Biomedical subjects

Simon Capewell

Publications and source records attributed to Simon Capewell.

25 records · Page 2Linked to original sources

PubMed2003

Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review.

CONTEXT: As more interventions become available for the treatment of coronary heart disease (CHD), policy makers and health practitioners need to understand the benefits of each intervention, to better determine where to focus resources. This is particularly true when a patient with CHD quits smoking. OBJECTIVE: To conduct a systematic review to determine the magnitude of risk reduction achieved by smoking cessation in patients with CHD. DATA SOURCES: Nine electronic databases were searched from start of database to April 2003, supplemented by cross-checking references, contact with experts, and with large international cohort studies (identified by the Prospective Studies Collaboration). STUDY SELECTION: Prospective cohort studies of patients who were diagnosed with CHD were included if they reported all-cause mortality and had at least 2 years of follow-up. Smoking status had to be measured after CHD diagnosis to ascertain quitting. DATA EXTRACTION: Two reviewers independently assessed studies to determine eligibility, quality assessment of studies, and results, and independently carried out data extraction using a prepiloted, standardized form. DATA SYNTHESIS: From the literature search, 665 publications were screened and 20 studies were included. Results showed a 36% reduction in crude relative risk (RR) of mortality for patients with CHD who quit compared with those who continued smoking (RR, 0.64; 95% confidence interval [CI], 0.58-0.71). Results from individual studies did not vary greatly despite many differences in patient characteristics, such as age, sex, type of CHD, and the years in which studies took place. Adjusted risk estimates did not differ substantially from crude estimates. Many studies did not adequately address quality issues, such as control of confounding, and misclassification of smoking status. However, restriction to 6 higher-quality studies had little effect on the estimate (RR, 0.71; 95% CI, 0.65-0.77). Few studies included large numbers of elderly persons, women, ethnic minorities, or patients from developing countries. CONCLUSIONS: Quitting smoking is associated with a substantial reduction in risk of all-cause mortality among patients with CHD. This risk reduction appears to be consistent regardless of age, sex, index cardiac event, country, and year of study commencement.

Cohort Studies↗

PubMed2003

Negotiating palliative care expertise in the medical world.

This paper explores the relationship between palliative medicine and the wider medical world. It draws on data from a focus group study in which doctors from a range of specialties talked about developing palliative care for patients with heart failure. In outlining views of the organisation of care, participants engaged in a process of negotiation about the roles and expertise of their own, and other, specialties. Our analysis considers the expertise of palliative medicine with reference to its technical and indeterminate components. It shows how these are used to promote and challenge boundaries between medical specialties and with nursing. The boundaries constructed on palliative medicine's technical contribution to care are regarded as particularly coherent within orthodox medicine. In contrast, its indeterminate expertise, represented by the 'holistic' and 'psychosocial' agendas, is potentially compromising in a medical world that prizes science and rationality. We show how the coherence of both kinds of expertise is contested by moves to extend palliative care beyond its traditional temporal (end-of-life) and pathological (cancer) fields of practice.

Focus Groups↗

PubMed2003

Why are patients in clinical trials of heart failure not like those we see in everyday practice?

BACKGROUND/OBJECTIVES: Evidence-based research has been criticized for not being relevant to the real world of patient care in the community, mainly because participants in research studies are dissimilar to those typically seen in every day practice. This article examines recruitment difficulties, and identifies the main reasons why patients with heart failure declined to participate in a research trial. METHODS: Postal survey of potential trial participants (n=667), at time of recruitment. Analysis of (1) clinical and sociodemographic characteristics of respondents and nonrespondents to survey, and decliners and consenters to participation in a randomized controlled trial. RESULTS: No significant differences were found between respondents and nonrespondents in respect to sociodemographic or clinical variables. Males (OR=1.58, CI=1.04-2.41), younger patients (OR=1.05, CI=1.03-1.08), and those prescribed an angiotensin converting enzyme (ACE) inhibitor (OR=1.68, CI=1.10-2.57) were significantly more likely to consent to participate. Main reasons for nonparticipation were perceptions of being too old, too unwell, or too busy. CONCLUSIONS: Explanations of the purpose of research need to counter against perceptions among participants and clarify the benefits and disadvantages of participating in an intervention study when unwell. Study design should recognize that many elderly patients have busy lives and caring responsibilities. Financial support for participation should be considered.

Aged↗

PubMed2003

Prospective cohort studies of coronary heart disease in the UK: a systematic review of past, present and planned studies.

