Search PubMed⌕ Search

Biomedical subjects

R Baker

Publications and source records attributed to R Baker.

At least 145 records · Page 8Linked to original sources
PubMed1999

Quality of care of patients with diabetes: collation of data from multi-practice audits of diabetes in primary care.

BACKGROUND: GPs are now playing a greater role in the care of patients with diabetes. The challenges described in the Saint Vincent Joint Task Force Report include achievement of a reduction in long-term complications by collecting key clinical information and systematically organizing care of patients with diabetes. The number of practices conducting audit and the number of primary care audit groups conducting multi-practice audits of diabetes have increased since the introduction of audit in 1991. OBJECTIVES: We aimed to determine the feasibility of collating data from multi-practice audits of diabetes in primary care and to describe the pattern of care for diabetes patients in primary care. METHODS: A confidential postal questionnaire was sent to all medical audit advisory groups that had completed a multi-practice audit of diabetic care. The main outcome measures studied were prevalence and treatment of known diabetes and annual compliance with key process measures. RESULTS: Data could be collated for 17 of the 25 audit groups that supplied data representing information from 495 practices with 38 288 diabetic patients. Seven audit groups supplied data from a population denominator comprising 1475512 patients giving a prevalence of 1.46% (range 1.1-1.7%), 50.7% (range 32.5-69.0%) were managed by general practice only, 19.1% (7.6-39.7%) by hospital care only and 30.2% (11.0-49.5%) by shared care. Annual mean compliance for process measures showed wide variations: glycated haemoglobin or fructosamine checked for 72.5% (range 25.3-89.3%), fundi checked for 67.5% (57.8-86.6%), urine checked for 65.8% (27.5-80.0%), blood pressure checked for 87.6% (76.9-96.5%), smoking checked for 71.45 (21.9-86.0%), feet checked for 67.7% (40.0-90.8%) and BMI checked for 52.5% (26.4-68.2%). CONCLUSION: This study shows the feasibility of collating audit data and the potential of this approach for describing patterns of care and highlighting general and local deficiencies. Information about levels of performance in large numbers of patients can be used to set standards or norms against which individual practitioners can compare their own activity. Comparison of the health needs of local populations with national data could be used to inform commissioning services. However, audits should employ uniform evidence-based criteria so as to facilitate collation and allow comparison.

Data Collection↗
PubMed1999

Approaches to the organization of multi-practice audits in primary health care in the UK.

OBJECTIVE: To investigate the approaches taken by audit groups in primary care in organizing multi-practice audits and to identify the strengths and weaknesses of the methods used. DESIGN: Postal questionnaire survey. SETTING: One hundred and six primary care audit groups in England and Wales. RESULTS: Ninety multi-practice audits had been conducted since 1993, 46 of which were audits of diabetes and 44 of asthma care. A total of 48 completed questionnaires (24 each for asthma and diabetes) were returned (response rate 53%). Audit groups reported inviting 3338 practices to take part, of which 1157 completed the audit. The commonest methods used to encourage practice participation were a personal letter (75%), audit group newsletter (63%) and sending an audit protocol to the practice (63%). Groups used various methods for selecting audit review criteria, however only three (6%) used a systematic review of available literature. Each audit group advocated a number of methods for identifying patients and for data extraction. Forty-one (85.6%) groups reported that practices received feedback of results in an individualized practice feedback report. In 19 (39.6%) audits, the audit group had not undertaken any follow-up. CONCLUSIONS: The findings indicate that multi-practice audit can encourage the participation of large numbers of practices. Audit groups are co-ordinating multi-practice audits and feeding back information to practices on a comparative basis. However, there are weaknesses in the design and conduct of some audits. Groups should pay more attention to the selection of audit criteria, methods of identifying and sampling patients, data collection procedures, and methods for implementing changes in performance. For other countries that are beginning quality improvement activities, the results of this study emphasize the need to give attention to basic methodological principles.

Asthma↗
PubMed1999

Production and evaluation of guidelines for the management of inflammatory bowel disease: the Leicester experience.

