Primary care usage at the end of life: a retrospective cohort study of cancer patients using linked primary and hospital care data

PURPOSE

Health service use is most intensive in the final year of a person's life, with 80% of this expenditure occurring in hospital. Close involvement of primary care services has been promoted to enhance quality end-of-life care that is appropriate to the needs of patients. However, the relationship between primary care involvement and patients' use of hospital care is not well described. This study aims to examine primary care use in the last year of life for cancer patients and its relationship to hospital usage.

METHODS

Retrospective cohort study in Victoria, Australia, using linked routine care data from primary care, hospital and death certificates. Patients were included who died related to cancer between 2008 and 2017.

RESULTS

A total of 758 patients were included, of whom 88% (n = 667) visited primary care during the last 6 months (median 9.1 consultations). In the last month of life, 45% of patients were prescribed opioids, and 3% had imaging requested. Patients who received home visits (13%) or anticipatory medications (15%) had less than half the median bed days in the last 3 months (4 vs 9 days, p < 0.001, 5 vs 10 days, p = 0.001) and 1 month of life (0 vs 2 days, p = 0.002, 0 vs 3 days, p < 0.001), and reduced emergency department presentations (32% vs 46%, p = 0.006, 31% vs 47% p < 0.001) in the final month.

CONCLUSION

This study identifies two important primary care processes-home visits and anticipatory medication-associated with reduced hospital usage and intervention at the end of life.

A multi-method and multi-informant approach to assessing post-traumatic stress disorder (PTSD) in children

Trauma exposure is highly prevalent among children globally, and is associated with elevated rates of PTSD. The goal of this study was to systematically evaluate the effects of multiple informants and multiple screening measures on the identification of specific PTSD symptoms and rates of PTSD diagnoses. Participants in this study included 350 maltreated children from two cohorts, one recruited from Connecticut (n = 130), and the other from Vermont (n = 220). Both cohorts completed the Screen for Child Anxiety-Related Emotional Disorders (SCARED) before a PTSD self-report measure. The KSADS psychiatric interview was also completed with the Connecticut cohort, with best-estimate ratings generated using parent and child interview, child self-report, and teacher questionnaire data. In addition to the SCARED and PTSD self-report scale, parents of the Vermont cohort completed the Child Behavioural Checklist. Significant differences emerged between parent and child report of sleep, nightmares, concentration, and irritability problems, suggesting the need for multiple informants in PTSD screening. Children also under-reported nightmares when asked in the context of a trauma-specific screening tool. As child trauma is associated with a broad range of psychiatric sequelae, comprehensive assessment using both general symptomatology and trauma-specific measures is recommended, since children often shut down when completing trauma measures.

Six-year follow-up of the SPHERE RCT: secondary prevention of heart disease in general practice

OBJECTIVE

To determine the long-term effectiveness of a complex intervention in primary care aimed at improving outcomes for patients with coronary heart disease.

DESIGN

A 6-year follow-up of a cluster randomised controlled trial, which found after 18 months that both total and cardiovascular hospital admissions were significantly reduced in intervention practices (8% absolute reduction).

SETTING

48 general practices in the Republic of Ireland and Northern Ireland.

PARTICIPANTS

903 patients with established coronary heart disease at baseline in the original trial.

INTERVENTION

The original intervention consisted of tailored practice and patient plans; training sessions for practitioners in medication prescribing and behavioural change; and regular patient recall system. Control practices provided usual care. Following the intervention period, all supports from the research team to intervention practices ceased.

PRIMARY OUTCOME

hospital admissions, all cause and cardiovascular; secondary outcomes: mortality; blood pressure and cholesterol control.

RESULTS

At 6-year follow-up, data were collected from practice records of 696 patients (77%). For those who had died, we censored their data at the point of death and cause of death was established. There were no significant differences between the intervention and control practices in either total (OR 0.83 (95% CI 0.54 to 1.28)) or cardiovascular hospital admissions (OR 0.91 (95% CI 0.49 to 1.65)). We confirmed mortality status of 886 of the original 903 patients (98%). There were no significant differences in mortality (15% in intervention and 16% in control) or in the proportions of patients above target control for systolic blood pressure or total cholesterol.

CONCLUSIONS

Initial significant differences in the numbers of total and cardiovascular hospital admissions were not maintained at 6 years and no differences were found in mortality or blood pressure and cholesterol control. Policymakers need to continue to assess the effectiveness of previously efficacious programmes.

TRIAL REGISTRATION NUMBER

Current Controlled Trials ISRCTN24081411.

