Biomedical subjects
Publications and source records attributed to N Craig.
A connection between measurable equilibrium thermodynamic quantities and a nonequilibrium property of supercooled polymeric liquids, namely, the fragility index, is proposed within the framework of a synthesis of generalized configurational entropy models. The theoretical predictions are compared with experimental data on five glass-forming polymers.
OBJECTIVES: To compare use, effect, and cost of personalised computer education with community psychiatric nurse education for patients with schizophrenia. DESIGN: Randomised trial of three interventions. Modelling of costs of alternatives. PARTICIPANTS: 112 patients with schizophrenia in contact with community services; 67 completed the intervention. INTERVENTIONS: Three interventions of five educational sessions: (a) computer intervention combining information from patient's medical record with general information about schizophrenia; (b) sessions with a community psychiatric nurse; (c) "combination" (first and last sessions with nurse and remainder with computer). MAIN OUTCOME MEASURES: Patients' attendance, opinions, change in knowledge, and psychological state; costs of interventions and patients' use of NHS community services; modelling of costs for these three, and alternative, interventions. RESULTS: Rates of completion of intervention did not differ significantly (71% for combination intervention, 61% for computer only, 46% for nurse only). Computer sessions were shorter than sessions with nurse (14 minutes v 60 minutes). More patients given nurse based education thought the information relevant. Of 20 patients in combination group, 13 preferred the sessions with the nurse and seven preferred the computer. There were no significant differences between groups in psychological outcomes. Because of the need to transport patients to the computer for their sessions, there was no difference between interventions in costs, but computer sessions combined with other patient contacts would be substantially cheaper. CONCLUSIONS: The computer based patient education offered no advantage over sessions with a community psychiatric nurse. Investigation of computer use combined with other health service contacts would be worth while.
The results of late surgery for symptomatic proximal migration of the radius after resection of the radial head for trauma are usually disappointing. Ulnar variance increases when the interosseous membrane is disrupted. Its integrity should be assessed to predict the results of further surgery. We describe a 29-year-old patient in whom distraction lengthening of the radius through an Ilizarov frame allowed him to regain pain-free function of the wrist and elbow after a complex Essex-Lopresti fracture dislocation and late symptoms of ulnar carpal impingement.
Examines the relationships between the macro-, meso-, and micro-levels in the NHS at the end of the fundholding period and considers their contemporary implications for primary care groups (PCGs) and local health care co-operatives (LHCCs). Fundholding achieved some success in challenging the way in which services were provided at the micro-level (the practice), but had a less marked effect in terms of changing service provision at the health authority (meso-) level or in developing collaborative working with trusts and health authorities in strategic decision making. The health authorities prioritized alternative models of devolved commissioning. Trusts regarded fundholders as a distraction who exerted influence and commanded trust management time disproportionate to their "market share". PCGs and LHCCs represent a shift back to the meso-level in service planning and purchasing. As such there is a risk that the micro-level benefits of fundholding and other forms of devolved commissioning will be lost, while uncertainties remain regarding the capacity of PCGs and LHCCs to incorporate GPs into a collaborative approach to strategic decision making.
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OBJECTIVE: To evaluate the costs and benefits of alternative systems of coronary heart disease monitoring in Scotland. DESIGN: An option appraisal was conducted to evaluate the costs and benefits of implementing a coronary heart disease monitoring system. This involved a review of existing Scottish datasets and relevant reports, specification of options, definition and weighting of benefit criteria by key stakeholders, assessment of options by experts, and costing of options. The options were assessed by 33 stakeholders (grouped as cardiologists, patient representatives, general practitioners, public health physicians, and policy makers), plus 13 topic experts. SETTING: Scotland (population 5.1 million). RESULTS: Between group mean benefit weights were: mortality rates and case fatality (10.6), quality of life (9.8), patient function (8.8), hospital activity (7.8), primary care activity (9.25), prescribing (5.72), socioeconomic impact (4.0), risk factors (7.4), prevalence (5.0), incidence (6.0), case registration (6.82), international comparability (4.2), breadth of coverage (8.8), and frequency (5.8). Differences between group weights were significant for prevalence (p = 0.048) and international comparability (p = 0.032). Four monitoring options were identified: a community epidemiology model, based on MONICA (monitoring trends and determinants in cardiovascular disease) study methodology applied to a series of eight representative communities, had the highest benefits, at an average annual discounted cost of approximately pound 360,000; models based on the Australian cardiovascular disease monitoring scheme and on enhanced routine data offered fewer benefits at discounted average annual costs ranging from pound 165,000 to pound 195,000; finally, a coronary heart disease registry modelled on the Scottish Cancer Registry scheme would have had fewer benefits and substantially higher costs than the other options. CONCLUSIONS: The most beneficial coronary heart disease monitoring system is the community epidemiology model, based on MONICA methodology. Option appraisal potentially offers an explicit and transparent methodology for evidence based policy development.
