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Biomedical subjects

D Mant

Publications and source records attributed to D Mant.

At least 37 records · Page 2Linked to original sources
PubMed1997

Preventive care for patients following myocardial infarction. The Wessex Research Network (WReN).

OBJECTIVE: We aimed to assess general practice care for patients following a myocardial infarction (MI). METHOD: A structured review was carried out of general practice records of patients identified from hospital administration data. A total of 266 survivors following MI were identified from the discharge data of 13 hospitals in Southern England and registered with 71 GPs belonging to the Wessex Research Network. Median time since hospital discharge was 2.1 years. The main outcome measures were the provision of appropriate preventive care, including cardiac rehabilitation, drug therapy, and lifestyle advice for modifiable risk factors. RESULTS: Basic care was provided to nearly all patients; 253 (95.1%, 95% Cl 91.8-97.4) had blood pressure documented after their MI, 216 of 234 patients eligible for aspirin (92.3%; 88.1-95.4) had been recommended treatment, and the provision of advice on smoking cessation was documented for 27 of 33 continuing smokers (81.8%; 64.5-93.0). However, only 73 of 236 patients eligible to attend a structured rehabilitation programme (30.9%; 25.0-36.8) were documented as having received rehabilitation. Of 89 patients with heart failure following MI, 33 (37.1%; 27.1-48.0) had no record of having been offered treatment with an ACE inhibitor. Total cholesterol measurement was documented for only 144 patients (54.1%; 48.1-60.1). We estimate that there is still the potential to prevent between 4 and 9 deaths in this group of 266 surviving patients in the next 2 years by further improving the quality of follow-up care. CONCLUSIONS: Preventive care in patients with proven ischaemic heart disease in general practice remains haphazard, even among doctors enthusiastic to participate in research and to audit their quality of care. As general practitioners we should ensure that we are providing high quality preventive care to patients with clinical disease before we focus on the even more demanding task of primary prevention.

Adult↗
PubMed1996

Routine follow up of breast cancer in primary care: randomised trial.

OBJECTIVE: To assess the effect on time to diagnosis of recurrence and on quality of life of transferring primary responsibility for follow up of women with breast cancer in remission from hospital to general practice. DESIGN: Randomised controlled trial with 18 month follow up in which women received routine follow up either in hospital or in general practice. SUBJECTS AND SETTING: 296 women with breast cancer in remission receiving regular follow up care at district general hospitals in England. MAIN OUTCOME MEASURES: Time between first presentation of symptoms to confirmation of recurrence; quality of life measured by specific dimensions of the SF-36 schedule, the EORTC symptom scale, and hospital anxiety and depression scale. RESULTS: Most recurrences (18/26, 69%) presented as interval events, and almost half (7/16, 44%) of the recurrences in the hospital group presented first to general practice. The median time to hospital confirmation of recurrence was 21 days in the hospital group (range 1-376 days) and 22 days in the general practice group (range 4-64). The differences between groups in the change in SF-36 mean scores from baseline were small: -1.8 (95% confidence interval -7.2 to 3.5) for social functioning, 0.5 (-4.1 to 5.1) for mental health, and 0.6 (-3.6 to 4.8) for general health perception. The change from baseline in the mean depression score was higher in the general practice group at the mid-trial assessment (difference 0.6, 0.1 to 1.2) but there was no significant difference between groups in the anxiety score or the EORTC scales. CONCLUSION: General practice follow up of women with breast cancer in remission is not associated with increase in time to diagnosis, increase in anxiety, or deterioration in health related quality of life. Most recurrences are detected by women as interval events and present to the general practitioner, irrespective of continuing hospital follow up.

Aftercare↗
PubMed1995

Randomised trial of lipid lowering dietary advice in general practice: the effects on serum lipids, lipoproteins, and antioxidants.

