Income distribution and life expectancy.
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Aged↗
Biomedical subjects
D P Forster
Publications and source records attributed to D P Forster.
The family study: a model for integrating the individual and community perspective in medical education.
The principles of and experience with a family study and survey undertaken by first-year medical students are reported. The family study is based on the observations made by pairs of students on a selected family, which includes a pregnant mother, in the Newcastle upon Tyne area. These observations include the family context, the pregnancy, the early development of the new-born baby, and the use of health and other services. The family survey records and analyses relevant data on the collective group of selected families. The family study acts as a preparation for clinical understanding by emphasizing the individual or family view. In addition, students learn that the collective epidemiological approach provided by the survey can guide the clinical impression gained from the observational study, yet each individual and family remains unique. An early opportunity is therefore provided for students to explore and integrate these two approaches.
Child↗
Evaluation of pure tone audiometry and impedance screening in infant schoolchildren.
STUDY OBJECTIVE: The aims were (1) to evaluate impedance measurements against pure tone audiometry as a screening method for the detection of middle ear changes associated with hearing loss in infant school children; (2) to estimate the costs of the health authority of each method. DESIGN: The study involved two stage screening in which both methods were offered, pure tone audiometry being carried out by school nurses and impedance screening by a doctor. SETTING: 18 infant or primary schools in Langbaurgh, Cleveland, UK. PARTICIPANTS: 610 previously unscreened infant school children took part in the study. MEASUREMENTS AND MAIN RESULTS: Main outcome measures were the sensitivity, specificity, and predictive value of each screening method, using clinical assessment and action as the validating technique. The sensitivity and the predictive value of a positive test in two stage impedance screening was markedly superior to that of pure tone audiometry. The specificity was similar using the two methods. In addition the impedance methods was more rapid and estimated to consume less resource as a screening procedure than pure tone audiometry. CONCLUSIONS: The superiority of the use of impedance screening established in this study should be confirmed in a subsequent audit carried out purely by school nurses.
Acoustic Impedance Tests↗
Mortality from causes amenable and non-amenable to medical care: the experience of eastern Europe.
OBJECTIVE: To investigate comparative national trends in mortality from conditions amenable to timely, appropriate medical care and from those considered not to be amenable to such care. DESIGN: Analysis of trends in direct age standardised mortality from the 1950s to 1987. SETTING: Four eastern European nations (Hungary, Czechoslovakia, Poland, the German Democratic Republic) and two western European (the Federal Republic of Germany and England and Wales) and two North American nations (United States and Canada). SUBJECTS: The total populations of the relevant countries during the period examined. MAIN OUTCOME MEASURES: Proportional changes over time in age standardised mortality. Mortality from amenable and non-amenable causes was restricted to the age group 0-64. RESULTS: A divergence in the trends for all cause mortality between eastern Europe and the western nations occurred in about 1970, when the rates in western countries steadily declined but those in eastern Europe remained fairly static. In the age group 0-64 mortality from causes considered amenable to medical care fell less quickly in eastern Europe than in the West, particularly after 1970. In the same age group, mortality from non-amenable causes rose in eastern European countries from the late 1960s compared with substantial declines in such mortality in the West. CONCLUSIONS: Non-amenable causes of death seem to be the principal, but not exclusive, reason for lack of improvement in trends in all cause mortality in eastern Europe from 1970. The agenda for action in eastern Europe should give priority to a healthier lifestyle and improvement of the environment though not neglect enhancements in the quality and efficiency of direct health services.
Adolescent↗
The role of unemployment in parasuicide.
Sixty-four in-patient cases of deliberate non-fatal self-poisoning were compared for psychosocial problems in a case-control study with a similar number of individually matched community controls. A strongly significant association was found between unemployment and self-poisoning. Further analysis revealed no firm evidence to support the hypotheses that unemployment was causally related to self-poisoning in an indirect manner or that it increased the vulnerability of individuals who self-poison to other stressful life events and difficulties. It is concluded that a possible explanation is that some third factor independently increases the risk of both unemployment and self-poisoning, giving rise to a non-causal relationship between these last two variables.
