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Biomedical subjects

R Carr-Hill

Publications and source records attributed to R Carr-Hill.

At least 19 recordsLinked to original sources
PubMed1999

Do measures of self-reported morbidity bias the estimation of the determinants of health care utilisation?

Most national surveys of health care utilisation capture only self-reported measures of morbidity. If self-reported morbidity is measured with error, then the results of applied work may be misleading. In this paper we propose a model of the relationship between morbidity and health service utilisation which allows for reporting errors and simultaneity. Errors in self-reported morbidity are expressed as a function of person-specific reporting thresholds and recent contact with health services, arising because of better self-evaluation of current health status or a desire to justify consumption of a publicly-provided good. We demonstrate the bias in ignoring the potential problems of reporting errors and simultaneity for a variety of special cases, but in the general case the biases are of ambiguous sign. The empirical nature of these biases is investigated using limiting long-standing illness (LLI) and recent contact with a General Practitioner (GP) in two waves of The UK Health and Lifestyle Survey. Biomedical measures of functioning are used as objective indicators of health status. We find evidence of substantial and significant differences between individuals in reporting thresholds and some evidence that the reporting of LLI may depend on recent visits to a GP. Adjustments for these biases significantly increase the estimated effect of morbidity on utilisation.

Adult↗
PubMed1999

Is hospital performance related to expenditure on management?

OBJECTIVES: Reducing the costs of management appears an easy target for those seeking to generate savings or to promote better spending in the National Health Service (NHS). However, an assessment of the appropriate amount of spending on management requires an evaluation of how much management contributes to organizational performance. METHODS: Using routinely available NHS acute hospital data, an econometric analysis was undertaken to test the hypothesis that there is a relationship between the proportion of a hospital's income spent on management and the performance of the hospital measured along three dimensions: the achievement of financial targets; performance against waiting time standards defined in the Patient's Charter; and costs of service provision. RESULTS: No general relationship was found between management costs and hospital performance. However, there was some evidence of a quadratic relationship between management spending and the amount of operating surplus generated and performance against the three-month waiting time standard for an inpatient admission specified in the Patient's Charter. These results suggest that performance returns reach an optimum when management expenditure is around 5-6% of hospital income. CONCLUSIONS: The evidence is not yet strong enough to draw a general conclusion that management costs in NHS acute hospitals are too high or that an undiscriminating reduction in management costs would have no detrimental effects on hospital performance. However, the findings should prompt managers to identify ways in which their activities are productive and how these can be measured, and what distinguishes effective from ineffective management.

Data Collection↗
PubMed1998

The influence of households on drinking behaviour: a multilevel analysis.

This paper examines the influence of household membership and area of residence on individual drinking behaviour using a multilevel modelling approach. The effects are investigated using data from the Health Survey for England (HSE) in which multiple interviews were conducted in the same household. With the use of postal address, the data were organised into a hierarchical structure of individuals within households within enumeration districts. After controlling for characteristics of individuals thought to influence or correlate with drinking behaviour, unexplained variation in alcohol consumption was attributed to individual, household and area effects. Household influences on drinking behaviour far outweigh the influences of place of residence. Policies aimed at reducing alcohol consumption, particularly by heavy drinkers, may be best targeted at the household level.

Adolescent↗
PubMed1998

Do minutes count? Consultation lengths in general practice.

OBJECTIVE: To document the variability in consultation length and to examine the relative weight of different kinds of characteristics (of the patients, of the general practitioner (GP), or of the practice) in affecting consultation length, and, thus, to assess whether consultation length can legitimately be used as a quality marker. DESIGN: A multilevel statistical analysis of 836 consultations across 51 GPs in ten practices. SETTING AND SUBJECTS: Ten general practices across four regions in England with varying list sizes, number of partners and fundholding status. MAIN OUTCOME MEASURES: Length of time face-to-face with patients in consultation measured in minutes and fractions of minutes. RESULTS: There is substantial inter-practice variation in consultation length, from a mean of 5.7 minutes to one of 8.5 minutes. In some practices the longest average GP consultation time is about twice that of the shortest. Trainees and new partners spend, on average, about 1 minute less than their longer-serving colleagues. Consultation lengths for individual GPs range from a mean of 4.4 minutes to 11 minutes. Late middle-aged women (55-64 years) receive the longest consultations, followed by elderly people, with children receiving the shortest consultations. The number of topics raised affects the length of the consultation by about 1 minute per additional topic. When female patients consult female GPs, approximately 1 minute is added to the average consultation. A significant fraction of the variability in consultation lengths can be explained in terms of characteristics of patients, of GPs and of practices. CONCLUSIONS: The fact that there is little unexplained variation in GP consultation lengths that might be attributable to variations in quality (i.e. GP-related) throws doubt on the proposition that length of consultation can be used as a marker for quality of consultation in general practice.

Aged↗
PubMed1998

Teams and seams: skill mix in primary care.

The study described in this paper is set against a background of rapid changes in primary (community) care delivery in the United Kingdom (UK) and consequently the methodology of the study has been shaped by three broad issues - workforce changes, increase in workload and changing roles and boundaries. Ten 'ordinary' general practices (general practitioners (GPs) and the 'attached' community nurses) participated in the study and a large amount of data were collected over a 2-week observation period. Three study objectives are described, relating to workload, delegation and attitudes to delegation. The characteristics of the workload of the three main groups of community nurses (practice nurses, district nurses and health visitors) are described and compared. Thirty-nine per cent of all the GP consultations (836) had a delegatable element and 17% were deemed to be delegatable in their entirety. General practitioners most frequently referred to delegation to practice nurses in the current team and nurse practitioners in an enhanced team. The study identified the activities most amenable to delegation to these two groups of nurses. Attitudes to delegation were sought through focus group discussions, with reservations being expressed by both doctors and community nurses. This study provides evidence that GPs are prepared to delegate a considerable proportion of their workload; this clearly has implications for the nursing profession.

