Variations in population health status. Non-response rates were not reported.
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Data Collection↗
Biomedical subjects
A Bowling
Publications and source records attributed to A Bowling.
What determines the choice of procedure in stress incontinence surgery? The use of multilevel modeling.
The purpose of this study was to identify the determinants of choice of surgical procedure (anterior colporrhaphy, colposuspension, or needle suspension) to treat stress incontinence in women. We used multilevel modeling of data on 271 patients in 18 hospitals in England in 1993-94. Patient-related factors included sociodemographic details, anatomical diagnosis, symptom severity, symptom impact, previous treatment, parity, comorbidity, and general health status. Surgeon-related factors were specialty, grade, and annual volume of procedures undertaken. Hospital teaching status was considered. Some patient-related factors were associated with choice of procedure: women with a concomitant genital prolapse, with a history of high parity, and with no previous nonsurgical treatment were more likely to undergo an anterior colporrhaphy than a colposuspension or needle suspension (although this finding could be confounded by surgical specialty). In addition, women were more likely to be treated by colposuspension if their surgeon specialized in incontinence surgery (measured by annual volume of cases). Finally, being treated by needle suspension depended on there being a consultant surgeon familiar with the procedure at the hospital attended. While choice of surgical procedure depends partly on the patient's anatomical diagnosis, it is also dependent on the specialty of the surgeon whom she consults and the hospital that she attends. This variability, in turn, could have implications for the patient (as the relative effectiveness of the different procedures is unknown) and for the purchasers of care (as the relative cost-effectiveness of procedures is also unknown).
Adult↗
Impact of surgery for stress incontinence on the social lives of women.
OBJECTIVE: To assess the feasibility of collecting disease-specific and generic data on the impact of surgery on the social lives of women with stress incontinence; to describe the social impact of surgery in a representative group; and to determine the effect of timing on the assessment of outcome. DESIGN: Longitudinal study; questionnaires before and three, six, and twelve months after surgery. SETTING: Eighteen hospitals in North Thames region. PARTICIPANTS: Four hundred and forty-two women undergoing surgery for stress incontinence between January 1993 and June 1994. MAIN OUTCOME MEASURES: Post-operative recovery time, stress incontinence symptom impact index, activities of daily living, and cost of protection. RESULTS: Post-operative recovery was uneventful for most women, but three months after surgery 24% of those in paid employment beforehand were still on sick or unpaid leave. Most women (75%) reported that stress incontinence had less adverse impact on their lives three months after surgery, though 18% reported no change, and 7% felt life was worse. The likelihood of improvement was similar regardless of whether pre-operative urodynamic studies had been conducted. The extent of improvement was dependent on pre-operative severity. Similar findings were obtained six and twelve months after surgery. After an initial slight but nonsignificant deterioration in their ability to carry out activities of daily living, women gained a slight benefit from surgery (proportion with no or only slight limitation rose from 72% to 82%; P=0.0001). The mean cost of protection (pads and towels) fell from 8.59 pound sterling a month before surgery to 2.99 pound sterling a month one year after surgery, by which time 68% of women were not using protection. In contrast, 11% were still spending over 10 pound sterling a month. CONCLUSIONS: It is possible to collect standard data on the impact of surgery on social functioning and, thus, provide women with better information on likely outcomes. The benefits of pre-operative urodynamic investigations need to be assessed. The stability of the outcome measures over the first post-operative year suggest that outcomes need to be assessed only once and at any time from three to twelve months after the operation.
Activities of Daily Living↗
Impact of surgery for stress incontinence on morbidity: cohort study.