Adaptation, Psychological↗
Use of regression analysis to explain the variation in prescribing rates and costs between family practitioner committees.
There are proposals to set up prescribing budgets for family practitioner committees (now family health services authorities) and indicative prescribing amounts for practices. An intelligible model is therefore required for specifying budgetary allocations. Regression analyses were used to explain the variation in prescription rates and costs between the 98 family practitioner committees of England and Wales in 1987. Fifty one per cent of the variation in prescription rates and 44% of the variation in prescription costs per patient could be explained by variations in the age-sex structure of family practitioner committees. The standardized mortality ratio for all causes and patients in 1987, and the number of general practice principals per 1000 population in 1987, but not the Jarman under-privileged area score were found to improve the predictive power of the regression models significantly (P less than 0.01). The predictions of the model for the 10 family practitioner committees with the highest and lowest prescription rates or costs are reported and discussed. Potential improvements in models of prescribing behaviour may be thwarted by two problems. First, the paucity of readily available data on health care need at family practitioner committee and practice levels, and secondly, the increasing complexity in the statistical techniques required may render the procedure less intelligible, meaningful and negotiable in a contentious field.
Costs and Cost Analysis↗
Health in Eastern Europe.
To assess trends in health in Eastern Europe, age-standardised mortality rates since 1950 in four Eastern European countries (German Democratic Republic, Poland, Czechoslovakia, and Hungary) were compared with those in two Western European countries (Federal Republic of Germany and England and Wales). In the Eastern European countries mortality rates had increased or were virtually unchanged since the mid-1960s, especially in middle aged and elderly men. Death rates in males in Poland, Czechoslovakia, and Hungary in the mid to late 1980s were as high as those in the two Western European countries in the early 1950s. There was a shorter time lag for females. This poor health record in Eastern Europe will need to be addressed by the policy makers in the new democracies.
Adult↗
Screening elderly people in primary care: a randomized controlled trial.
A randomized controlled trial was carried out to test the effectiveness of a screening programme carried out by nurses for elderly people aged 75 years and over in a general practice. A total of 151 people were randomly allocated to the test group and 145 to the control group. The test group received a home visit from a nurse at which an assessment lasting 45 minutes was made of: activities of daily living, social functioning, sensory functions, mental and emotional problems, current medical problems, blood pressure, urinalysis, haemoglobin level and compliance with medication. Both groups completed a selection of items from four health indices before and 20 months after the intervention. At follow up, the test group scored significantly better than the control group on a morale scale. However, this trial provided no evidence for better resolution of physical problems or finding activities of daily living easier in the test group compared with the control group. It is suggested that the main benefit of such a screening process is that the special attention and education provided improves adaptation to old age and awareness of the support systems available. The government has proposed an annual review of elderly people in their own home and this study suggests that the objectives of this scheme should be clarified.
Aged↗
Modifying clinical practice: two initiatives in the English National Health Service.
Two information systems in the English National Health Service (NHS) are described and discussed. The performance indicator scheme enables service inputs and activity to be readily compared between district health authorities (DHAs) or hospitals. Quality of care is not measured directly by performance indicators but in certain circumstances a limited assessment may be inferred from the health service input and activity data. Experiments in management budgeting and resource management are reported in which the NHS accounting system is being changed to one which is more patient-based and from which costs can be identified for clinically meaningful groups of patients. Variation in service activity, derived from the performance indicator system, has been used by the government with other evidence to make the case for NHS reform. Realistic implementation of the proposed NHS reforms will depend on the success of the budgeting experiments.
Budgets↗
The NHS reforms. Conditions for successful change.
