There have been few prospective epidemiological studies of asymptomatic hyperglycaemia as a risk factor for cardiovascular disease and all causes mortality in women. Gender-specific all causes, cardiovascular disease (CVD), ischaemic heart disease (IHD) and stroke mortality rates and relative risks for asymptomatic hyperglycaemics (top 5%) have been compared to normoglycaemics (bottom 95%) during a mean follow-up of 11.6 years (range 10-14) among 4696 men and 5714 women aged 45-64 at entry in the west of Scotland. Univariate analysis showed that asymptomatic hyperglycaemia was associated with increased risk of all causes, CVD, IHD and stroke mortality in both genders. The degree of this association was greater in women than in men. Using multiple logistic regression (MLR) analysis to take into account differences in age, systolic (SBP) and diastolic blood pressure (DBP), serum cholesterol, body mass index (BMI), and cigarette smoking, high causal blood glucose level was still a significant risk factor for CVD mortality in both genders. It was also a significant risk factor for all causes, IHD and stroke mortality in women but not in men. This study shows that to a lesser degree asymptomatic hyperglycaemia shows the same gender differentials in risk of mortality as have been demonstrated amongst known diabetics.

Cardiovascular Diseases↗

PubMed1994

Doctor-shopping in Hong Kong: implications for quality of care.

Doctor-shopping is defined as the changing of doctors without professional referral in the same illness episode. Two surveys on samples of patients attending Government Out-Patient Departments (GOPDs) in Hong Kong in 1989 (n = 869) and 1990 (n = 901) estimated the prevalence of shopping at nearly 40%, the main reason being a persistence of symptoms. Doctor-shoppers were likely to be younger with higher expectations of health care and who expressed dissatisfaction about aspects of the present service. In Hong Kong, patients perceive western medicine to be more effective and have high expectations of the effects of western drugs, in particular, in their administration by injection. Patients should be warned about iatrogenic health risks incurred from doctor-shopping; health education programmes are needed to modify unrealistic views about quality care. Health care providers in a mixed care system should promote greater continuity of care between doctors and both the public and private sectors, and identify and resolve problems which may be responsible for discontinuity of care.

Adult↗

PubMed1994

Bronchial responsiveness in children exposed to atmospheric pollution in Hong Kong.

Bronchial responsiveness was studied by histamine challenge in 423 school children with mean (SEM) age of 10.85 (0.05) years living in two districts of Hong Kong with contrasting levels of air pollution. Differences between districts of residence were observed, with a higher prevalence of bronchial hyperreactivity (BHR) in children living in the more polluted district (chi 2 = 7.74, df = 3, p = 0.052). Bronchial hyperreactivity was defined as a 20 percent or greater drop in FEV1. The district effect remained after exclusion of children with a history of wheeze and those diagnosed asthmatic for prevalence of BHR (chi 2 = 8.93, df = 3, p = 0.030) and for degree of bronchial reactivity (BR) after adjustment for other socioeconomic factors and smoking in the home (z = 1.97, p = 0.049). Bronchial reactivity was defined as the percentage drop in FEV1 per cumulative histamine dose from postsaline to end dose. The results demonstrate that studies on bronchial responsiveness can be used to assess the effects of air quality on the respiratory health of children and will be employed to measure the impact of new air quality control measures in Hong Kong.

Air Pollution↗

PubMed1994

Coordinating and standardizing long-term care: evaluation of the west of Scotland shared-care scheme for hypertension.

BACKGROUND: The long-term management of patients with chronic conditions such as hypertension presents problems for the health services. Shared care addresses these by coordinating care and defining responsibilities. AIM: This study set out to investigate the feasibility, acceptability and cost effectiveness of shared general practitioner-hospital care for well-controlled hypertensive patients in an urban area by comparing three matched groups of patients. METHOD: A total of 554 outpatient clinic attenders, considered suitable for shared care by their consultant, were randomly allocated to shared care or follow up in the outpatient clinic; a third group of 277 patients was selected from a nurse practitioner clinic. Main outcome measures were the proportion of patients in the second year of follow up who had undergone a complete review (blood pressure measurement, serum creatinine level result and electrocardiograph report), acceptability to patients and general practitioners as assessed by questionnaire, and cost per complete review in year two (National Health Service and patient costs). RESULTS: After two years 220 (82%) shared care patients had had a complete review compared with 146 (54%) outpatient clinic attenders and 202 (75%) nurse practitioner clinic attenders. Blood pressure control was similar in each group. Of 297 general practitioners invited, 85% wished to participate in the study; 61% of questionnaire respondents subsequently wanted shared care to continue while 25% were unsure. Half of the patients receiving shared care preferred this method of follow up. The rank order of cost-effectiveness ratios was shared care, nurse practitioner care and conventional outpatient care, relative differences being most marked when only patient costs were considered. CONCLUSION: Shared care for hypertension is feasible in an urban setting, acceptable to the majority of participants and is a cost-effective method of long-term follow up.