Consensus guidelines for the management of patients with inflammatory bowel disease were produced by gastroenterologists, gastrointestinal surgeons and a cross-section of general practitioners (GPs) from Leicestershire in order to develop a seamless pattern of care with a common approach to diagnosis and treatment. It was hoped that the guidelines would encourage a movement towards care in the community for many patients with stable disease and so speed up new consultation rates. The study then assessed the impact of these guidelines on the referral letters of GPs to hospital consultants, the prediction of disease and adherence to them on re-referring patients after discharge. The guidelines were distributed to all 487 GPs in the Leicester Health Authority area and the gastroenterology teams within the hospitals. The value of the guidelines was assessed by an audit of referral letters, the length of time from referral letter to out-patient appointment, both before and after the launch of the guidelines, adherence to the guidelines on re-referral, and monitoring the outcome of the discharged patients. Whilst the guidelines may have helped GPs to manage stable patients in the community, the content of referral letters and the diagnostic abilities of GPs were not seen to improve since the launch of the guidelines. However, only 5% of stable patients who were discharged from one clinic were re-referred for inflammatory bowel disease.

Attitude↗
PubMed1999

Left in limbo: patients' views on care across the primary/secondary interface.

OBJECTIVES: To discover the views of patients about their experiences across the interface between primary and secondary health care, including referral from general practitioners, outpatient and inpatient care, discharge, and aftercare. DESIGN: A qualitative study involving individual and focus group interviews of patients and interviews of carers. SUBJECTS: 33 patients who had attended at least one outpatient appointment or had been an inpatient between two and four months previously, and eight carers of patients with chronic conditions. SETTING: Three acute hospitals and one community health service in Leicestershire. MAIN OUTCOME MEASURES: Common themes in the views of patients and carers towards their experiences of care. RESULTS: Five themes emerged. The first four were: "getting in" (access to appropriate care), "fitting in" (orientation of care to the patient's requirements), "knowing what's going on" (provision of information), and "continuity" (continuity of staff and coordination and communication among professionals). The fifth theme was "limbo" (difficulty in making progress through the system), which was influenced by failures in care in relation to the other four themes. CONCLUSIONS: The concept of progress is central to patients' views of care. It involves both progress through the healthcare system and progress towards recovery or adjustment to an altered health state. Patients' views on how well they progress through the healthcare system may be an appropriate indicator for monitoring health service performance.

Continuity of Patient Care↗
PubMed1999

Measuring patients' attitudes to care across the primary/secondary interface: the development of the patient career diary.

BACKGROUND: A growing number of new ways of organising services across the primary/secondary interface are being introduced and evaluated. The principal motive for such reorganisation is to improve the efficiency of health care. However, unless the impact of the new services on patients is investigated and taken into account, it is possible that patients' reactions could be negative, a factor that could lead to unexpected consequences in the use and costs of services. OBJECTIVE: To develop a measure of patients' attitudes towards care across the interface between primary and secondary care. DESIGN: Generation of questions to be included in the measure from a qualitative study of patients' experiences of care across the interface; administration of pilot versions of the measure to samples of patients referred to secondary care; refinement of questions guided by analysis of response patterns, principal components analysis and internal consistency; administration of the final version of the patient career diary in complete form retrospectively to patients referred to secondary care, and one section alone to patients attending outpatient departments for follow up appointments. Face validity was assessed by analysis of open comments in a sample of 50 diaries, and review of the diary by 34 health professionals. Construct validity was assessed by investigation of levels of correlation between components of each section of the diary and the components of the healthcare section overall. SETTING: In the final field test, patients were attending various hospital services, including cardiology, dermatology, neurology, gynaecology, general surgery, general medicine, ophthalmology, trauma and orthopaedics, and gastroenterology. RESULTS: The final version of the diary included 109 questions in seven sections: general practitioner (GP) visits and referral, other GP visits, first outpatient visit, other outpatient visits, inpatient stay and discharge, care after discharge, and care overall. Response rates were poor for retrospective completion of the entire diary, but excellent when a section was given separately. Principal components analysis confirmed that components relating to issues identified as important to patients in the qualitative study had been included in the diary. Levels of internal consistency were good, and comments of patients and health professionals supported validity. CONCLUSION: The patient career diary is a valid and reliable measure of patients' attitudes to care across the interface. It should be given in sections to ensure adequate response rates, and is suitable for use in the evaluation or quality of patterns of care across the interface. In future, the impact on patients of new ways of organising services across the interface should be investigated by use of measures such as the patient career diary.

Attitude↗
PubMed1999

Minority distrust of medicine: a historical perspective.

