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Biomedical subjects

I Nazareth

Publications and source records attributed to I Nazareth.

At least 19 recordsLinked to original sources
PubMed2001

When is it cost-effective to change the behavior of health professionals?

Because of the workings of health care systems, new, important, and cost-effective treatments sometimes do not become routine care while well-marketed products of equivocal value achieve widespread adoption. Should policymakers attempt to influence clinical behavior and correct for these inefficiencies? Implementation methods achieve a certain level of behavioral change but cost money to enact. These factors can be combined with the cost-effectiveness of treatments to estimate an overall policy cost-effectiveness. In general, policy cost-effectiveness is always less attractive than treatment cost-effectiveness. Consequently trying to improve the uptake of underused cost-effective care or reduce the overuse of new and expensive treatments may not always make economic sense. In this article, we present a method for calculating policy cost-effectiveness and illustrate it with examples from a recent trial, conducted during 1997 and 1998, of educational outreach by community pharmacists to influence physician prescribing in England.

Cost-Benefit Analysis↗
PubMed2001

Sexual dysfunction after treatment for testicular cancer: a systematic review.

OBJECTIVES: We aimed to assess the nature and risk of sexual dysfunction in men after treatment for testicular cancer. METHOD: Systematic review of sexual dysfunction in men treated for testicular cancer. The odds ratio or proportions of subjects with reduced sexual drive, erectile dysfunction or orgasmic/ejaculatory dysfunction was calculated. RESULTS: A detailed review of 79 of the 227 citations was conducted. The highest level of evidence found, were controlled studies. Six controlled studies examined sexual function in 709 patients after they had received treatment. Seven uncontrolled studies examined sexual function in 337 subjects before and after treatment for testicular cancer. Most studies were limited by low response rates, use of unvalidated questionnaires and inclusion of a variety of treatment modalities. Few assessed psychological function and none examined its possible interaction with sexual dysfunction. Meta-analysis of the controlled studies indicated significantly reduced or absent orgasm (OR=4.62, 95% CI=2.47-8.63) together with erectile (OR=2.47, 95% CI=1.54-3.96) and ejaculatory dysfunction (OR=28.57, 95% CI=1.75-464.78) up to 2 years after treatment. Effects on sexual function were less consistent in the uncontrolled studies. CONCLUSIONS: The controlled studies indicate that sexual dysfunction persists for up to 2 years after treatment. However, better evidence is needed in studies that control for the impact of the testicular cancer, the treatment modality and psychological reactions to both.

Clinical Trials as Topic↗
PubMed2001

A pharmacy discharge plan for hospitalized elderly patients--a randomized controlled trial.

OBJECTIVES: to investigate the effectiveness of a pharmacy discharge plan in elderly hospitalized patients. DESIGN: randomized controlled trial. SUBJECTS AND SETTINGS: we randomized patients aged 75 years and older on four or more medicines who had been discharged from three acute general and one long-stay hospital to a pharmacy intervention or usual care. INTERVENTIONS: the hospital pharmacist developed discharge plans which gave details of medication and support required by the patient. A copy was given to the patient and to all relevant professionals and carers. This was followed by a domiciliary assessment by a community pharmacist. In the control group, patients were discharged from hospital following standard procedures that included a discharge letter to the general practitioner listing current medications. OUTCOMES: the primary outcome was re-admission to hospital within 6 months. Secondary outcomes included the number of deaths, attendance at hospital outpatient clinics and general practice and proportion of days in hospital over the follow-up period, together with patients' general well-being, satisfaction with the service and knowledge of and adherence to prescribed medication. RESULTS: we recruited 362 patients, of whom 181 were randomized to each group. We collected hospital and general practice data on at least 91 and 72% of patients respectively at each follow-up point and interviewed between 43 and 90% of the study subjects. There were no significant differences between the groups in the proportion of patients re-admitted to hospital between baseline and 3 months or 3 and 6 months. There were no significant differences in any of the secondary outcomes. CONCLUSIONS: we found no evidence to suggest that the co-ordinated hospital and community pharmacy care discharge plans in elderly patients in this study influence outcomes.

Aged↗
PubMed2001

GPs' views on their management of sexual dysfunction.