Chronic Disease↗

PubMed1993

How do we measure consumer opinions of outpatient clinics?

Consumer opinion of care in outpatient departments is increasingly seen as an important measure in the process of quality assurance. However, there are many ways of measuring consumer opinion. The aim of this series of studies was to compare different methods so as to throw light on when and where to use them. What is revealed is that there is no one right answer; instead, a combination of methods will allow the development of a balanced view of consumer opinion and an agenda for action.

Age Factors↗

PubMed1993

Gender differential in all-cause and cardiovascular disease mortality.

The gender differential in mortality from all causes, cardiovascular disease (CVD), ischaemic heart disease (IHD) and stroke during the mean follow-up of 11.6 years (range 10-14) was examined among 4696 men and 5714 women aged 45-64 at entry in West of Scotland. Overall mortality was 19.4/1000 person-years of observation among men and 10.8/1000 person-years among women. A multiple logistic regression model was used to control the influence of gender, along with seven other cardiovascular risk factors simultaneously. The risk factors considered were age, systolic (SBP) and diastolic blood pressure (DBP), serum cholesterol, causal blood glucose, body mass index (BMI) and cigarette smoking. Both the prevalence of risk factors and relative mortality risk associated with them differed by gender. Adjustment slightly reduced the gender differential in overall mortality from 2 to 1.9 and from 1.5 to 1.4 for stroke deaths. Multiple logistic regression increased minimally the gender differential for mortality from 2.4 to 2.8 for CVD and from 2.8 to 3.4 for IHD, suggesting that these cardiovascular risk factors do not account for the overall gender difference in mortality rates. Age, SBP, DBP, blood glucose and cigarette smoking were significant predictors of mortality for both genders. Serum cholesterol was a statistically significant predictor of CVD death only for men.

Age Factors↗

PubMed1993

Using the Community Health Index, general practitioner records and the National Health Service Central Registry for a 14 year follow-up of a middle-aged cohort in the west of Scotland.

Record linkage provides an opportunity for relatively inexpensive follow-up in cohort studies. Most studies have used hospital records. However, the Community Health Index, which is a computer-held list of all patients registered with General Practitioners (GPs), now offers opportunities for measuring morbidity at the primary care level. Searching for patients individually on this computer-held Index, we identified 96% of a middle-aged cohort recruited 14 years earlier in a longitudinal study in the West of Scotland. Of these, information was obtained for 78% through direct postal survey and for 87% through contact with GPs. In total, follow-up information was obtained on 903 (92%) of those thought to be alive. The National Health Service Central Registry records data and cause of death and will pass this information to special studies which have 'flagged' individuals' records. Seven per cent of the deaths in this sample had been missed by this process. This may need to be taken into account in previous studies of mortality for this cohort. New studies could expect successful long-term follow-up through record linkage to the Index or the Registry, and automatic record linkage with the Index would be worth investigating.

Cohort Studies↗

PubMed1993

Collecting, communicating and using information.

Explore the source record for details and available documents.

Computers↗

PubMed1992

Trends in mortality from stroke in Scotland, 1950-1986.

The Scottish Registrar General's Annual Reports have been used to study trends in mortality from stroke in Scotland during 1950-1986 in those aged 45 to 74. In 1950 the age-adjusted mortality rate was 347.4 per 100,000 population for men and 360.8 for women, falling to 199.6 for men and 155.8 for women in 1986. This downward trend has increased from 1976 for males. The average annual decline in age-adjusted mortality from stroke over the 37-year period was 4.0 per 100,000 in males and 5.5 in females. This reduction in death rates was proportionally higher for women compared with men in all age groups over 55 years. As with cardiovascular deaths, mortality from stroke was lower in the east than in the central region and west of Scotland. The reduction in mortality resulted in a substantial 'saving' of lives, estimated at 12,500 between 1980 and 1984.

Age Factors↗

PubMed1992

The quality and relevance of peripheral neuropathy data on a diabetic clinical information system.

