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Biomedical subjects

A Scott

Publications and source records attributed to A Scott.

At least 109 records · Page 6Linked to original sources
PubMed1999

Measuring progress towards a primary care-led NHS.

BACKGROUND: The push towards a 'primary care-led' National Health Service (NHS) has far-reaching implications for the future structure of the NHS. The policy involves both a growing emphasis on the role of primary care practitioners in the commissioning of health services, and a change from hospital to primary and community settings for a range of services and procedures. Although the terminology has changed, this emphasis remains in the recent Scottish Health Service White Paper and its English counterpart. AIM: To consider three questions in relation to this policy goal. First, does the evidence base support the changes? Secondly, what is the scale of the changes that have occurred? Thirdly, what are the barriers to the development of a primary care-led NHS? METHOD: Programme budgets were compiled to assess changes over time in the balance of NHS resource allocation with respect to primary and secondary care. Total NHS revenue expenditure for the 15 Scottish health boards was grouped into four blocks or 'programmes': primary care, secondary care, community services, and a residual. The study period was 1991/2 to 1995/6. Expenditure data were supplied by the Scottish Office. RESULTS: Ambiguity of definitions and the absence of good data cause methodological difficulties in evaluating the scale and the appropriateness of the shift. The data that are available suggest that, at the aggregate level, there have been changes over time in the balance of resource allocation between care settings: relative investment into primary care has increased. It would appear that this investment is relatively small and from growth money rather than a 'shift' from secondary care. In addition, the impact of GP-led commissioning is variable but limited. CONCLUSION: General practitioners' (GPs') attitudes to the policy suggest that progress towards a primary care-led NHS will continue to be patchy. The limited shift to date, alongside evidence of ambivalent attitudes to the shift on the part of GPs, suggest that this is a policy objective that may not be achieved.

Delivery of Health Care↗
PubMed1998

Segregation analysis of idiopathic talipes equinovarus in a Texan population.

"Idiopathic" talipes equinovarus (ITEV) is a nonsyndromal congenital anomaly of one or both feet. Casting and surgery are often necessary to obtain correct foot alignment. In spite of treatment, residual deformities of the feet occur and calf muscles may be hypoplastic. The cause of ITEV is unknown but genetic factors have been postulated. Complex segregation analysis was performed on 173 ITEV families including 93 Caucasian and 48 Hispanic families. The recessive mixed model was the best fitting model and no differences were found based on ethnicity. These results confirm previous studies suggesting that there is a genetic component to the development of ITEV.

Clubfoot↗
PubMed1998

Genetic epidemiology study of idiopathic talipes equinovarus.

Previous genetic studies of idiopathic talipes equinovarus (ITEV) suggest an environmental and genetic component to the etiology of ITEV. The present study was undertaken to assess the role of causal factors in the development of ITEV. A total of 285 propositi were ascertained, with detailed family history information available in 173 cases and medical records on the remaining 112 propositi. Information was collected on specific prenatal, parental, and demographic factors. No racial heterogeneity was noted among any of the factors. The overall ratio of affected males to females was 2.5:1. The incidence of twinning among all propositi was significantly increased (P=0.006) above the expected population frequency. A family history of ITEV was noted in 24.4% of all propositi studied. These findings, in addition to the detailed analysis of 53 pedigrees with ITEV history, suggest the potential role of a gene or genes operating in high-risk families to produce this foot deformity.

Clubfoot↗
PubMed1998

Lipid and stress dependence of amphotericin B ion selective channels in sterol-free membranes.