Community Health Nursing↗
PubMed1997

Informing prescribing allocations at district level in England.

OBJECTIVES: To derive a predictive model based on the morbidity, demographic and socio-economic characteristics of district populations to explain variations in prescribing costs in England. METHOD: Inter-relations between morbidity, demographic, socio-economic, general practice supply characteristics and net ingredient cost per age, sex and temporary resident originated prescribing unit (ASTRO-PU) were explored statistically for 90 districts in England using 1994 cost data. The possibility of mutual inter-relationship between 'supply' and 'demand' was examined; then the associations between a range of factors and prescribing costs were estimated using ordinary least squares regression and the predictive power of the possible models was systematically examined. RESULTS: Whilst there was a relatively weak relationship between the supply factors that were measured, there did not appear to be any reciprocal relationship. Three parsimonious models estimated using ordinary least squares multiple regression techniques based on combinations of permanent sickness, low birth weight and the proportion of general practitioners registered for postgraduate certificate of education were identified. The models explained up to 61% of variation between districts in prescribing costs. CONCLUSIONS: 'Need' and 'supply' characteristics are independently associated with variations in prescribing costs at district level. The negative association between the proportion of general practitioners eligible for postgraduate education allowance and prescribing costs may reflect 'better' prescribing but could not be introduced into a resource allocation formula without introducing perverse incentives. The combination of permanent sickness and low birth weight complement each other by providing a proxy measure of morbidity mostly applicable to adult males (permanent sickness) and mothers (low birth weight being a measure of maternal health). These variables should be considered further for use in the process of allocating resources for prescribing to districts.

Cost Allocation↗
PubMed1995

Is enumeration district level an improvement on ward level analysis in studies of deprivation and health?

AIM: To investigate whether enumeration district (ED) level data reflect the aggregate characteristics of people living in that district better than ward level analysis. DESIGN AND SETTING: Reanalysis of the fourth national morbidity survey in general practice (MSGP4). Socioeconomic data on patients who had consulted 60 practices over one year were linked via postcode to ED and thence to small area statistics data for that ED and to the corresponding electoral ward. RESULTS AND CONCLUSIONS: There was no evidence that patients were likely to be more representative samples of the population of an ED than of a ward.

Data Interpretation, Statistical↗
PubMed1994

The dangers of managerial perversion: quality assurance in primary health care.

The promotion of primary health care (PHC) at the Alma Ata conference has been followed by a variety of managerial initiatives in support of the development of PHC. One of the more promising vehicles has been the implementation of quality assurance mechanisms. This paper reviews recent examples of this genre and argues that the thrust of both primary health care and quality assurance are in danger of being distorted by a rather antiquated approach to management.

Community Health Planning↗
PubMed1993

Assessing the effectiveness of quality assurance.

Traces the origins of the fashion for quality assurance and discusses the requisites of a quality assurance strategy. On the basis of a Department of Health funded study in England and Wales in 1989, draws attention to the wide range of activities which have been swept into the quality assurance net, the striking differences between the factors cited as constraining or facilitating the development of quality assurance, and the abysmal lack of data on cost or resources or to any systematic monitoring and evaluation. Suggests that the purchaser-provider split may have worsened the situation.

England↗
PubMed1993

Clinical birthweight standards for a total population in the 1980s.

OBJECTIVE: To derive clinical standards for singleton birthweight in a population based on area of residence. DESIGN: Analysis of variables recorded in Aberdeen Maternity and Neonatal Databank, calculating for each birth a standardised birthweight score, taking account of determining factors. SUBJECTS: All singleton live births of 32 to 42 weeks gestation to Aberdeen City District residents from 1979 to 1983. RESULTS: Basic standards of birthweight are presented correcting for gestational age, sex of the baby and parity of the mother. Birthweight is not normally distributed and empirical data are presented rather than smoothed curves. Adjustment for maternal height is straightforward but adjustment for maternal weight must take account of the gestation at which the woman was weighed. A method of calculating the appropriate correction for height and weight is described in detail. CONCLUSION: Birthweight is not normally distributed at each week of gestation. Standardisation for parity, gestation and sex of the baby is essential, but adjustment for maternal size is complex.

Birth Weight↗
PubMed1993

Consumption and harm: drinking patterns of the Irish, the English and the Irish in England.

There has been controversy over the relationship between alcohol consumption and related problems amongst the Irish in England. Irish migrants have high Standardised Mortality Ratios for chronic liver disease and cirrhosis and high hospital admission rates for alcohol-related diagnoses in England. Yet it has been considered that people from the Republic of Ireland, whether living in Ireland (Conniffe et al., 1990) or in England (Pearson et al., 1991), actually drink less than the English. This paper reviews the evidence. In recent years Irish per capita volume alcohol consumption has been comparable to that of the U.K., although the distribution of consumption differs. Women in Ireland are less likely to drink than women in England and Wales, while men in Ireland are more likely to drink at high-risk levels than men in England and Wales: their average weekly consumption levels are closer to those of high-consuming men in Yorkshire and Humberside, who also drink more than the U.K. national average. Men in Ireland also appear to be more likely to experience drinking problems than their counterparts in England and Wales, although this may be related to factors other than the total amount of alcohol consumed. Although a previous study of General Household Survey data indicated low-risk alcohol consumption levels for people from the Irish Republic living in Britain, a reanalysis of these data adjusting for age and gender shows drinking rates that are very high.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1992

Marking time.

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Nursing Staff, Hospital↗