Recent philosophical work has disclosed a host of problems in our apparently natural ways of classifying things. The contemporary classification of certain groups as "minorities" exemplifies some of these problems. I argue that these classifications are arbitrary and misleading. Through examining several of the most significant ethical moments in the history of modern medicine, including the thought and conduct of Nazi physicians, the Tuskegee study, Beecher's questioning of post-war research practices and Percival's enunciation of a universalist ethic for physicians, I make a case against racial and ethnic classification of patients. Such classifications can play a destructive role in determining the sort of health care which minorities receive. Embracing them, even with the intent of improving the lot of those who do not fare well in the present health care environment, is subversive of the egalitarian stance which has been central to medical ethics since Hippocrates.

Ethics, Medical↗
PubMed1999

Collation and comparison of multi-practice audit data: prevalence and treatment of known diabetes mellitus.

BACKGROUND: Different methods have been used to determine the prevalence and treatment of diabetes. Despite the large number of studies, previous estimations of prevalence and treatment have been carried out on relatively small numbers of patients, and then in only a few practices in single geographical regions. AIM: To investigate the feasibility of collating data from multi-practice audits organized by primary care audit groups in order to estimate the prevalence and treatment of patients with known diabetes, and to discuss the methodological issues and reasons for variation. METHOD: A postal questionnaire survey of all primary care audit groups in England and Wales that had conducted a multi-practice audit of diabetes between 1993-1995. Prevalence rates and patterns of diabetic care were compared with other community-based surveys of known diabetes from 1986-1996 identified on MEDLINE. RESULTS: Twenty-five (43%) audit groups supplied data from multi-practice audits of diabetes. Seven (28%) multi-practice audits involving 259 practices fulfilled the inclusion criteria for prevalence estimation. The overall prevalence of diabetes based on a population of 1,475,512 patients was 1.46% (range between audit groups = 1.18% to 1.66%; chi 2 = 308; df = 6; P < 0.0001). Male to female ratio was 1.15:1. Treatment of diabetes could be ascertained for 10 (40%) audit groups comprising 319 practices. Of these, 23.4% (range = 16.5%-27.4%) were controlled by diet, 48.5% (range = 43.6%-55.8%) were prescribed oral hypoglycaemic drugs, and 28.2% (range = 25.0%-32.4%) were treated with insulin. There were significant variations between audit groups in treatment pattern (chi 2 = 250; df = 18; P < 0.0001). CONCLUSION: Prevalence and treatment rates of diabetes and other chronic diseases can be assessed and compared using data from multi-practice audits. Collation of audit data could improve the precision of quantitative estimates of health status in populations. A standard method of data recording and collection may provide a new approach that could considerably improve our ability to monitor disease and its management.

Diabetes Mellitus↗
PubMed1998

Effects of indirect light and propranolol on melatonin levels in normal human subjects.

An indirect lighting protocol was developed to measure nocturnal melatonin suppression by light in normal human subjects. Goals were to minimize both discomfort due to staring intensely at a bright light source, and behavioral variation due to wandering gaze. Subjects sat with a bank of five full-spectrum light sources placed behind them. Lights reflecting off the surfaces before each subject produced a hemisphere of light that measured 500 lx +/- 5%. Subjects retired to bed in darkness by midnight and then sat in the hemisphere of light from 02.00 h to 04.00 h. Blood for melatonin was drawn at 20-30-min intervals from midnight to 06.00 h. Plasma melatonin was measured by radioimmunoassay. The indirect lighting protocol was used to compare the effects of 500 lx light to dark (21 subjects) and to study varying light intensities from 300 to 2000 lx (7 subjects). We studied the effects of the sitting posture in very dim light of 20-30 lx (6 subjects). We also studied the effects of propranolol plus dark and propranolol plus 500 lx light on melatonin levels. Subjects received placebo, 10 mg propranolol or 40 mg propranolol orally at 23.00 h, and were then exposed to either the dark or light condition. Melatonin levels obtained with the indirect lighting protocol were consistent with studies using direct lighting; light of 500 lx significantly suppressed nocturnal melatonin and suppression was dose related between 300 and 2000 lx. Sitting in dim light had no significant effect on melatonin suppression when compared with the supine posture in the dark in six subjects. Propranolol caused a dose-dependent decrease in melatonin levels in both the dark and the light. There was no relationship between suppression of melatonin by propranolol and suppression by light.

Adolescent↗
PubMed1998

Effects of treatment with formoterol on bronchoprotection against methacholine.