The idea that amphotericin B (AmB) may not require sterols to form ion selective channels has recently been criticized on the grounds that egg phospholipids commonly used in experiments may contain small amounts of sterol which associate with AmB to form AmB/sterol pore channel structures. It was recently shown in this laboratory that modest osmotic stress can enhance the formation of AmB channels in sterol-free egg phosphatidylcholine (eggPC) membranes. We have tested AmB's ability to form ion channels/defects in synthetic palmitoyl oleoyl (POPC), dieicosenyl (DEPC) and natural eggPC osmotically stressed large unilamellar vesicles (LUV) using pyranine fluorescence detected ion/H+ exchange. These sterol-free POPC LUV exhibit greatly increased sensitivity to cation selective AmB channel formation when osmotically stressed; even more than eggPC. Under these stressed conditions, AmB activity was observed at [AmB]/POPC ratios as low as 3.5x10(-4), corresponding to about 34 AmB molecules/vesicle. DEPC vesicles were almost completely unresponsive, demonstrating a strong bilayer thickness dependence. These results prove conclusively that AmB can form sterol-free channels and do so within therapeutic concentration ranges (>0.5-10x10(-6) M) in a stress-dependent manner. This phenomenon may allow us to use osmotic stress changes in simple model systems to spectroscopically isolate and characterize the thus-far elusive AmB channel forming aggregate. In addition, this stress dependence may be responsible for the potentiation of renal toxicity of AmB in the ascending branch of the loop of Henle which is under greatest osmotic stress.

Amphotericin B↗
PubMed1998

The use of multilevel analysis in health economics: an application to examining the effect of competition on general practitioners' behaviour.

Multilevel modelling is a relatively new technique developed in the area of educational research. To illustrate the use of this technique in health economics, this paper estimates a multilevel logit model to examine the effect of competition on the behaviour of Australian general practitioners. The main hypothesis tested is that GPs in areas of high competition are more likely to recommend a follow up consultation compared to GPs in areas of low competition. The results suggest that competition influences the decision to recommend a follow up visit for one out of the five medical conditions analysed. The use of multilevel analysis represents a methodological improvement on previous models of GP behaviour. However, before multilevel analysis is more widely adopted it is argued that it should be more formally assessed against more standard and equivalent methods already used by economists, such as random effects panel data models.

Australia↗
PubMed1998

A study of interrater reliability when using videofluoroscopy as an assessment of swallowing.

Videofluoroscopic assessment of swallowing is widely used in clinical settings. The interpretation of such assessments depends on subjective visual judgments but the reliability of these judgments has been poorly researched. This study measured interrater reliability of judgments, made by speech pathologists, of videofluoroscopic images of subjects swallowing liquid and semisolid boluses. A 5-point rating scale was used in three conditions: individually after careful reading; together with other speech pathologists in group discussion; and individually after the group discussion. Analysis of the ratings for the three conditions revealed that the level of agreement among raters was generally higher for semisolid swallows than for liquid swallows. The highest levels of agreement occurred for ratings made after group discussions. The levels of agreement were lowest when raters worked alone, relying only on reading the scale. Individual rating after group discussion resulted in higher levels of agreement than sole reliance on reading the scale. Factors influencing the levels of interrater agreement, including the timing of observations, bolus consistency, the quality of the image, and the complexity of the task, are discussed.

Deglutition↗
PubMed1998

Agency in health care. Examining patients' preferences for attributes of the doctor-patient relationship.

Recently, some health economists have re-examined the nature of the agency relationship in health care. This paper presents a study conducted to establish the relative value to patients of various attributes of the general practice consultation. In the sample of patients recruited, the most important attribute was 'being able to talk to the doctor', whilst 'who chooses your treatment' was the least important. Although patients preferred more information to less, only females and highly qualified respondents preferred to choose the treatment themselves. The results of this study have implications for the education of doctors in communication skills and for further research into the agency relationship in health care.

Adult↗
PubMed1998

Dementia and help with household tasks: a comparison of cases and non-cases.

This paper is based on data, relating to people aged 75+ living in the community, from the city of Liverpool and from a rural area of North Wales. It compares those suffering from cognitive brain disorders with those identified as being cognitively unimpaired. Levels of need, and sources of help with a range of domestic and home maintenance tasks are identified. Results show that most help for those who are cognitively impaired comes from relatives living in the same household, while help for those who are physically impaired comes primarily from spouses or relatives living in different households. Cases do not demonstrate a higher level of use of formal services than non-cases. Implications for policy and practice are discussed.

