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Biomedical subjects

M Eccles

Publications and source records attributed to M Eccles.

At least 19 recordsLinked to original sources
PubMed1999

A framework for incorporating cost-effectiveness in evidence-based clinical practice guidelines.

In England, recent health care reforms emphasise the role of clinical guidelines in promoting effective and efficient health care. Introducing economic data into guidelines raises some methodological issues: specifically, the provision of valid and generalisable cost estimates, the weight placed upon cost 'evidence', and the presentation of cost-effectiveness information in a manner accessible to clinicians. A series of primary care guidelines, explicitly including consideration of health economic information, have recently been published, intended to help clinicians to aggregate the attributes of treatment choices to derive treatment recommendations consistent with both the clinical decision-making process and social objectives. Clinicians involved in developing guidelines responded well to the process and consistently managed to agree treatment recommendations, often after considerable debate about the evidence for treatment. In none of the guideline areas, all of which addressed common diseases, was there adequate information to estimate a cost per quality-adjusted-life-year, and it is unclear how helpful this approach would have been had it been possible. The implications of this method are discussed, guidance offered for economists new to guideline development and future areas of work identified.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1998

Missense mutation and hexanucleotide duplication in the PAX2 gene in two unrelated families with renal-coloboma syndrome (MIM 120330).

We present a family with autosomal-dominant inheritance of renal insufficiency caused by renal hypoplasia in six individuals. In all affected individuals, signs of optic disk dysplasia were detected, but most patients were asymptomatic. A heterozygous missense mutation in the PAX2 gene causing a Gly75 to Ser substitution was present in all affected individuals. A second, unrelated patient presented with ocular complaints related to optic disk dysplasia, and had a history of vesico-ureteral reflux. A heterozygous hexanucleotide duplication in the PAX2 gene was detected leading to the duplication of GluThr at positions 74 and 75. The mutations in these two families are the first mutations in the PAX2 gene that do not lead to a truncated protein. Mechanistically, these mutations are expected to result in abnormal folding of the PAX2 protein. These observations further expand the spectrum of clinical features associated with PAX2 mutations, and suggest that a distinct genetic disorder can be identified in patients with renal dysplasia through a careful eye examination. As the ocular manifestations in this syndrome are variable anomalies of retinal and optic disk dysplasia, we prefer the term "papillo-renal syndrome".

Abnormalities, Multiple↗
PubMed1998

Teaching the theory behind guidelines: the Royal College of General Practitioners Guidelines Skills Course.

In the face of a perceived lack of widespread understanding of the theoretical issues underlying the development, dissemination and implementation of clinical guidelines, the Royal College of General Practitioners Guidelines Group developed a 2-day course aimed at teaching the theory in these areas. The course was targeted at potential opinion formers and ran on six occasions. Postal questionnaire assessment of the course revealed high levels of satisfaction with all aspects of the course and high levels of reported use of the knowledge gained. Further developments of the course are discussed.

Clinical Competence↗
PubMed1997

A new self-completion outcome measure for diabetes: is it responsive to change?

Self-completion instruments assessing subjective health are increasingly being used to measure patient outcome. However, there is very little evidence as yet of existing instruments' responsiveness to change. This paper describes a study to evaluate the responsiveness to change of a self-completion instrument for the measurement of clinical outcome in patients with diabetes. A prospective follow-up study of 48 patients with non-insulin-dependent diabetes commencing insulin therapy was carried out, with assessments at baseline (i.e. pre-intervention), 6 weeks and 3 months post-intervention. The outcome measures used were the changes in scores on the self-completion instrument for symptom level, physical function, energy, depression, psychological distress and barriers to activity, HbA1c, non-fasting serum cholesterol and the body mass index (BMI). There were significant improvements in HbA1c and non-fasting serum cholesterol and worsening of the BMI, as expected. The self-completion instrument detected significant improvements in patient-reported symptoms within 6 weeks of the intervention (p < 0.01) and in energy levels (p < 0.05). There is evidence from this study of the self-completion instrument's ability to respond to change and it has potential for use in evaluative studies.

Aged↗
PubMed1997

Defining hypertension in older people from primary care case notes review.