Nanoscale anisotropic plastic deformation in single crystal aragonite

The nanoscale anisotropic elastic-plastic behavior of single-crystal aragonite is studied using nanoindentation and tapping mode atomic force microscopy imaging. Force-depth curves coaxial to the axis exhibited load plateaus indicative of dislocation nucleation events. Plasticity on distinct slip systems was evident in residual topographic impressions where four pileup lobes were present after indentation with a conospherical probe and distinct, protruding slip bands were present after indentation with a Berkovich pyramidal probe. A finite element crystal plasticity model revealed the governing roles of the {110}<001>slip system family, as well as the (100)[010], (100)[001], (010)[100], (010)[001], (001)[100] and (001)[010] systems.

Clinical interpretation of ultrasound biometry for dating and for assessment of fetal growth using a wheel and chart: is it sufficiently accurate?

OBJECTIVES

To investigate how accurately practicing obstetricians (experts) can apply dating rules and compare the interpretation of gestation-sensitive ultrasound data with those of a computer system.

SUBJECTS

Seventeen practicing obstetricians. Members of the Royal College of Obstetricians and Gynaecologists, from 14 different units throughout the UK.

DESIGN

Six cases with menstrual and ultrasound data together with identical ultrasound charts and obstetric wheels.

MAIN OUTCOME MEASURES

Concordance between the calculated estimated date of delivery (EDD) and growth assessment provided by the experts and the computer system.

RESULTS

The calculation of the EDD by the experts was imprecise (59% within 3 days overall). Concordance with the computer calculation was poorest when the ultrasound measurements lay close to the upper or lower centile lines (average 7% within 3 days of the computer). Interpretation of growth showed good concordance with the computer when gestation was not critical to the interpretation (94%), but very poor when gestation was critical (7%).

CONCLUSIONS

Calculation of EDD by means of an obstetric wheel and charts is not precise. Compared with the computer system, these errors have a significant effect on the subsequent interpretation of growth scans when the data are borderline. A computer system provides the more accurate method for interpreting gestation-sensitive ultrasound biometry.

Tarsal navicular stress fracture in athletes

Stress fracture of the tarsal navicular bone is now frequently recognised. The majority of navicular stress fractures are partial fractures in the sagittal plane. They occur mainly in track and field athletes. A number of theories regarding the aetiology of this fracture have been proposed. Athletes with a history of vague, activity-related midfoot pain, with associated tenderness over the dorsal proximal navicular ('N' spot) should be suspected of having a navicular stress fracture. Plain radiography frequently fails to demonstrate the fracture, thus radionuclide scanning is the investigation of choice to detect navicular stress injury. A computed tomography (CT) scan should be performed to confirm the presence of the fracture. Various methods of treatment have been employed. A minimum of 6 weeks of strict non-weightbearing cast immobilisation is the treatment of choice. After removal of the cast, a further 6 week programme of rehabilitation with a graduated return to activity, joint mobilisation and soft tissue massage is required. Surgery for nonunion or delayed union is rarely required if initial treatment is appropriate.

Outcome of conservative and surgical management of navicular stress fracture in athletes. Eighty-six cases proven with computerized tomography

Eighty-two athletes with 86 clinical navicular stress fractures, all imaged with computerized tomography, were followed for an average of 33 months (range, 6 to 108) after diagnosis. Initial treatment consisted of at least 6 weeks of nonweightbearing cast immobilization for 22 fractures, at least 6 weeks of limitation of activity with continued weightbearing for 34 fractures, and a period of less than 6 weeks of conservative treatment for another 19 fractures. Five patients attempted to continue playing sports. Six patients had immediate surgery. Nineteen of 22 patients (86%) who had initial non-weightbearing cast immobilization treatment returned to sports, compared with only 9 of 34 patients (26%) who initially continued weightbearing with limited activity (P < 0.001). After failure of the latter treatment, successful outcomes were seen for 6 of 7 patients (86%) treated with nonweightbearing cast immobilization, while 11 of 15 patients (73%) who had one surgical procedure were able to return to sports. These results indicate that nonweightbearing cast immobilization is the treatment of choice for navicular stress fractures. Also, this treatment compares favorably with surgical treatment for patients who present after failed weightbearing treatments. Computerized tomographic appearances of healing fractures do not necessarily mirror clinical union, and postimmobilization management should be monitored clinically.

Nucleotide sequences of the coat protein genes and flanking regions of cucumber mosaic virus strains C and WL RNA 3

Several strains of cucumber mosaic virus (CMV) have been classified, and nucleic acid hybridization data indicate that these strains differ widely in nucleotide sequence. We have constructed cDNA clones of the coat protein coding regions of CMV strains C and WL, and have compared the nucleotide sequences of the RNA 3 intergenic region, coat protein gene, and 3' untranslated region with published CMV sequences from the same regions of the Q, D and Y strains. These comparisons show that the C and WL strains belong to different CMV subgroups, and that the subgroups are more closely related in sequence than suggested by previous nucleic acid hybridization studies.