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OBJECTIVE: To compare the use and effect of a computer based information system for cancer patients that is personalised using each patient's medical record with a system providing only general information and with information provided in booklets. DESIGN: Randomised trial with three groups. Data collected at start of radiotherapy, one week later (when information provided), three weeks later, and three months later. PARTICIPANTS: 525 patients started radical radiotherapy; 438 completed follow up. INTERVENTIONS: Two groups were offered information via computer (personalised or general information, or both) with open access to computer thereafter; the third group was offered a selection of information booklets. OUTCOMES: Patients' views and preferences, use of computer and information, and psychological status; doctors' perceptions; cost of interventions. RESULTS: More patients offered the personalised information said that they had learnt something new, thought the information was relevant, used the computer again, and showed their computer printouts to others. There were no major differences in doctors' perceptions of patients. More of the general computer group were anxious at three months. With an electronic patient record system, in the long run the personalised information system would cost no more than the general system. Full access to booklets cost twice as much as the general system. CONCLUSIONS: Patients preferred computer systems that provided information from their medical records to systems that just provided general information. This has implications for the design and implementation of electronic patient record systems and reliance on general sources of patient information.
Seven members of the human 3beta-hydroxysteroid dehydrogenase (3beta-HSD) gene family (HGMW-approved symbols HSD3BP1-HSD3BP5) have been cloned and physically mapped. HSD3B1 and 2 express 3beta-HSD enzymes; HSD3Bpsi1-5 are unprocessed pseudogenes that are closely related to HSD3B1 and 2 but contain no corresponding open reading frames. mRNA is expressed from psi4 and psi5 in several tissues, but with altered splice sites that disrupt reading frames. A 0.5-Mb contig of 3 yeast artificial chromosome and 32 bacterial artificial chromosome genomic clones contained no additional members of the gene family. The seven genes and pseudogenes mapped within 230 kb in the order HSD3Bpsi5-psi4-psi3-HSD3B1-psi1-psi2 -HSD3B2. HSD3B1 and 2 are in direct repeat, 100 kb apart. Six HSD3B2 mutations involve substitutions that are present in several of the pseudogenes. In four cases, mutations arose in CpG sites that are conserved within the gene cluster. The tendency for CpG sites to mutate by transition provides an adequate explanation for these HSD3B2 mutations, which are unlikely to be due to recombination or conversion within the gene family.
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.
OBJECTIVES: To investigate the benefit of carotid endarterectomy relative to medical treatment, by comparing the outcome for different groups of patients following transient ischaemic attacks. METHODS: A Markov model was used to describe the survival and quality of life of patients treated for a transient ischaemic attack. The benefit is measured in terms of quality adjusted life months (QALMs). The outcome was estimated using a computer simulation with parameters based on published studies on the probability of events following treatment. The benefit of carotid endarterectomy was explored using a baseline set of parameters and a sensitivity analysis. RESULTS: The baseline scenario of a 65-year-old male patient with the model factors set at an intermediate level showed a benefit for surgery of 3 QALMs compared with medical treatment alone. The sensitivity analysis showed that the most favourable combination of factors had a benefit of 13.4 QALMs and the least favourable a loss of 2 QALMs. Of all 128 factor combinations, 79.9% showed a benefit for surgery, 5.5% showed equal benefit, and 15.6% showed a benefit for medical treatment. CONCLUSIONS: Computer simulations have the potential for deriving estimates of benefit for different patient groups from the results of clinical trials. Combined with reliable information on costs, the technique could also demonstrate variations in cost-effectiveness for these groups. For patients following a transient ischaemic attack, the results from this simulation and limited cost information suggest that carotid endarterectomy is unlikely to be a cost-effective intervention in the UK for many patient groups despite a reduction in the risk of stroke.