A method of defining blood pressure (BP) status from a review of primary care patient records was developed and then validated using the case notes of a general practitioner with an interest in hypertension. Data were drawn from the records of the previous 6 years of all 65 to 80-year-old patients in the practice (n = 263). Patients were then categorised as hypertensive, normotensive or 'undetermined' by using a flowchart based on the mean of the three most recent BP measurements, antihypertensive medication and comorbidities of ischaemic heart disease, myocardial infarction, angina, oedema or cardiac failure. Mean systolic BP of > or = 160 mm Hg and/or diastolic BP of > or = 90 mm Hg were used as a threshold definition of hypertension and of BP control. Disagreement between general practitioner and the notes based definition occurred in 11% of patients (5% hypertensive, 6% normotensive). Reasons for disagreement were: controlled hypertensives with comorbidities such as angina or heart failure (4%), isolated elevated readings (3%), use of antihypertensive medication for separate indications (2%), other reasons (2%). The resulting sensitivity and specificity was 86% and 88% respectively. Including the recording of a diagnosis of hypertension in the definition increased the sensitivity to 98% with specificity unchanged at 88%. Actual sensitivity of the instrument when used in other practices is likely to lie between 88% and 98% depending on the quality of the doctor's recording of the diagnosis of hypertension. These findings suggest that data from primary care case notes can provide a ready and valid means of defining cases of hypertension for studying the management of hypertension in primary care and for research purposes.

Aged↗
PubMed1997

Doctors' attitudes towards the detection and treatment of hypertension in older people.

Within the former northern region a questionnaire was sent to a one in two random sample of general practitioners and to consultant physicians involved in the treatment of older hypertensive patients, to determine current attitudes of doctors to the management of hypertension in older people. A total of 407 general practitioners and 125 consultant physicians (including 38 consultant geriatricians) completed the questionnaire; response rates of 58% and 73% respectively. The median (range) threshold level for intervention of an otherwise well 75-year-old patient was 180 (140-240)/100 (90-120) mm Hg for general practitioners as against current recommendations of > or = 160/90 mm Hg. Geriatricians adopted significantly lower thresholds than both general practitioners and other specialists. Target blood pressure (BP) and drug therapy were in line with British Hypertension Society recommendations. The majority of general practitioners stated that they would initiate treatment for hypertension later, be less aggressive in their treatment and accept higher levels of BP than with younger patients. Approximately half perceived compliance and lifestyle changes as problematic in older people, while approximately a third were concerned about the problems created by drug treatment and uncertainty about the practicality of treating all older hypertensive patients. A quarter expressed reluctance to initiate hypertensive treatment because of side effects and to treat isolated systolic hypertension. These stated attitudes amongst general practitioners may explain the continuing conservatism in the management of hypertension. This study found considerable variation in diagnostic threshold between doctors, which suggests that current management of hypertension in older people is likely to vary significantly.

Aged↗
PubMed1997

The inter-rate reliability of a generic measure of severity of illness.

BACKGROUND: There has been increasing interest in the development of measures to quantify baseline severity of illness and thus provide a more meaningful interpretation of health outcomes. OBJECTIVE: We aimed to assess the inter-rater reliability of a generic measure of illness severity, the Duke University Severity of Illness (DUSOI) checklist. METHODS: Selected general practices and hospital outpatient departments across Tyneside and Humberside in the UK were used as the setting. Thirty-three clinicians were posted copies of the same set of 14 patient records and asked to rate the severity of illness of each patient using the DUSOI. The subjects were 27 GPs, three consultant chest physicians and three diabetologists. The main outcome measures were: (i) intraclass correlation coefficients used to express clinician agreement upon severity scores; and (ii) a 'gold standard', constructed in order to assess clinician agreement upon the health problems identified in the patient record to be considered as constituents of overall severity. RESULTS: It was found that the degree of inter-rater reliability of severity scoring was satisfactory, with an intraclass correlation coefficient of 0.43. In terms of identification of problems to be rated, there was considerable agreement between raters and a specially compiled 'gold standard' of health problems. CONCLUSION: The DUSOI has potential use in routine clinical practice, but strategies should be developed in order to maximize the reliability of rating illness severity on such a generic measure.

Ambulatory Care↗