OBJECTIVES: To describe the impact of surgery for stress incontinence on the severity of symptoms, other mental and physical symptoms, and overall health. To describe the incidence of postoperative complications. DESIGN: Prospective cohort study; questionnaires completed by patients before and 3, 6, and 12 months after surgery. Questionnaires completed by surgeons both before and after surgery. SETTING: 18 hospitals in the North Thames region. SUBJECTS: 442 women treated surgically for stress incontinence between January 1993 and June 1994. 367 women returned the 3 month questionnaire; 364 returned the 6 month questionnaire; and 359 returned the 12 month questionnaire. 49 surgeons provided perioperative information on 285 of the 442 women and postoperative information on 278. MAIN OUTCOME MEASURES: Stress incontinence symptom severity index, other urinary symptoms, bowel function, mental health, complications, global measures. RESULTS: Most women (288; 87%) reported an improvement in the severity of their stress incontinence, though only 92 (28%) were cured (continent). These improvements persisted for at least 12 months. The likelihood of improvement was similar regardless of whether urodynamic pressure studies had been conducted before surgery. Following surgery, women were less likely to suffer from urinary frequency, nocturia, postvoid fullness, dysuria, and urgency. While mental health improved for 194 (71%), a quarter of women reported deterioration. Only 37 (10%) were satisfied with postoperative pain control. A third experienced one or more complications while in hospital, most commonly difficulty urinating. This problem affected 1 in 11 women after discharge. A year after surgery two thirds of women reported feeling better (251; 72%), that the outcome met or exceeded their expectations (230; 66%), and that they would recommend the operation to a friend in a similar situation (239; 68%), and that they would recommend the operation to a friend in a similar situation (239; 68%). Surgeons tended to be more optimistic about the effects of surgery; they were satisfied with the outcome in 176 (85%) cases and would again treat 245 (94%) of the women as they had done previously. CONCLUSIONS: Although surgery reduces the severity of stress incontinence it is not as effective as current textbooks suggest. Women considering surgery should be provided with more accurate information on the likelihood of an improvement in symptoms and the occurrence of complications, including postoperative pain. Urgency and urge incontinence should not be considered contraindications to surgery. The need for urodynamic assessment before surgery should be reappraised.
Cohort Studies↗
Rationing health care. Access to treatment should be equal, regardless of age.
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Age Factors↗
Activities of daily living: changes in functional ability in three samples of elderly and very elderly people.
OBJECTIVES: to investigate changes in functional ability and physical health, psychiatric morbidity, life satisfaction, service use and social support. DESIGN: a structured interview survey of three samples of elderly people living at home at two points in time. The three samples comprised one census of people aged 85 and over [City (of London) and Hackney], and two random samples of people aged 65-84 (City and Hackney and Braintree). The follow-up interviews took place 2.5-3 years after the baseline interviews. SETTING: City and Hackney (East London) and Braintree (Essex). Respondents were interviewed at home by one of 12 trained interviewers. SUBJECTS: 630 people aged 85+ at baseline (70% response rate) and 78% of survivors re-interviewed at follow-up; 464 people aged 65-84 in Hackney at baseline (67% response rate), and 83% of survivors re-interviewed; 276 people aged 65-84 in Braintree at baseline (82% response rate), and 78% of survivors re-interviewed. MAIN OUTCOME MEASURES: scores on scales of functional ability, psychiatric morbidity, life satisfaction and social support, and items measuring number and type of health symptoms and services used. CONCLUSIONS: decreasing levels of physical functioning were associated with poor mental health, trouble with feet and problems with muscles and joints. There were no associations with level of physical functioning and use of rehabilitative or general medical services, use of social worker or carer relief. Few respondents used preventive or rehabilitation services.
Activities of Daily Living↗
Evaluation of specialists' outreach clinics in general practice in England: process and acceptability to patients, specialists, and general practitioners.