Programme Budgeting (PB) has been widely promoted as a model for the better conduct of the work of Health Authorities in the National Health Service in the United Kingdom. This paper reports on a project which looked at the development of PB in Newcastle and North Tyneside Health Authority (NNTHA), concentrating on the construction of a computerised tool for the compilation and analysis of programme budgets. The main activities carried out were a survey of user requirements for PB, a survey of data availability, the collection of data to construct programme budgets, and development of a relational database for storing and manipulating PB information. The main source of data was the Contract Minimum Data Set, which was supplemented by data from a number of other sources to give comprehensive information on spending in NNTHA. Costed activity data were produced, which could be aggregated in a large number of ways, such as by care setting (inpatient, outpatient, community, general practice, etc.), disease group (ICD9 chapter headings), case mix (Healthcare Resource Groups) and socio-demographic variables (age/sex, locality of GPs practice).
Choices need to be made between competing uses of health care resources. There is debate about how these choices should be made, who should make them and the criteria upon which they should be made. Evaluation of health care is an important part of this debate. It has been suggested that the contribution of health economics to the evaluation of health promotion is limited, both because the methods and principles underlying economic evaluation are unsuited to health promotion, and because the political and cultural processes governing the health care system are more appropriate mechanisms for allocating health care resources than systematic economic analysis of the costs and benefits of different health care choices. This view misrepresents and misunderstands the contribution of health economics to the evaluation of health promotion. It overstates the undoubted methodological difficulties of evaluating health promotion. It also argues, mistakenly, that economists see economic evaluation as a substitute for the political and cultural processes governing health care, rather than an input to them. This paper argues for an economics input on grounds of efficiency, accountability and ethics, and challenges the critics of the economic approach to judge alternative mechanisms for allocating resources by the same criteria.
When the internal market was introduced, the National Health Service Management Executive envisaged purchasing as a process by which contracts would be developed from information concerning current services, modified in the light of strategic purchasing objectives, epidemiological needs assessment and indicators of comparative performance and efficiency. Our concern in this paper is with the promotion of efficiency. We distinguish between three levels and, in particular, discuss how the programme budgeting and marginal analysis framework can be used in the promotion of efficiency at 'top-level' decision making. PB/MA can be used to give a focus to needs assessment and forge explicit links between individual contracts within a well defined health strategy. The objectives of the current research and development ongoing within Newcastle and North Tyneside Health Authority are outlined. The intention is to achieve programme budgeting which is more responsive to decision makers' needs and is consistent with the contracting cycle. However, a number of constraints are expected to impede development. They include transferability of national and international information; absence of local information on epidemiology, effectiveness and cost-effectiveness; limitations on the accuracy and precision of programme budgets; and whether purchasers make strategic decisions based on macro budgets. The contribution of each of these constraints is explored.
This paper outlines a general strategy for mathematical modeling of cycling performance. This strategy involves formulating one expression describing the power available for external work from physiological sources. The variables used in this expression include maximal aerobic power (VO2max), fractional utilisation of VO2max, mechanical efficiency, maximal accumulated oxygen deficit, and the time constants relating to the expression of aerobic and anaerobic capacities. A second expression describing the power demand of cycling is then constructed. The variables used in this expression include the mass, projected frontal area and drag characteristics of the system, the coefficient of rolling resistance, environmental variables such as temperature, barometric pressure, relative humidity, wind speed and direction and the slope of the course. The two expressions are equated and solved using an iterative procedure. Two series of trials were used to assess the predictive accuracy of the model, one using track endurance performances and the other a 26 km road time-trial. The correlations between actual and predicted times have been excellent (0.92-0.95, p < or = 0.0001), with small mean differences (0-1.83% of mean performance time) and mean absolute differences (1.07-3.24%). The model allows us to make predictions about the effect of equipment changes and environmental factors, to compare performances under very different conditions, and to predict the limits of the possible in cycling performance. A range of options designed to improve cycling performance is described.
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The performance of the National Health Service is assessed in part by an Efficiency Index (EI) which is applied to the service as a whole as well as to individual health authorities. The EI relates increases in the amount of patient care activity to increases in total expenditure. The index can give a misleading impression of performance, creates perverse incentives and is at odds with the overall strategy of the health service which is to place greater emphasis on the promotion of health and to provide more care in primary and community-based settings. The philosophy, validity and appropriateness of the EI are discussed.