BACKGROUND: Sexual dysfunction is an important aspect of sexual heath that is prevalent in the population but frequently goes undetected. OBJECTIVE: The aim of this study was to investigate the role of the GP in the management of problems of sexual dysfunction. METHODS: A postal questionnaire was sent to the 218 GPs on the Camden and Islington Health Authority List. The questionnaire collected demographic information on the GPs, their clinical interests, experience, postgraduate qualifications and their view of the clinical importance of sexual dysfunction. Their clinical management of the most recent patient encounter in the previous month was explored using a critical incident technique and they were asked to list their views on barriers to the management of sexual dysfunction and to provide a list of suggestions for tackling these barriers. RESULTS: A total of 133 GPs responded to the questionnaire. Although only eight had a special interest in sexual health, 41 and 50 reported a special interest in mental and women's health, respectively. Forty-six had received postgraduate training in taking a sexual history, 45 in the diagnosis of a sexual problem, 49 in the management of sexual dysfunction, 39 in psychosexual counselling and 24 had training in all four areas. Most GPs (87) categorized sexual dysfunction as medium priority, 25 as high priority and 18 as low priority; three GPs did not respond to this query. Several barriers to the management of sexual dysfunction in general practice were identified. Most doctors identified more than one barrier. CONCLUSIONS: The participating GPs offered specific suggestions that focused on the need for more professional and patient education, consultation time, psychosexual counsellors and relevant secondary care service.

Adult↗
PubMed2001

Panic disorder with agoraphobia associated with dizziness: characteristic symptoms and psychosocial sequelae.

The aim of this study was to assess the prevalence of symptoms of panic disorder in a representative community sample of people with dizziness and to compare the profile of those whose panic was consistently linked to attacks of dizziness with those in whom dizziness was just one of many, variable somatic symptoms of panic. Validated questionnaires assessing physical and psychological symptoms, occupational disability, and handicap were administered to 128 people reporting dizziness in an epidemiological survey. Nearly two thirds of the sample reported having panic attacks, and one in four met key criteria for panic disorder. People whose panic symptoms were consistently associated with dizziness reported higher rates of vertigo than those with panic unrelated to dizziness, and higher rates of fainting, agoraphobic behavior, and occupational disability than either comparison group. Explanation of perceptual-motor triggers for disorientation may increase the predictability of attacks, thus reducing vulnerability to dizziness-provoked panic.

Adult↗
PubMed2001

The barriers to effective management of heart failure in general practice.

BACKGROUND: Several studies have shown that most patients with heart failure are not investigated and treated according to published guidelines. More effective management could reduce both mortality and morbidity from heart failure. AIM: To identify the reasons for gaps between recommended and actual management of heart failure in general practice. DESIGN OF STUDY: A nominal group technique was used to elicit general practitioners' (GPs') perceptions of the reasons for differences between observed and recommended practice. SETTING: Ten Medical Research Council General Practice Framework practices in the North Thames region. METHOD: Data were collected on the investigation and treatment of heart failure in the 10 participating practices and presented to 49 GPs and 10 practice nurses from those practices. RESULTS: Of the 674 patients requiring echocardiograms, 226 were referred for echocardiography (34%), and 183/391 (47%) with probable heart failure were prescribed angiotensin-converting enzyme inhibitors. A wide variety of barriers were elicited. The main barrier to the use of echocardiograms in the diagnosis of heart failure was lack of open access. The main barrier to the use of angiotensin-converting enzyme inhibitors in treating heart failure was GPs' concerns about their possible adverse effects. CONCLUSION: The barriers to the effective management of heart failure in general practice are complex. We recommend further research to establish whether multifaceted intervention programmes based on our findings can improve the management of heart failure in primary care.

Aged↗
PubMed1999

A randomized trial of Evidence-based OutReach (EBOR): rationale and design.

There is increasing interest in evaluating the methods used to implement the findings from medical research. This paper describes the Evidence-based OutReach (EBOR) trial, which is the first large randomized study in the United Kingdom that will evaluate the effectiveness and efficiency of educational outreach visits by trained pharmacists who are delivering messages derived from four evidence-based clinical practice guidelines. General practices form the unit of allocation and analysis. The study design addresses important factors that may influence the effectiveness of the intervention, such as the pharmacist who delivers the messages, the health authority in which practices are located, and the size of a practice.