OBJECTIVE: To determine the relative efficacy in general practice of dietary advice given by a dietitian, a practice nurse, or a diet leaflet alone in reducing total and low density lipoprotein cholesterol concentration. DESIGN: Randomised six month parallel trial. SETTING: A general practice in Oxfordshire. SUBJECTS: 2004 subjects aged 35-64 years were screened for hypercholesterolaemia; 163 men and 146 women with a repeat total cholesterol concentration of 6.0-8.5 mmol/l entered the trial. INTERVENTIONS: Individual advice provided by a dietitian using a diet history, a practice nurse using a structured food frequency questionnaire, or a detailed diet leaflet sent by post. All three groups were advised to limit the energy provided by fat to 30% or less and to increase carbohydrate and dietary fibre. MAIN OUTCOME MEASURES: Concentrations of total cholesterol and low density and high density lipoprotein cholesterol after six months; antioxidant concentration and body mass index. RESULTS: No significant differences were found at the end of the trial between groups in mean concentrations of lipids, lipoproteins, and antioxidants or body mass index. After data were pooled from the three groups, the mean total cholesterol concentration fell by 1.9% (0.13 mmol/l, 95% confidence interval 0.06 to 0.22, P < 0.001) to 7.00 mmol/l, and low density lipoprotein cholesterol also fell. The total carotenoid concentration increased by 53 nmol/l (95% confidence interval 3.0 to 103, P = 0.039). CONCLUSIONS: Dietary advice is equally effective when given by a dietitian, a practice nurse, or a diet leaflet alone but results in only a small reduction in total and low density lipoprotein cholesterol. To obtain a better response more intensive intervention than is normally available in primary care is probably necessary.

Antioxidants↗
PubMed1995

Evaluating primary care follow-up of breast cancer: methods and preliminary results of three studies.

OBJECTIVE: To evaluate a primary care centred system of routine follow-up of women with breast cancer in remission. DESIGN, PATIENTS AND OUTCOME MEASURES: Three related studies are reported: 1) A randomized controlled trial (RCT) involving 296 women with breast cancer in remission (stage I, II, or III) all receiving routine follow-up at two district general hospitals in England. Women in the control group received follow-up in hospital clinics according to the usual practice. Women in the experimental group received follow-up from their own general practitioners (GP), and were referred back to hospital clinics if any breast cancer related problems developed. The main outcome of the trial was 'diagnostic delay': the time from the first presentation of signs or symptoms suggestive of recurrence to the time that recurrence was diagnosed. 2) A prospective descriptive study of a cohort of 141 women who were eligible for the trial, but who declined to participate. 3) A national survey of 376 specialists in breast cancer, and a survey of 226 general practitioners of the patients eligible for the RCT described above, to determine their views on follow-up of breast cancer in remission. RESULTS: 1) The randomized trial to evaluate primary care follow-up of breast cancer in remission has been successfully conducted and final results are pending. 2) Patients who were eligible but declined to participate in the trial were significantly older than participants (mean age 64.3 years compared with 60.7 years; difference 3.6 years; 95% confidence interval 0.53; 6.59). The two groups were similar in clinical characteristics and quality of life. 3) The majority of specialists and GPs preferred a system of routine follow-up which was primarily provided by their own professional group. CONCLUSIONS: A general practice centred system of routine follow-up of women with breast cancer in remission is acceptable to both patients and general practitioners. Final results of a randomized trial evaluating quality of care and quality of life outcome measures are pending.

Aged↗
PubMed1995

Specialist and general practice views on routine follow-up of breast cancer patients in general practice.

The practice of routinely following-up breast cancer in hospital clinics is of widespread concern: studies have shown that it is not an effective way of detecting recurrent disease and it places great strain on cancer services which are already overstretched. A general practice centred system of routine follow-up may be a solution to this problem in those countries which have a strong primary care base. Such a system would have other benefits such as continuity of care for the patient. The objective of this study was to determine the views of general practitioners and specialists on follow-up of patients with breast cancer in remission, with special emphasis on their views on the transfer of routine follow-up from the hospital to general practice. A postal questionnaire survey of British breast cancer specialists (response rate 77.0%) and a personal interview survey of British general practitioners (response rate 81.8%) were conducted. The results show that British general practitioners are willing to take on greater responsibility for the routine follow-up care of their patients with breast cancer. However, there was frequently a mis-match between specialists' and general practitioners' views on this subject.

Aftercare↗
PubMed1995

Hormone replacement therapy: characteristics of users and non-users in a British general practice cohort identified through computerised prescribing records.