OBJECTIVES: The wider study aimed to evaluate specialists' outreach clinics in relation to their costs, processes, and effectiveness, including patients' and professionals' attitudes. The data on processes and attitudes are presented here. DESIGN: Self administered questionnaires were drawn up for patients, their general practitioners (GPs) and specialists, and managers in the practice. Information was sought from hospital trusts. The study formed a pilot phase prior to a wider evaluation. SETTING: Nine outreach clinics in general practices in England, each with a hospital outpatient department as a control clinic were studied. SUBJECTS: The specialties included were ear, nose, and throat surgery; rheumatology; and gynaecology. The subjects were the patients who attended either the outreach clinics or hospital outpatients clinics during the study period, the outreach patients' GPs, the outreach patients' and outpatients' specialists, the managers in the practices, and the NHS trusts which employed the specialists. MAIN OUTCOME MEASURES: Process items included waiting lists, waiting times in clinics, number of follow up visits, investigations and procedures performed, treatment, health status, patients' and specialists' travelling times, and patients' and doctors' attitudes to, and satisfaction with, the clinic. RESULTS: There was no difference in the health status of patients in relation to the clinic site (ie, outreach and hospital outpatients' clinics) at baseline, and all but one of the specialists said there were no differences in casemix between their outreach and outpatients' clinics. Patients preferred, and were more satisfied with, care in specialists' outreach clinics in general practice, in comparison with outpatients' clinics. The outreach clinics were rated as more convenient than outpatients' clinics in relation to journey times; those outreach patients in work lost less time away from work than outpatients' clinic patients due to the clinic attendance. Length of time on the waiting list was significantly reduced for gynaecology patients; waiting times in clinics were lower for outreach patients than outpatients across all specialties. In addition, outreach patients were more likely to be first rather than follow up attenders; rheumatology outreach patients were more likely than hospital outpatients to receive therapy. GPs' referrals to hospital outpatients' clinics were greatly reduced by the availability of outreach clinics. Both specialists and GPs saw the main advantages of outreach clinics in relation to the greater convenience and better access to care for patients. Few of the specialists and GPs in the outreach practices held formal training and education sessions in the outreach clinic, although over half of the GPs felt that their skills/expertise had broadened as a result of the outreach clinic. CONCLUSIONS: The processes of care (waiting times, patient satisfaction, convenience to patients, follow up attendances) were better in outreach than in outpatients' clinics. However, waiting lists were only significantly reduced for gynaecology patients, despite both GPs and consultants reporting reduced waiting lists for patients as one of the main advantages of outreach. Whether these improvements merit the increased cost to the specialists (in terms of their increased travelling times and time spent away from their hospital base) and whether the development of what is, in effect, two standards of care between practices with and without outreach can be stemmed and the standard of care raised in all practices (eg, by sharing outreach clinics between GPs in an area) remain the subject of debate. As the data were based on the pilot study, the results should be viewed with some caution, although statistical power was adequate for comparisons of sites if not specialties.
Attitude of Health Personnel↗
Discriminative power of the health status questionnaire 12 in relation to age, sex, and longstanding illness: findings from a survey of households in Great Britain.
STUDY OBJECTIVE: To assess the ability of the health status questionnaire 12 (HSQ-12) to discriminate between older and younger age groups, its appropriateness for use with an older population in terms of the spread of responses across categories, floor or ceiling effects, and its ability to discriminate between those with and without a reported longstanding illness and type (sensitivity and specificity). DESIGN AND SETTING: The vehicle for the study was the Office for National Statistics (ONS) omnibus survey in Great Britain. The sampling frame was the British post-code address file of "small users", stratified by region, and socioeconomic factors. This file includes all private household addresses. The postal sectors were selected with probability proportional to size. Within each sector 30 addresses were selected randomly. The number of selected addresses was 3000. PARTICIPANTS: Altogether 1912 adults aged 16 and over were interviewed in person in their own homes, giving a response rate of 72%. MEASURES: The HSQ-12, and the ONS general household survey questions on longstanding illness; the ONS omnibus standard sociodemographic items. MAIN RESULTS: There were exceptionally high rates of item response in all age groups. The score differences by construct (e.g., age group, sex, longstanding illness) were in the expected directions with statistically significant age gradients. Age was associated with most of the HSQ-12 domains, although this association had interactions with longstanding illness or sex. The differences in HSQ-12 scores with reported longstanding illness and type of longstanding illness made theoretical sense, which supports the discriminative power of the scale. The frequency distributions for HSQ-12 items in relation to age and sex, and by reporting of longstanding illness are also presented here in order to demonstrate ceiling effects. Most respondents in all age groups achieved high (good) scores on the "social functioning" subscale. The HSQ-12 had good results for specificity when tested against reporting of a longstanding illness, although this was at the expense of sensitivity. CONCLUSIONS: The results support the use of the HSQ-12 with older populations, particularly for those with chronic illnesses, although it will reveal relatively few problems among younger populations. The results presented here indicate that it will require supplementation with more sensitive disease and/or domain specific scales in the areas of interest or intervention, but it provides an acceptable, brief, core measure of health related quality of life. This paper present the first British normative data using the HSQ-12.