Family Practice↗
PubMed1999

Medical education in the community--the UNITRA experience.

The creation of the independent black state of Transkei, under the apartheid regime, resulted in inadequate allocation of resources to the region. These inequalities were translated into health care. Despite these limitations, over the last five years an innovative community-based educational programme involving medical students, nurses and health educators is evolving at the relatively new medical school in this region. This programme, however, has not been free of difficulties. There is an urgent need to address these issues using a combination of administrative, educational and research approaches. This would provide a strong basis for the further development of this educational programme that could serve as a unique South African example of medical education in the community.

Black or African American↗
PubMed1999

Outcome of symptoms of dizziness in a general practice community sample.

BACKGROUND: Dizziness is commonly experienced in the community, but little is known about the long-term progression of the condition. OBJECTIVE: We aimed to assess over 18 months the outcome of symptoms of dizziness in a sample of patients identified from London general practices. METHOD: We followed up at 18 months a cohort of patients who reported symptoms of dizziness with or without anxiety, panic reactions or avoidance of situations that provoked the symptoms. The subjects completed a structured questionnaire both at baseline and at 18 months. RESULTS: At 18 months, 24% (95% CI = 23.5-34.8%) were more handicapped and 20% (95% CI = 15.2-25.2%) had recurrent dizziness, while 20% (95% CI = 14.9-24.8%) had improved. Patients with significant dizziness were more likely to consult their GP (OR = 14.4, 95% CI = 7.0-29.1) and were more likely to receive treatment (OR = 7.8, 95% CI = 3.2-22.4) or be referred to hospital (OR = 8.4, 95% CI = 3.2-22.4). The independent predictors of handicapping dizziness at 18 months were a history of fainting (OR = 2.4, 95% CI = 1.2-4.7), vertigo (OR = 2.6, 95% CI = 1.3-5.0) and avoidance of a situation that provoke dizziness (OR = 4.8, 95% CI = 2.5-9.0). CONCLUSION: Four per cent of all patients registered with a GP suffer persistent symptoms of dizziness and at least 3% are severely incapacitated by their symptoms. The presence of vertigo, fainting and avoidance in a person with dizziness is predictive of chronic handicapping dizziness. Further research is required on the progressions of symptoms of dizziness in a sample of GP attenders and those in the community.

Adolescent↗
PubMed1999

Evaluation of general practice computer templates. Lessons from a pilot randomised controlled trial.

We conducted a pilot randomised trial of computerised templates for the management of asthma and diabetes in general practice in six general practices in North London. Uptake of the guidelines by general practitioners and practice nurses was assessed using qualitative (semi-structured interviews designed to assess the users' views) and quantitative (change in use of the template during the study period) outcome measures. The practice nurses used the templates frequently but general practitioners rarely used them. Several reasons were offered for non-use of the templates, such as the length of the template and non-involvement in the care of asthma or diabetes. Despite this, however, health professionals were favourably disposed to the use of templates for general clinical care. Pilot investigations of computerised templates are best achieved by observational or quasi-experimental methods rather than a randomised controlled trial. The use of both qualitative and quantitative methods in this study allowed exploration of the barriers to use of computers.

Asthma↗
PubMed1998

Feasibility and effectiveness of providing vestibular rehabilitation for dizzy patients in the community.

Since the majority of people with dizziness in the community are never referred for specialist testing and treatment, the purpose of this study was to investigate whether it was desirable and feasible to provide vestibular rehabilitation for this patient population. Demand for therapy was assessed by a survey of 9198 working age people randomly sampled from six general practices. One in 10 respondents reported current, handicapping dizziness, but fewer than 2% of those with dizziness severe enough to merit treatment proved suitable and willing to attend hospital for testing and rehabilitation. Nevertheless, vestibular rehabilitation was clearly beneficial for the 16 patients who completed the therapy programme, as their scores on measures of symptoms, disability, handicap and postural stability improved significantly post-therapy to near-normal levels. We conclude that there is a need for provision of vestibular rehabilitation in primary care for patients with dizziness in the community.