STUDY OBJECTIVE: To assess the feasibility of recruiting a cohort of women, including long term users of postmenopausal hormone replacement therapy (HRT), through computerised general practice prescribing records, and to compare clinical and demographic characteristics of users and non-user controls. DESIGN: Cross sectional analysis of questionnaire data. SETTING: Subjects were recruited through 17 general practices in the Oxfordshire, south west Thames, and north west Thames regions that contributed to the VAMP Research Database. PARTICIPANTS: A total of 2964 women aged 45-64 years were identified. Altogether 1482 were long term (> 1 year) users of HRT and 1482 were non-user controls: 1037 (70%) of the users and 819 (55.3%) of the controls agreed to participate and provided questionnaire data. MAIN RESULTS: Users of HRT were more likely to have undergone hysterectomy than controls. Most women with a history of hysterectomy used unopposed oestrogen, while those with intact uteri generally used a combination of oestrogen and a progestagen. Among women who had undergone hysterectomy, HRT users did not differ significantly from controls over a range of demographic and clinical characteristics but they were more likely to be past users of oral contraceptives. Among women with intact uteri, users were similar to controls in terms of reported clinical characteristics, but were of higher social class and were more likely to be past users of oral contraceptives and to have had a mammogram after the age of 50. Compared with the general population, all categories of women recruited to the study were of higher social class and exhibited more health conscious behaviours. CONCLUSIONS: Electronic general practice prescribing records provide a feasible and efficient method for recruiting women to a cohort of HRT. Women who agreed to participate in this study were not representative of the general population, emphasising the importance of internal controls in such a study. Among participants, HRT users who had not undergone hysterectomy showed evidence of better health than non-users on some dimensions. In the whole sample, however, there were no appreciable differences in social class and self reported health indicators between users and controls.

Cohort Studies↗
PubMed1994

Prevention.

Explore the source record for details and available documents.

Family Practice↗
PubMed1994

Meta-analysis on efficacy of nicotine replacement therapies in smoking cessation.

Nicotine-replacement therapy (NRT) by gum, transdermal patch, intranasal spray, or inhalation is expensive but how effective is it? We have done a meta-analysis of controlled trials to see how effects on abstinence rates are influenced by the clinical setting, the level of nicotine dependency, the dosage of NRT, and the intensity of additional advice and support offered. Published or unpublished randomised controlled trials of NRT that have assessed abstinence at least 6 months after the start of NRT were identified and 53 trials (42 gum, 9 patch, 1 intranasal spray, 1 inhaler), with data from 17,703 subjects, were included in the analyses. Use of NRT increased the odds ratio (OR) of abstinence to 1.71 (95% confidence interval 1.56-1.87) compared with those allocated to the control interventions. The ORs for the different forms of NRT were 1.61 for gum, 2.07 for transdermal patch, 2.92 for nasal spray, and 3.05 for inhaled nicotine. These odds were non-significantly higher in subjects with higher levels of nicotine dependence but they were largely independent of the intensity of additional support provided or the setting in which NRT was offered. We conclude that the currently available forms of NRT are effective therapies to aid smoking cessation.

Administration, Cutaneous↗
PubMed1994

The effectiveness of nicotine replacement therapies in smoking cessation.

OBJECTIVE: To determine the effectiveness of nicotine replacement therapies (NRTs) (including gum, transdermal patch, intranasal spray, and inhaled preparations) in facilitating smoking cessation, and to determine whether the effect was influenced by the clinical setting in which the smoker was recruited and treated, the level of nicotine dependency, the dosage of NRT used, or the intensity of additional advice and support offered to the smoker. DATA SOURCES: Published trials of NRT were identified by a systematic search of 7 electronic databases, published reviews, reference lists from clinical trials, conference abstracts, smoking and health bulletins, and a bibliography on smoking and health. Unpublished trials were identified by approaching manufacturers of NRT. STUDY SELECTION: A total of 53 trials (42 gum, 9 patch, 1 intranasal spray, and 1 inhaler), with data from 17,703 patients, were included in the analyses. Only trials that assessed abstinence at least 6 months after the commencement of therapy were included. DATA EXTRACTION: Data were extracted from the trial reports by 2 authors independently. Where the methodology was unclear or the results were not expressed in a form which allowed extraction of key data we wrote to the investigators for the required information. DATA SYNTHESIS: Use of NRT increased the odds ratio (OR) of abstinence to 1.71 (95% confidence interval [CI], 1.56 to 1.87) compared with those who had been allocated to the control interventions. The OR for the different forms of NRT were 1.61 for nicotine gum (95% CI, 1.46 to 1.78), 2.07 (95% CI, 1.62 to 2.62) for transdermal patch, 2.92 (95% CI, 1.49 to 5.74) for nasal spray, and 3.05 for inhaled nicotine (95% CI, 1.42 to 6.57). These odds were not significantly higher in patients with higher levels of nicotine dependence (Fagerstrom score > or = 7; P = 0.06), but they were largely independent of the intensity of additional support provided or the setting in which the NRT was offered. CONCLUSION: We conclude that the currently available forms of NRT are effective therapies to aid smoking cessation.