PURPOSE: In addition to their bronchodilatory effects, beta(2)-agonists protect against bronchoconstriction, such as that caused by methacholine challenge. However, tachyphylaxis to this beneficial effect develops after chronic use of beta(2)-agonists. We studied whether the frequency or dose of treatment with a long-acting beta(2)-agonist (formoterol) affects the degree of bronchoprotection afforded against methacholine challenge and to compare this with the effects of a short-acting beta(2)-agonist (terbutaline). PATIENTS AND METHODS: In a randomized, parallel group, double-blind study at two centers, patients with stable asthma of mild to moderate severity who were treated with inhaled corticosteroids were treated with formoterol 6 micrograms twice daily, 24 micrograms twice daily, 12 micrograms once daily; terbutaline 500 micrograms four times daily; or placebo. Treatments were given by dry powder inhaler for a period of 2 weeks. Of the 72 patients who were enrolled, 67 completed the study. Methacholine challenge was performed to calculate the provocative dose that caused a 20% fall in forced expiratory volume in 1 second at baseline (unprotected) after an initial 1-week run-in without beta(2)-agonists, 1 hour after the first dose of study treatment, and again 1 hour after 7 and 14 days of study treatment. RESULTS: Each of the four active treatments exhibited significant tachyphylaxis (P < 0.05) to protection against methacholine challenge when comparing first/last dose (as geometric mean protection ratio versus baseline): formoterol 24 micrograms twice daily (9.6-fold/1.6-fold), 12 micrograms once daily (7.1-fold/2.2-fold), 6 micrograms twice daily (6.2-fold/2.3-fold), and terbutaline 500 micrograms four times daily (2.9-fold/2.0-fold). There were no significant differences among treatments after 2 weeks in bronchoprotection against methacholine challenge. For all formoterol regimens, the bronchodilator response 1 hour after inhalation was maintained over the 2-week treatment period. Diurnal control of morning and evening peak flow was significantly better with formoterol 24 micrograms twice daily than with terbutaline. CONCLUSIONS: Tachyphylaxis to bronchoprotection against methacholine challenge develops after 2 weeks of therapy with formoterol, a long-acting beta(2)-agonist, at all three dosage regimens that were tested. In contrast, the bronchodilator effects of formoterol were maintained during the 2 weeks of treatment.

Adolescent↗
PubMed1998

From genes to behavior in the vestibular system.

The central nervous system of all vertebrate embryos is derived from a series of conspicuous segments, called neuromeres, that are particularly visible in the midbrain and hindbrain areas, giving rise to the brain stem sensory and motor nuclei. This article focuses on a series of eight embryonic rhombomeric segments whose progeny can be identified in adults by the locations of iteratively homologous reticulospinal neurons and cranial motor nuclei IV through XII. Evidence shows that these rhombomeric units represent domains of gene expression, lineage restriction, and accordingly, individual vestibular neuronal phenotypes with unique oculomotor and spinal projections. Preliminary electrophysiologic and behavioral correlates of a few vestibulo-oculomotor subgroups are used as examples to illustrate the hypothesis that homologous vestibular phenotypes likely exist in all taxa because the genetic prepattern is already well established in primitive vertebrates. Finally, the segmented hindbrain arrangement responsible for the longitudinally arranged column of vestibular subnuclei is placed in perspective with genetic and molecular approaches that will eventually permit a causal reconstruction of the signaling mechanisms responsible for the development of unique vestibular subgroups.

Animals↗
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↗
PubMed1998

Measuring change in health in general practice: a comparison of a simple transition question with the Nottingham Health Profile.

OBJECTIVE: To compare a simple transition question with a standard measure of distress [the Nottingham Health Profile (NHP)] in the measurement of change in health of patients attending general practitioners. SETTINGS AND SUBJECTS: Two hundred and thirty one patients attending for acute or chronic illness, or follow-up consultations in a single general practice. MEASURES: Patients completed the NHP at the consultation and again after 2 weeks. They also completed the transition question after 2 weeks, which asked how the patient felt in comparison with 2 weeks before. In addition, patients in the chronic category were reviewed at 2 weeks by the general practitioner. Analysis sought the level of agreement between the changes in NHP scores and the transition question responses. RESULTS: Levels of correlation between changes in NHP scores and the transition question were low, and for patients with chronic illness correlation was only moderate between the transition question and the general practitioner's assessment. The transition question was less sensitive to deterioration in health. CONCLUSIONS: Caution is required in the interpretation of finding from the use of simple transition questions that ask patients how they feel. Further evaluation of transition questions with different wording and format is required.

Chronic Disease↗