Adolescent↗
Health care rationing: the public's debate.
OBJECTIVE: To elicit the views of a large nationally representative sample of adults on priorities for health services. DESIGN: An interview survey based on a random sample of people aged 16 and over in Great Britain taken by the Office of Population Censuses and Surveys. SUBJECTS: The response rate to the survey was 75%, and the total number of adults interviewed was 2005. MAIN OUTCOME MEASURES: A priority ranking exercise of health services supplemented with attitude questions about priorities, who should set priorities, and budget allocation. RESULTS: The results of the main priority ranking exercise of 12 health services showed that the highest priority (rank 1) was accorded to "treatments for children with life threatening illness," the next highest priority (rank 2) was accorded to "special care and pain relief for people who are dying." The lowest priorities (11 and 12) were given to "treatment for infertility" and "treatment for people aged 75 and over with life threatening illness." Most respondents thought that surveys like this one should be used in the planning of health services. CONCLUSIONS: The public prioritise treatments specifically for younger rather than older people. There is some public support for people with self inflicted conditions (for example, through tobacco smoking) receiving lower priority for care, which raises ethical issues.
Adolescent↗
Sociodemographic and symptomatic characteristics of women undergoing stress incontinence surgery in the UK.
OBJECTIVES: To: (i) describe the sociodemographic characteristics of women undergoing surgery for stress incontinence in the UK and the ways in which they differ from women of a similar age in the general population: (ii) the severity and impact of their symptoms and their expectations of surgery and: (iii) their general state of health. PATIENTS AND METHODS: A prospective cohort study was carried out on 442 women undergoing surgery for stress incontinence in 18 hospitals in the North Thames region between January 1993 and June 1994. Sociodemographic factors, stress incontinence severity, symptom impact scores, and general health status were measured. RESULTS: Women undergoing surgery for stress incontinence were similar to their peers in the general population apart from being more likely to have smoked (61.4 against 51.1%), to have subsequently given up (39.5 and 25.3%) and to be of higher parity (> or = 4; 19.7 and 12.0%). Most women (81.6%) reported moderate to very severe stress incontinence. The impact of symptoms was correlated positively with severity (P < 0.001) after accounting for its positive correlation with mental health status (P < 0.005), socioeconomic status (P < 0.05) and its negative correlation with age (P < 0.02). Many women also suffered from other urinary symptoms including urgency (76%) and frequency (42.3%). Apart from their urinary problems, women were in good health (77% reported no or only mild coexistent conditions). However, a very high proportion (34.2%) had previously undergone a hysterectomy. CONCLUSIONS: These results suggest that women undergoing stress incontinence surgery are remarkably similar to their peers, apart from their primary condition. The effect that stress incontinence has on women's lives depends not only on the severity of the problem but also on other factors. The high rate of previous hysterectomy warrants further study.
Adult↗
Appropriateness of admission and the last 24 hours of hospital care in medical wards in an east London teaching group hospital.
OBJECTIVE: To assess the rates of inappropriateness of admission and last day of care on adult medical wards in an east London hospital, to identify associations with any inappropriateness and to assess what services need to be improved or provided if patients assessed as "inappropriate" are to be more appropriately placed in the future. DESIGN: From the patients' medical notes, nursing notes and ward charts, a trained reviewer with nursing and university qualifications collected concurrent information about each patient's first 24 hours as an in-patient and about the last 24 hours of care preceding discharge. Patients were also interviewed before discharge and 7-10 days after discharge, and their health status and level of satisfaction about the discharge process assessed. SETTING: The three adult medical wards at the Homerton Hospital in Hackney, east London. This hospital is within the St Bartholomew's Hospital Teaching Hospital Group. SUBJECTS: The case-notes of a random sample of 625 adult in-patients were reviewed. END POINTS: Appropriateness of admission and last day of care. MAIN OUTCOME MEASURES: The main instrument used was the Appropriateness Evaluation Protocol (AEP). This is an instrument devised to assess the appropriateness of adult patient admission to, and specific days of care in, acute hospital beds through case-note review against a structured set of criteria. RESULTS: The study presented here reported that 31% of in-patient admissions to adult medical wards in an east London hospital were inappropriate, and also that 66% of the last days of stay were inappropriate. CONCLUSIONS: There is clearly considerable room for improvement in relation to cooperation between service providers in order to maximise efficient bed use. Delays due to waiting for medications from pharmacy, and the combination of more "inappropriate" cases wanting help from social services after discharge with the fact that many of them were still in hospital because they were waiting for these services to be organized, suggest that inappropriateness could be reduced through increased efficiency or increased provision in these areas. The study reported here is unique in its inclusion of patient interview data.