The NHS Review has proposed the most radical organisational change in health care since the inception of the service itself in 1948. Yet, the problems entailed in gaining acceptance for reforms of such magnitude are scarcely touched on in the white paper. The scale and strength of opposition which the proposals have subsequently met within the NHS have shown clearly that the issue of the management of change is likely to be central in the acceptance or otherwise of the proposals and subsequently their success or failure. Donald Forster and Roger Hadley outline the framework within which the issues posed by change can be analysed and assessed. In keeping with the government's preference for a management perspective, they emphasise insights from the literature on the management of change rather than the detail of the white paper.
Organizational Innovation↗
A randomised controlled trial of individual counselling of smokers in pregnancy.
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Adult↗
Performance indicators in health service management--a clinical analogy.
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England↗
Medicinal self-poisoning and prescription frequency.
Deliberate non-fatal self-poisoning due to medicinal agents more than doubled in England and Wales during the period 1968-78. Interregional analysis showed a significant positive correlation between the rate at which psychotropic drugs were prescribed by general practitioners (GPs) and the medicinal self-poisoning rate. Regression analysis indicated that a reduction of 1000 psychotropic prescriptions would be associated with 3.8 fewer self-poisoning admissions due to medicinal agents. Causal and non-causal links between the psychotropic prescription rate and the medicinal self-poisoning rate were both considered, but the balance of the evidence seems to favour the causal interpretation. Overall, it is suggested that the benefits of such reduced prescribing outweight the costs. A significant relationship was not found between unemployment and medicinal self-poisoning.
Adolescent↗
Prescription frequency, iatrogenesis and economic evaluation.
Iatrogenesis is classified into two broad types: direct and indirect. By indirect iatrogenesis is meant the accidental or deliberate misuse of prescribed medication. Deliberate indirect iatrogenesis is explored through an analysis of deliberate non-fatal self-poisoning. A statistically significant relationship, previously found, between deliberate non-fatal self-poisoning and the frequency of prescription of psychotropics is used to evaluate the economic consequences of self-poisoning to the hospital sector. In the decision to use or not to use a particular drug, the importance of risk-benefit analysis is stressed. This analysis is used to distinguish between a drug's safety and efficacy. In general, no one criterion should be used to choose between alternative drugs. Finally, some policy implications of the analysis for psychotropic prescriptions are considered.
Drug Prescriptions↗
Acute illness in infants: a general practice study.
The character and frequency of acute illness in infants presenting to a general practice over a 16-week period was studied. Symptoms were classified as 'major' or 'minor' in accordance with the definitions used in a multicentre study in infant mortality.Of the 126 consultations reviewed, 106 (84 per cent) included at least one major symptom. None of the illnesses resulted in hospital admission or had a fatal outcome. It was concluded that this classification of symptoms into ;major' and ;minor' categories is not sufficiently discriminating to use in general practice. More specific definitions are required.
Acute Disease↗
Cost-effectiveness study of outpatient physiotherapy after medial meniscectomy.
In a randomised controlled trial comparing the outcome of two groups of men aged 16-45 one group received outpatient physiotherapy after medial meniscectomy and the other did not. In clinical aspects of knee function there was no significant difference between the test group and control group measured at specified intervals up to 26 weeks postoperatively. Similarly, there was no significant difference between the groups in the time taken to return to work or in the mean fall in take-home pay as a result of meniscectomy. The mean cost per patient of providing outpatient physiotherapy in the test group was 23 pounds at 1976 prices. Thus the least costly way of returning male patients aged 16-45 to activity is by not providing routine outpatient physiotherapy after medial meniscectomy. Further randomised controlled trials are, however, required to determine the value of physiotherapy in other age groups and other conditions.
Absenteeism↗
Accidental poisoning in young children.
Cases of accidental childhood poisoning admitted to hospital were compared with community controls and hospital controls matched for age and sex. The relative risks of factors in the cases compared with both the control groups were significant for roughness, aggressiveness, noisiness, and pica behaviour in the child, and for large families. Mothers' knowledge of the toxicity of common household products and drugs did not give significant risk differences between cases and controls. The majority of poisonings occurred during the summer months.
Child, Preschool↗