Aged↗
PubMed1998

Evaluating innovation in general practice: a pragmatic framework using programme budgeting and marginal analysis.

BACKGROUND: Innovation in primary care in the UK, in terms of new service developments, is occurring at a fast pace. However, little information is available on the costs and benefits of these changes. OBJECTIVES: We aimed to illustrate the use of programme budgeting and marginal analysis (PBMA) as a framework for evaluating innovation in primary care, using an example of practice-based diabetes care. The aim was to examine changes in the use of practice resources and the changes in benefits to patients, following the introduction of a diabetes clinic. METHODS: PBMA is a form of pragmatic economic evaluation combining practice data for the 'before' period and data from the literature to model the 'after' period. RESULTS: In 1995/6, the total amount of resources devoted to diabetes care in the two practices was 145813 pound sterling (634 pound sterling per patient). Of this sum, 62% was allocated to out-patient visits, 28% to prescribing, 5% to hospital admissions, 2% to GP consultations and 2% to tests. The literature suggests that a nurse-run diabetes clinic would result in similar health outcomes and better access for patients. The introduction of such a clinic could potentially save each practice between 2000 pound sterling and 16000 pound sterling per year. This result takes into account a wide range of assumptions about changes in resource use, but does depend on the findings of previous studies. CONCLUSIONS: The results of this study show that PBMA is a useful framework for helping practices be accountable and make 'evidence-based' decisions about service innovations in primary care.

Adult↗
PubMed1998

Schizophrenia and delusional disorder in older age: community prevalence, incidence, comorbidity, and outcome.

The opportunity to assess prevalence, incidence, and outcome of schizophrenia and delusional disorder was provided by an age- and sex-stratified random sample of 5,222 persons age 65 years and over. This sample was chosen from general practitioner lists, and interviewed by psychiatric nurses trained to use the Geriatric Mental State (GMS)-AGECAT computerized diagnostic system. GMS-AGECAT ensured the reliability of the selection of cases between the two waves of the study. A subsample was interviewed by a research psychiatrist. The sample was followed up 2 years later using the same method by interviewers blind to the initial findings. The protocols of all nominated cases and subcases of schizophrenia/paranoid disorder diagnosed by AGECAT were reviewed by a clinician and DSM-III-R diagnoses were made. Refusal rate was 13 percent for initial interviews (wave 1) and 15 percent for reinterview 2 years later (wave 2). The prevalence of DSM-III-R schizophrenia was 0.12 percent (95% confidence interval [CI] 0.04-0.25) and delusional disorder 0.04 percent (95% CI 0.00-0.14). The minimum incidence of schizophrenia for new cases was 3.0 (95% CI 0.00 to 110.70); for new and relapsed cases, 45.0 (95% CI 3.54-186.20); and for delusional disorder, 15.6 (95% CI 0.02-135.10) per 100,000 per year. Two of the five cases with schizophrenia were known to have been first diagnosed before age 65. After 2 years, none of the cases of schizophrenia had recovered fully, but none was deluded at followup. Two had developed dementia. The outcome was bad because they remained cases of some type of psychiatric illness but good because of the improvement in their schizophrenia/delusion disorder symptoms.

Aged↗
PubMed1998

Neutron yields from 435 MeV/nucleon Nb stopping in Nb and 272 MeV/nucleon Nb stopping in Nb and Al.