Adult↗
The effects of illness on quality of life: findings from a survey of households in Great Britain.
STUDY OBJECTIVE: To obtain national population norms on pertinent domains of quality of life, and the relative importance of these domains to people with reported longstanding illness. DESIGN AND SETTING: The vehicle for the study was the Office of Population Censuses and Surveys omnibus survey in Great Britain. The sampling frame was the British postcode address file of "small users", stratified by region and socioeconomic factors. This file includes all private household addresses. The postal sectors are selected with probability proportional to size. Within each sector 30 addresses are selected randomly with an target size of 2000 adults. PARTICIPANTS: The total number of adults interviewed was 2033 (one per sampled household), resulting in 2031 usable questionnaires, and representing a response rate of 77%. MAIN RESULTS: Of those who reported a longstanding illness, the most common, freely mentioned, first most important effects of the longstanding illness on their lives were (in order of frequency) ability to get out and about/stand/walk/go out shopping, being able to work/find a job, and effects on social life/leisure activities. Analysis of the areas of life affected by longstanding illness, showed considerable variation in relation to the condition. For example, respondents with mental health disorders (mainly depression) were most likely to report as the first most important effect the availability of work/ability to work, followed by social life/leisure activities; respondents with digestive and endocrine (for example, diabetes) disorders were most likely to report dietary restrictions; while respondents with cardiovascular disease, respiratory, and musculoskeletal disorders were most likely to report ability to get out and about/stand/walk/go out shopping. CONCLUSIONS: These results support the current trend of developing disease specific health related quality of life questionnaires rather than using generic scales.
Activities of Daily Living↗
What things are important in people's lives? A survey of the public's judgements to inform scales of health related quality of life.
The research presented here aimed to obtain population norms on pertinent domains of quality of life and health related quality of life, and the relative importance of these domains to people. The OPCS Omnibus Survey was used as the vehicle for the study. This is a monthly survey of a random sample of 2000 adult members of the population in Great Britain, based on a random sample of households. The data was collected for a one month period. The response rate to the survey was 77%. In response to a generic question about the five (priority ordered) most important things in their lives (good or bad), respondents were most likely to freely mention as the first most important thing in their lives relationships with family or relatives, followed by their own health, the health of another (close) person and finances/standard of living/housing. When responses relating to respondents' priority ranked areas 1-5 were combined, the most frequently mentioned area of life was finances/standard of living/housing, followed by relationships with family and friends, own health, the health of close others and social life/leisure activities. Thus, different distributions were obtained depending on whether priority ordering or frequency with which item was mentioned was analysed. Of those who reported a longstanding illness, the conditions which were most likely to be reported as affecting their lives were respiratory conditions, joint disorders and heart and circulatory diseases. The most commonly freely mentioned first most important effects of the longstanding illness on their lives were (in order of frequency) ability to get out and about/stand/walk/go out shopping, being able to work/find a job and effects on social life/leisure activities (based on office coding from verbatim responses recorded on the questionnaire). When the responses relating to respondents' priority ranks 1-5 were combined, the most frequently mentioned area of life affected was ability to get out and about/stand/walk/go out shopping, followed by social life/leisure activities, and availability of work/ability to work. Again, differences in distributions were obtained depending on the method of analysis. Further investigations also revealed differences according to the method of questioning and coding (respondent vs office). When respondents selected their own codes from a showcard in relation to health effects, there were some discrepancies with their (office coded) verbatim replies (which were recorded by the interviewer before they saw the showcard, for later office coding). The showcard had the effect of prompting them, and the then most commonly mentioned first most important effects of the longstanding illness on their lives were (in order of frequency) pain, tiredness/lack of energy/lethargy, social life/leisure activities, and availability of work/ability to work. This discrepancy illustrates the biasing influence of using showcards, in comparison with the open coding of actual verbatim responses back in the office (on the assumption that the latter are more valid-unprompted-responses). Analysis of the domains included in the most popularly used health status scales, which are used to measure health related quality of life, revealed that several items ranked as important by the public were missing.
