology outpatient departments. However, it can result in an increase in use of physiotherapy services.

Evaluation of a Hospital at Home scheme for the early discharge of patients with fractured neck of femur

The community health services in Southern Derbyshire, in conjunction with an acute hospital, established a pilot scheme for the early discharge of fractured neck of femur patients from hospital to their own homes. The scheme was evaluated by prospectively comparing a group of patients using Hospital at Home (HAH) and a group receiving hospital care only. The main outcomes measured were the proportion of hospital admissions for fractured neck of femur using HAH, length of stay, patient satisfaction, general health status at discharge as measured by the Nottingham Health Profile, and three-month mortality and readmission rates. Costs were calculated based on prices charged by providers of the services. In the first year of the scheme, 76 (18 per cent) of the 432 hospital admissions for fractured neck of femur fitted the selection criteria and agreed to admission to HAH. Thirty-four patients were identified who were suitable for HAH but not admitted to it. The comparison of the 76 HAH patients and 34 hospital patients revealed that HAH patients were discharged from hospital an average of 7 days earlier; patients in both groups were satisfied with the care they received; the general health status of the two groups at discharge was similar, with the exception that HAH patients had better emotional health on discharge from care; the three-month mortality rate was similar in both groups (5 per cent); the readmission rate for HAH patients appeared higher than for hospital patients but this difference was not statistically significant (15.8 per cent versus 8.8 per cent, Fisher's exact test, p = 0.187).(ABSTRACT TRUNCATED AT 250 WORDS)

Validating the SF-36 health survey questionnaire: new outcome measure for primary care

OBJECTIVES

To test the acceptability, validity, and reliability of the short form 36 health survey questionnaire (SF-36) and to compare it with the Nottingham health profile.

DESIGN

Postal survey using a questionnaire booklet together with a letter from the general practitioner. Non-respondents received two reminders at two week intervals. The SF-36 questionnaire was retested on a subsample of respondents two weeks after the first mailing.

SETTING

Two general practices in Sheffield.

PATIENTS

1980 patients aged 16-74 years randomly selected from the two practice lists.

MAIN OUTCOME MEASURES

Scores for each health dimension on the SF-36 questionnaire and the Nottingham health profile. Response to questions on recent use of health services and sociodemographic characteristics.

RESULTS

The response rate for the SF-36 questionnaire was high (83%) and the rate of completion for each dimension was over 95%. Considerable evidence was found for the reliability of the SF-36 (Cronbach's alpha greater than 0.85, reliability coefficient greater than 0.75 for all dimensions except social functioning) and for construct validity in terms of distinguishing between groups with expected health differences. The SF-36 was able to detect low levels of ill health in patients who had scored 0 (good health) on the Nottingham health profile.

CONCLUSIONS

The SF-36 is a promising new instrument for measuring health perception in a general population. It is easy to use, acceptable to patients, and fulfils stringent criteria of reliability and validity. Its use in other contexts and with different disease groups requires further research.

Cost effectiveness of minor surgery in general practice: a prospective comparison with hospital practice

The cost effectiveness of general practitioners undertaking minor surgery in their practices was determined in a prospective comparison of patients having minor surgery undertaken in five general practices over a 12 week period in 1989, and in the departments of dermatology and general surgery in Rotherham District General Hospital over a contemporaneous eight week period. There were no differences between the settings in the reported rates of wound infection or other complications and only one general practice patient was subsequently referred to hospital for specialist treatment. General practitioners sent a smaller proportion of specimens to a histopathology laboratory than hospital doctors (61% versus 90%, P less than 0.001); incorrectly diagnosed a larger proportion of malignant conditions as benign (10% versus 1%, P less than 0.05) and inadequately excised 5% of lesions where this never happened in hospital (difference not significant). General practice patients had shorter waiting times between referral and treatment, spent less time and money attending for treatment and more of them were satisfied with their treatment. The cost of a procedure undertaken in general practice was less than in hospital--pounds 33.53 versus pounds 45.54 for the excision of a lesion and pounds 3.00 versus pounds 3.22 for cryotherapy of a wart (1989-90 prices). Performing minor surgery in general practice would seem cost effective compared with a hospital setting. However, the risk of general practitioners inadequately excising a malignancy and not sending it to a histopathology laboratory must be addressed and the conclusion regarding cost effectiveness only applies where general practice is a substitute for the hospital setting and not an additional activity.

Epidemiology of babies dying at different ages from the sudden infant death syndrome

An analysis of data from the United Kingdom multicentre study of postneonatal mortality has been made to assess whether there are causally distinct groups of babies dying from the Sudden Infant Death Syndrome (SIDS), and to develop explicit risk factor profiles for the subgroups. The 303 SIDS babies in the multicentre study were divided into four subgroups by age at death: weeks 1-7, 8-15, 16-23, and 24 or more weeks. Contrasts between these subgroups with respect to 28 epidemiological characteristics and to pathology findings were investigated. Significant contrasts in the number of previous pregnancies, duration of the 2nd stage of labour, gestational length, family finances and repair of housing were found. Overall, very strong evidence of epidemiological differences was found (chi 2(9) = 29.3, p less than 0.001), and of contrasts in the nature and degree of any acquired terminal disease. It is concluded that there are different causes of SIDS with different distributions according to age at death.

Feasibility of new prognostic classification for rectal cancer

Sixty slides from 60 blocks taken from 30 colonic carcinomas were circulated twice to six histopathologists of varying experience. Five of the six pathologists showed a good to excellent intraobserver agreement for assessment of the character of the invasive margin (0.44 less than kappa less than 0.82), which was not significantly affected by sampling (0.40 less than kappa less than 0.56, comparing both slides from each tumour) or observer (five of six pathologists agreeing on 46 of 60 slides). Pathologists were unreliable in assessing peritumoural lymphocytic infiltrates, with only two pathologists achieving moderate levels of intraobserver agreement (-0.03 less than kappa less than 0.52). The interobserver agreement for peritumoural lymphocytic infiltrates was also low (kappa less than 0.29) between the three most experienced pathologists. The assessment of peritumoural lymphocytic infiltrates was significantly affected by sampling, the two pathologists with the lowest intraobserver variation achieving kappa values of 0.21 and 0.10 between the 30 paired slides from each tumour. The character of the invasive margin was reliably assessed, was not dependent on sample, and added useful prognostic information, but peritumoural lymphocytic infiltration is not a reproducible observation and may therefore not add useful prognostic information in routine use.