Administration, Cutaneous↗
PubMed1994

Modelling different strategies to prevent coronary heart disease in primary care.

Strategies for prevention of coronary heart disease (CHD) in primary care need to take into account the number of people who require screening, further assessment, intervention and follow-up (i.e. the patient workload generated for the general practitioner) as well as the anticipated reductions in morbidity and mortality. Risks of CHD for various risk profiles were estimated from equations produced by the Framingham study. This enabled an estimate of the number of avertable CHD events to be compared against the patient workload implications for the general practitioner when different screening and intervention strategies were used. The Framingham equations were applied to a population of 5727 men and women aged 35-64 years of age registered with general practices in the south of England. Adopting an unselective approach to screening resulted in 14.1% (n = 73) of the 517 CHD events predicted over a 10 year period being averted. A limited screening strategy, involving 25% (n = 1436) of the patients would avert 5.6% (n = 29) of the predicted CHD events, whilst more extended strategies involving between 37% (n = 2131) and 46% (n = 2660) of the practice population respectively would result in between 6.9% (n = 36) and 9.3% (n = 48) of events being averted. The marginal benefit in averting CHD events decreased as more screening criteria were included. Almost all (99%) of the people identified by the selective screening strategies would require some form of intervention, predominantly lifestyle advice. Lowering the systolic blood pressure by 15 mmHg instead of 10 mmHg was equally effective as a 5% improvement in the overall rate of smoking cessation.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Dietary intervention in primary care: validity of the DINE method for diet assessment.

Primary health care staff are involved increasingly in the provision of dietary advice for health promotion, often without adequate training in nutrition assessment or counselling. At present no brief diet assessment methods are available which have been validated for this purpose in the UK. We report on the accuracy of the Dietary Instrument for Nutrition Education (DINE) in classifying dietary fat and fibre intakes. This structured questionnaire can be administered and scored in under 10 minutes by primary care staff without specialized nutritional knowledge, and includes a dietary counselling component. The classification of fat and fibre intakes as low, medium or high by the DINE method was compared to that of a detailed 4-day diet record in a population of 206 factory workers. There was exact agreement of categorization for 53% of fat intakes and 52% of fibre intakes, and only 6% of fat intakes and 5% of fibre intakes were grossly misclassified (placed in a high category by one method and a low category by another). Pearson correlation coefficients between the two methods were 0.51 for fat, 0.46 for fibre and 0.43 for the polyunsaturated:saturated fat ratio. The DINE method is a brief and inexpensive tool for diet assessment in primary care health promotion programmes.

Counseling↗
PubMed1994

Role of primary care in the prevention of malignant melanoma.

One of the targets for health in the United Kingdom is the reduction in the year-on-year increase in the incidence of skin cancer. Most of the mortality associated with skin cancer is attributable to malignant melanoma. One possible way to reduce the incidence of malignant melanoma is to develop a strategy for prevention based in primary care. This paper considers the arguments for and against three possible strategies: giving general advice; identifying patients at high risk; and undertaking early diagnosis. It is concluded that elements of all three strategies are likely to prove useful, but that major studies need to be undertaken before any strategy is adopted on a national basis.

Adult↗
PubMed1994

An analysis of randomized controlled trials published in the US family medicine literature, 1987-1991.

BACKGROUND: Randomized controlled trials (RCTs) are frequently used to evaluate the effectiveness of health care interventions in family medicine. The value of the information obtained from RCTs depends largely on the quality of design and the way in which they are conducted and reported. Despite the increasing number of RCTs being conducted in family medicine, there is a scarcity of descriptive data on the methodological characteristics, including design features and quality of RCTs in this setting. METHODS: All 55 RCTs published in four peer-reviewed US family medicine journals between 1987 and 1991 were identified and their methodological characteristics reviewed. Three potential sources of bias were assessed in each of the trial reports: (1) control of selection bias at entry, (2) control of selection bias after entry, and (3) control of bias in assessing outcome(s). RESULTS: Fifty-five RCTs published between January 1987 and December 1991 were identified in the four journals. The absolute number of RCTs published over the 5 years increased steadily, and there was a 49% increase in the proportion of RCT articles. Measures used to control for selection bias before entry into the study were reported in 14 (25%) of the RCTs, the statistical power of the trial in 5 (9%), and whether the study had been reviewed by an institutional review board in 6 (11%). CONCLUSIONS: The RCTs analyzed offered some imaginative solutions to the logistic difficulties of conducting RCTs in general practice. Nevertheless, the methodology and reporting of RCTs in the future should be improved.

Bias↗