Adolescent↗
Volunteers or victims: patients' views of randomised cancer clinical trials.
Randomised clinical trials are essential for the objective evaluation of different treatment strategies in cancer. However, in the field of oncology, very few of the eligible patients are entered into trials, and most treatments have only been tested on a small percentage of patients. For doctors, a major deterrent to participating in trials is the lack of resources--particularly time, but often also the local facilities. This report suggests that patients themselves are willing to take part in clinical research, and are attracted by being treated by a doctor with a specialist interest in the disease and encouraged by the possibility that their progress will be monitored closely. With the recent NHS changes, it is timely for the Department of Health and other national health departments to consider carefully what can be done to ensure that no new treatments are adopted without effective evaluation. This will require departments of health to identify and implement ways to facilitate accrual of appropriate numbers of patients onto research protocols (whether non-randomised phase I or phase II studies or large, multicentre phase III trials) over short time periods.
Adolescent↗
Involving the public: practical and ethical issues.
There has been little theoretical or methodological debate about health care rationing. This paper discusses the technical, ethical and political issues surrounding health services priorities and rationing debates in the context of a survey that the authors carried out in the former City and Hackney Health District, which asked the public, and doctors, to prioritise health services. In particular, the issue of the implementation of findings from consultation exercises is raised.
Community Participation↗
Genetic study of hyperkalemic periodic paralysis in horses.
Four Quarter Horses (1 stallion, 3 mares) with hyperkalemic periodic paralysis were mated to unaffected horses to determine the genetic basis of the disease. The affected stallion was bred to 11 unaffected mares (4 Quarter Horses, 1 Arabian, 2 Standardbreds, and 4 Thoroughbreds). The 3 affected mares were bred to an unaffected Quarter Horse stallion. Of the 15 offspring obtained from these matings, 9 were affected with hyperkalemic periodic paralysis, and 6 were unaffected, consistent with an autosomal dominant mode of inheritance. Diagnosis was established by results of oral administration of potassium chloride and demonstration of characteristic clinical signs accompanied by hyperkalemia. Oral administration of potassium chloride resulted in marked increases in plasma potassium concentrations in affected and unaffected foals, although hyperkalemia was associated with clinical signs of hyperkalemic periodic paralysis in the affected foals. Evaluation of blood samples from affected and unaffected offspring revealed no linkage with erythrocyte and serum markers at 24 loci.
Animals↗
Changes in life satisfaction over a two and a half year period among very elderly people living in London.
Research evidence concerning the contributions of social networks and support to the subjective wellbeing (i.e. life satisfaction) of older persons is not consistent. This paper reports the results of an investigation of the effects life satisfaction at baseline, social network type and health status, on life satisfaction at follow-up at two and a half years later among people ages 85+ living in the East end of London. The percentage of the total variation in overall life satisfaction which was explained by the model was 47%. Baseline life satisfaction score explained most of this (43%), and the remaining variation was explained largely by functional status and age. Previous analyses of baseline life satisfaction reported that health and functional status had accounted for most of the variation between groups, far more than social network and support variables.
Activities of Daily Living↗
Explorations in consultation of the public and health professionals on priority setting in an inner London health district.
The methodology for eliciting the public's priorities for health services is in its infancy. This paper presents the results from a series of exploratory exercises on priorities in City and Hackney. The authors surveyed the opinions of members of community groups and tenants' associations, and compared their responses with those of a random sample of the public as well as general practitioners, consultants and public health doctors. This revealed some disagreement on priorities between these groups. The public, in consistency with the results from other studies, prioritised perceived life saving technologies as high, in contrast to community services and services for people with mental illnesses, which they prioritised as medium to low, in contrast to all the samples of doctors; the public also prioritised health education and family planning as fairly low, as did the GPs and consultants, in contrast to the public health doctors who prioritised them as high. Before DHAs embark on these studies as part of priority setting, they must answer the question: "what will they do if they disagree with the results?"
Attitude of Health Personnel↗