Neutron fluences were measured from 435 MeV/nucleon Nb ions stopping in a Nb target and 272 MeV/nucleon Nb ions stopping in targets of Nb and Al for neutrons above 20 MeV and at laboratory angles between 3 degrees and 80 degrees. The resultant spectra were integrated over angles to produce neutron energy distributions and over energy to produce neutron angular distributions. The total neutron yields for each system were obtained by integrating over the angular distributions. The angular distributions from all three systems are peaked forward, and the energy distributions from all three systems show an appreciable yield of neutrons with velocities greater than the beam velocity. Comparison of the total neutron yields from the two Nb + Nb systems suggests that the average neutron multiplicity decreases with decreasing projectile energy. Comparison of the total yields from the two 272 MeV/nucleon systems suggests that the total yields show the same dependence on projectile and target mass number as do total inclusive neutron cross sections. The data are compared with Boltzmann-Uehling-Uhlenbeck model calculations.

Aluminum↗
PubMed1998

A survey of oral health in a population of adults with developmental disabilities: comparison with a national oral health survey of the general population.

During 1991, an oral health assessment of 101 adults with developmental disabilities aged from 21 to 53 years was undertaken as part of a broader health survey which also included medical, psychological and nutritional assessments. The study group consisted of a random sample of adults chosen from the developmentally disabled population known to be living in the lower North Shore area of Sydney. This paper describes the results of the oral health assessment and compares them with an oral health survey of the Australian population done in 1987/88. Forty-six per cent of the study group were males (mean age 33.5 years) and 54 per cent were females (mean age 33.0 years). Compared with similar age subgroups in the Australian population, the following factors were more frequently reported in the developmentally disabled group: a dental visit in the last 12 months (65 per cent vs 50 per cent; Odds Ratio (OR) 1.9:95 per cent Confidence Interval (CI): 1.3-2.8); use of public rather than private dental services (42 per cent vs 6 per cent; OR 11.3:95% CI 7.5-16.9); oral mucosal pathology requiring treatment (15 per cent vs 2 per cent; OR 8.5:95% CI 5.2-13.8); severe periodontal disease (16 per cent vs 3 per cent; OR 6.9:95% CI 4.2-11.4); and moderate to severe malocclusion (26 per cent vs 11 per cent; OR 2.1:95% CI 1.3-3.5). Fifty-eight per cent of subjects felt they needed no dental treatment but on examination of the oral mucosa, periodontal tissues and teeth, over 90 per cent were found to require some sort of dental treatment.

Adult↗
PubMed1998

Increased general practice workload due to a primary care led National Health Service: the need for evidence to support rhetoric.

Recent policy initiatives have focused on shifts in the balance of care from secondary care to primary care. A consequence of such shifts is increased workload in primary care. The aim of this paper is to appraise the literature critically to assess whether changes in the balance of care have led to additional work for general practices. In particular, the implications of this literature for the measurement of workload in general practice are highlighted. After an extensive, systematic literature search, only 12 studies that met the review criteria were identified. Although the studies pointed to negligible effects on the number of general practitioner (GP) visits, they failed to capture the many other attributes of a practice's work that are likely to be influenced by a shift in the balance of care. These include both qualitative (e.g. stress and mental effort) and quantitative (i.e. the use of resources in the practice, such as GPs, nurses and other staff's time and administration) measures of workload. The studies may therefore have under-estimated the effect on practice workload. To identify correctly the impact on workload of shifts in the balance of care, studies evaluating shifts need to improve their measurement of general practice workload. Furthermore, an extended definition of workload needs to be developed and tested, and workload monitored over time.

Family Practice↗
PubMed1997

Do fee descriptors influence treatment choices in general practice? A multilevel discrete choice model.

Before 1990 Australian general practitioners (GPs) were remunerated according to consultation length. This was assumed to encourage GPs to prescribe more, counsel less and provide fewer treatments than were 'appropriate'. In an attempt to change this behaviour, the remuneration system was altered to reflect the content of consultations. This paper analyses, through the use of multilevel modelling, the effect of content-based descriptors on the discrete choice behaviour of GPs while controlling for patient, GP and practice characteristics. GPs who used content-based descriptors were just as likely to prescribe, counsel and treat compared to GPs who used time-based descriptors.

Australia↗