Routinely collected peripheral neuropathy data entered on a diabetic clinical information system since 1979 have been audited for completeness, consistency, accuracy (inter-observer variation), validity by comparison with biothesiometry, and relevance by life table analysis for foot ulceration. Peripheral neuropathy was defined by a neuropathy disability score > or = 4. The data were 98% complete. Forty-nine of 3405 (1.4%) had inconsistent records. Agreement between observers for clinical examination was significant (p < 0.05) for aggregate neuropathy score and its individual components except the knee jerk: Kappa score for observer variation for neuropathy score 0.56 (95% confidence interval 0.36-0.76). There was good agreement between neuropathy defined as aggregate score > or = 4, and as combined vibration perception thresholds for both feet > 60 V: Kappa statistic 0.62 (95% confidence interval 0.44-0.80). The chance of developing a foot problem in 3 years increased from 3% for patients with a score of zero to 45% for people with a score of between 9 and 12. We conclude that the calculation of a clinical neuropathy score is a simple, valid and relevant method for diabetes care both in hospital and the community. When combined with palpation of peripheral pulses most patients at risk of foot ulceration can be identified allowing targeting of preventive chiropody and orthotic resources.

Diabetic Neuropathies↗

PubMed1992

Treatment of hyperthyroidism by radioactive iodine. Summary of a UK national survey prepared for the Royal College of Physicians Committee on Endocrinology and Diabetes.

Explore the source record for details and available documents.

Aftercare↗

PubMed1991

Studies on the respiratory health of primary school children in urban communities of Hong Kong.

The first stage of a 2-year survey of respiratory morbidity in primary school children was conducted in two districts of Hong Kong in April/May 1989. One group (2009) of children was from Kwai Tsing District, which had high levels of exhaust emission from factories. The other group (1837) was from Southern District where atmospheric pollution was considered to be relatively low. After adjustment for gender, age, socioeconomic factors, child smoking and exposure to parental smoking, the prevalence ratios of sore throat, evening cough, cough for more than 3 months, morning phlegm and wheezing were found to be significantly higher in Kwai Tsing. The difference between the districts is likely to be related to the environmental air quality. The study, which is continuing, will provide the basis for an evaluation of the impact of new low sulphur fuel regulations introduced in July 1990.

Acute Disease↗

PubMed1990

Clinical outcome and costs of care in radioiodine treatment of hyperthyroidism.

The long-term clinical outcome and costs of treatment of hyperthyroidism with radioiodine have been examined in two cohorts of patients from Sheffield and Scotland. The majority of patients in both series were considered to have Graves' disease. The Sheffield patients (660) were included in a trial of three radioiodine dose regimens of 3,500 (312), 7,000 (323) and 14,000 (25) rad determined using a formula for accurate dosimetry. The Scottish patients (3,920) drawn from five centres in Aberdeen, Dundee, Edinburgh, Glasgow and Inverness were treated using an arbitrary scale, for the activity of radioiodine administered, related to goitre size. Their results are grouped into five MBq 'dose' bands: 37-185, 186-370, 371-555, 556-740 and 741+. The proportion of patients with persistent hyperthyroidism was higher in both cohorts for low-dose radioiodine regimens, but 15-25% of patients who received high doses showed persistent hyperthyroidism. Early and late onset hypothyroidism was lower after low doses but differences between the treatment groups were small in terms of clinical benefit. Total morbidity at 10 years follow-up, in terms of hyperthyroidism, and hypothyroidism, was highest after low-dose therapy. There was little variation in total costs, but patient costs were lowest for the Scottish regimen and highest for low-dose therapy. A dose of at least 370-555 MBq which will ensure early elimination of hyperthyroidism will also limit the medical workload and total costs.

Adult↗

PubMed1989

Antithyroid drugs in the treatment of hyperthyroidism of Graves' disease: long-term follow-up of 434 patients. Scottish Automated Follow-Up Register Group.

A study of antithyroid drug (ATD) therapy with a mean follow-up period of 10 years (range 2-25) in 434 patients with Graves' disease has been made by linking hospital records with those of a central follow-up register. The majority (89%) were treated with carbimazole and 87% received combined therapy with triiodothyronine (T3) (73%) or thyroxine (T4) (14%). Sixty-one per cent were assessed for T3 suppression tests on completion of treatment, of whom 61% (95% CL, 55-67%) suppressed. The overall 5-year cumulative proportion developing recurrent hyperthyroidism was 54-62% with rates of 26-44% in suppressed patients and 65-79% in those not suppressed. In unsuppressed patients, most (72%) of the recurrences occurred within 1 year with only an additional 10% predicted up to 10 years. In suppressed patients 30% of recurrences occurred in the first year, 60% between 1 and 5 years and a further 10% between 5 and 10 years. Suppression with T3 is probably the best and cheapest predictor of outcome but has an accuracy of only 70% for both positive and negative tests which limits its usefulness in planning long-term follow-up and surveillance. A standard format should be adopted for the analysis and reporting of follow-up studies, based on actuarial methods of estimating the cumulative proportion with recurrences or other events, to facilitate comparisons between different centres.

Adult↗