Biomedical subjects
R Carr-Hill
Publications and source records attributed to R Carr-Hill.
Assessing the outcomes of nursing care.
There are many dimensions to outcome measurement for patient care and this study focuses on one aspect of outcome, namely that which is most concerned with the immediate effects of nursing care. Traditionally, outcome studies have been almost exclusively concerned with measuring the clinical outcomes of care with very little attempt being made to assess the effect of the nurses' contributions to that care. One of this study's purposes has been to redress this imbalance. As part of a research project on skill mix and the effectiveness of nursing care, a number of patient-focused standards related to the outcome of nursing care were designed. These were tested, in a case study situation, on 15 wards at seven acute hospitals. Initial testing indicates that these outcome measures show promise as a valid and reliable evaluation instrument with the utility for easy application in the clinical setting. They are being presented as a possible way forward to assessing the outcomes of nursing care.
Rationality and the use of formulae in the allocation of resources to health care.
The paper describes how the apparent move towards rationality in allocating resources in the National Health Service using statistically based formulae is illusory. This is not just a technical problem of poor application of statistical techniques. The basic problem is to find a combination of factors reflecting dimensions of need and then appropriate weights with which to combine them within the context of the guiding principles of equity and efficiency. The paper explains how there has been little consistency in measuring need and how statistical methods have often masked the lack of appropriate data and models. Alternative approaches to measuring need within a policy context are discussed and a research agenda is outlined which, rather than concentrating on evermore complex statistical techniques, focuses on the necessity for more validly operationalizing 'needs' and their resource implications.
Right approach, wrong method.
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Measure for measure.
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Equity and efficiency.
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Area variations in health outcomes: artefact or ecology.
It is a long-standing belief that the size of the difference between the poor (lower social groups) and the rich (higher social groups) in health outcomes will vary according to the characteristics of the area. However typical approaches to analyses of this kind of question violate standard statistical assumption. The basic problem is how to estimate the size of a 'ward effect' (the disadvantage of living in a 'poor' ward over and above effects associated with individual or household circumstances). This is complicated by the hypothesized existence of intra-ward correlated errors; the only way to avoid this bias is to explicitly model the different variance components using multi-level modelling techniques. The purpose of this paper is to illustrate this technique. Analysis using several of the health outcomes in the Health and Lifestyle Survey data, suggests that the ward effect is quite substantial, and remains after 'controlling for' age, gender and several other socio-demographic variables. This 'ward effect' appears to be best represented by the proportions without access to a car and the preponderance of working class members (RGSC IV and V) in the population. Whilst the verdict on the original hypothesis remains 'not proven', the hypothesis has been shown to be more complex than its simplistic statement suggests. The analyses have shown how to unpack these complexities and, more generally, have illustrated the power of the multi-level modelling technique.
Questions of quality.
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The measurement of inequities in health: lessons from the British experience.
There has been an acrimonious debate about trends in inequality in health in the U.K. over the last couple of years. Whilst the acrimony is highly specific to the U.K. context, the terms of the debate contain general lessons for others who would venture into the same territory. This paper has focused on problems with using occupational classifications, with using groups of different size, with assessing trends in inequalities in death, with the measurement tool employed, with comparing patterns of ill-health and with the framework of explanation. The U.K. debate provides a good example of the first problem. Much of the debate has had to rely on the classification of occupation at the time of death by the Registrar General's Department. The scheme used was devised in 1911 and has persisted despite the massive changes in occupational structure since then. The groups now contain different occupational titles, and it is not at all clear what is being referred to by the RG scheme. Moreover, the balance of the RG groups has shifted dramatically. Any scheme applied regularly and routinely to mortality statistics over time will have these problems--it is not surprising that it is very difficult to interpret patterns of class death rates. The argument over trends in the U.K. has sometimes focused exclusively on the measurement tool--the standardized mortality ratios. Various alternatives have been proposed, in particular the Gini coefficient which clearly answers a different, possibly rather uninteresting, question. The correct way of comparing 'top' and 'bottom' is to devise a method which produces a group of constant size in the different communities or at different times. The focus on death rather than survivorship is queried as is the usual restriction to comparing rates of early death. Possibilities of comparing patterns of ill-health are examined in the fifth section. Whilst routine health care data or survey morbidity data are invaluable, it seems highly unlikely that they can be compared between communities or over time. The alternative is to develop a series of 'risk' indicators and these are discussed in Section 5.3. The examination of patterns of inequalities in death and ill-health highlights the complexity of discussing aetiology. We consider the balance between long-term and short-term effects and the possible role of (ill)-health on the social mobility process, and problems of directly relating low income to poor health.
Putting patients before the machine.
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Let the patient speak.
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Is birth weight determined genetically?
Birthweight correlations were analysed among 505 intergenerational pairs of first births to women aged 18-25 identified from a large obstetric data bank. After standardisation for fetal sex, maternal height, gestational age, and proteinuric pre-eclampsia residual correlations of between 0.1402 and 0.1725 were found, suggesting only a small genetic effect. It is concluded that genetic factors play only a small part in determining birth weight.
The Nottingham health profile: a useful tool for epidemiologists?
The Nottingham health profile has been portrayed as a multipurpose measure of health status, capable of being used in population surveys and in evaluation of medical interventions. This paper examines basic operating characteristics of the profile, using data collected in a large survey of the community. Examination of the response pattern suggests that the NHP is not effective in discriminating health statuses as the modal response is zero. If it is to be used as a screening tool then there are considerable redundancies so that two or three items are sufficient; and for a diagnostic purpose, the existence of substantial covariation between items makes interpretation difficult. There is a need for an instrument fulfilling one or all of these purposes, but we need to know the operating characteristics of any instrument in detail before applying it. These results demonstrate that the methodological base of the NHP has yet to be established.
The inequalities in health debate: a critical review of the issues.
There has been an ongoing dispute about inequalities in health ever since the suppressed publication of the Black Report in 1980. It has recently been given a new edge by three publications: the proceedings of an SSRC Workshop held in November 1983 and the Registrar General's Decennial Supplement for 1979-1983, and another half-suppressed report, this time from Health Education Council. The first and third broadly claim that inequalities in health are widening; the second that they are irrelevant. This paper reviews the debate since 1980 around the issues of measurement (how to assess differences between social groups and how to compare across time) and the four kinds of explanation examined by the Black Report. The concluding discussion emphasises the essentially political nature of the debate over the 'trends' but concludes that, whilst most agree on the importance of materialist/structuralist variables, there are differences in the policy implications of the different explanatory positions. However, on the whole these will not be resolved by 'further research': the time is long overdue for a redistribution of resources to eradicate poverty.