Adolescent↗
PubMed1998

Neuro-otological and psychiatric abnormalities in a community sample of people with dizziness: a blind, controlled investigation.

OBJECTIVES: To determine neurootological and psychiatric abnormalities associated with complaints of dizziness in an epidemiological community sample of people of working age, and the extent of comorbidity between neuro-otological and psychiatric dysfunction. METHOD: A survey of 3884 people randomly selected from six general practice lists identified 262 people with significant dizziness, from which a subsample of 15 men and 22 women were recruited for testing. Dizzy subjects were evaluated by blind neuro-otological testing, computerised dynamic posturography, a computerised psychiatric assessment, neuro-otological and general medical examination, and diagnosis. An age matched control group of 18 men and 22 women underwent the same evaluation. RESULTS: Tests of auditory, vestibular, and oculo-motor function did not discriminate between dizzy subjects and controls, but dizzy subjects had significantly worse balance on posturographic testing, more diagnoses of medical disorder, and a higher prevalence of psychiatric morbidity. CONCLUSIONS: The findings suggest that dizziness in the community is typically characterised by mild physical disorder accompanied by some psychiatric disturbance. As the combination of minor physical and psychiatric disorder is known to be unusually persistent and handicapping, treatment programmes must be provided for this prevalent syndrome, perhaps by a partnership between primary care and neuro-otological and psychiatric hospital outpatient clinics with experience and expertise in the diagnosis and management of dizziness and psychiatric disturbance.

Adolescent↗
PubMed1998

Prevalence and presentation of dizziness in a general practice community sample of working age people.

BACKGROUND: Dizziness is known to be a common, handicapping condition in the elderly, and a strong association between dizziness and anxiety disorders has been observed in hospital samples. However, little is known about the prevalence of dizziness among people of working age in the community and its implications for psychosocial functioning and general practice consultation and treatment. AIM: To determine the prevalence of dizziness, giddiness, vertigo, and unsteadiness, and associations with disability and handicap, symptoms of panic and agoraphobia, and general practice consultation and treatment. METHOD: Postal questionnaires were completed by 2064 people aged 18-64 years randomly sampled from the patient lists of four London practices. Validated survey items were used to assess symptoms, panic and agoraphobia, levels of occupational disability and handicap, and general practice consultation and treatment. RESULTS: More than one in five responders (n = 480) had experienced dizziness during the past month; nearly half of these (n = 225) reported some degree of handicap and 30% had been dizzy for more than five years. Almost half (n = 221) of those with dizziness also reported anxiety and/or avoidance behaviour. Multiple physical and psychological symptoms were associated with higher levels of handicap. Only one in four of the 225 dizzy responders reporting some degree of handicap had received any form of treatment. CONCLUSION: Dizziness is a common, chronic, and often untreated symptom in people aged 18-65 years, associated with extensive handicap and psychological morbidity.

Adult↗
PubMed1998

A controlled evaluation of small-group education of general practitioners in the management of drug users.

We evaluated the effectiveness of small-group education of general practitioners (GPs) in the management of drug users. A total of 40 doctors were trained. Some 28 doctors who were unable to attend and 30 who did not want training participated as comparison groups. Sixteen months after the education, trained doctors notified significantly more drug users to the British Home Office database and more often prescribed methadone at first consultation with a drug user.

Education, Medical, Continuing↗
PubMed1997

A randomized trial of the impact of telephone and recorded delivery reminders on the response rate to research questionnaires.

BACKGROUND: A range of factors have been shown to affect the response rate to mailed questionnaires, but particular strategies to improve patients' response in trials conducted in general practice require further study. METHODS: Non-responders in a larger trial were randomized to receive a telephone or recorded delivery reminder on the third contact. The cost of administration of each method was estimated. RESULTS: Significantly more patients returned completed questionnaires when sent questionnaires by recorded delivery, although the cost per patient contacted was nearly three times more than for contact by telephone. CONCLUSION: Our study indicates that sending reminders by recorded delivery, although more expensive, is more effective than telephone reminders for recruiting patients to a study in general practice using research questionnaires.

Adult↗