BACKGROUND: Prospective cohort studies have made enormous contributions to our understanding of coronary heart disease (CHD) epidemiology in the UK. However, identification of cohorts and dissemination of key characteristics and results can be haphazard, and it is difficult to identify studies which are at the planning stage. METHODS: We carried out a systematic review of cohort studies by searching MEDLINE and relevant websites and consulting key individuals. We included all large prospective UK cohort studies that focused on the development of CHD in predominantly healthy subjects. RESULTS: The MEDLINE search retrieved 1558 hits and we identified 39 cohorts that met inclusion criteria. 'Early' cohorts were important in defining the major risk factors for CHD, particularly smoking, cholesterol, blood pressure, physical activity and body mass index. Prospective cohort studies have subsequently appraised potentially important novel risk factors including nutritional status, genetic determinants, haemostatic factors, lipid sub-fractions, psychosocial factors and the 'life course' perspective. Psychosocial factors have been relatively neglected, as have women, ethnic minorities and the elderly. Key methodological issues include minimizing losses to follow up, standardized measurements, quality assurance systems, change in risk factors over time, residual confounding, regression dilution bias, detection of non-fatal events, measurement of quality of life, and generalizability. CONCLUSIONS: The current and proposed prospective UK cohorts have sufficient power potentially to determine the importance of many traditional and newer CHD risk factors on cardiovascular risk in men, women and even ethnic minorities. However, secure financial support and hence sustainability will remain essential to maximize long-term benefits.

Cohort Studies↗

PubMed2002

Doctors' perceptions of palliative care for heart failure: focus group study.

OBJECTIVES: To identify doctors' perceptions of the need for palliative care for heart failure and barriers to change. DESIGN: Qualitative study with focus groups. SETTING: North west England. PARTICIPANTS: General practitioners and consultants in cardiology, geriatrics, palliative care, and general medicine. RESULTS: Doctors supported the development of palliative care for patients with heart failure with the general practitioner as a central figure. They were reluctant to endorse expansion of specialist palliative care services. Barriers to developing approaches to palliative care in heart failure related to three main areas: the organisation of health care, the unpredictable course of heart failure, and the doctors' understanding of roles. The health system was thought to work against provision of holistic care, exacerbated by issues of professional rivalry and control. The priorities identified for the future were developing the role of the nurse, better community support for primary care, and enhanced communication between all the health professionals involved in the care of patients with heart failure. CONCLUSIONS: Greater consideration should be given to the care of patients dying with heart failure, clarifying the roles of doctors and nurses in different specialties, and reshaping the services provided for them. Many of the organisational and professional issues are not peculiar to patients dying with heart failure, and addressing such concerns as the lack of coordination and continuity in medical care would benefit all patients.

Attitude of Health Personnel↗

PubMed2002

Heart failure in a cold climate. Seasonal variation in heart failure-related morbidity and mortality.

OBJECTIVES: This study was done to determine whether seasonal variation exists in hospitalizations and deaths due to heart failure (HF) and to examine possible contributors to such variability. BACKGROUND: Although seasonal variation in the incidence of acute myocardial infarction and sudden death is well recognized, it is less well documented in HF. METHODS: We used the linked Scottish Morbidity Record scheme, which provides individualized morbidity and mortality data for the entire Scottish population. RESULTS: Between 1990 and 1996, there were a total of 75,452 male and 81,269 female hospitalizations related to HF in Scotland, with an average rate of admissions per 100,000 population of 8.4 and 8.5 per day, respectively. Significantly more admissions occurred in winter compared to summer (p < 0.0001). In women, the peak rate of admission occurred in December (12% more than average) and the lowest rate in July (7% less than average) (odds ratio [OR] 1.14, p < 0.001). The respective figures for men were 6% more, 8% less (OR 1.16, p < 0.001). In both genders, the greatest variation occurred in those aged >75 years---peak winter rates being 15% to 18% higher than average. There was also a winter peak in concomitantly coded respiratory disease; this seasonal excess accounted for approximately one-fifth of the winter increment in HF hospitalizations. Seasonal variation in mortality was also seen in these patients. The number of male deaths in December was 16% higher, and in July 7% lower, than average (OR 1.25, p < 0.001). In women, the equivalent figures were 21% higher (January) and 14% lower (July) (OR 1.21, p < 0.001). Again, the greatest variation occurred in those aged >75 years---peak rates being 23% to 35% higher than average. CONCLUSIONS: There is substantial seasonal variation in HF hospitalizations and deaths, particularly in the elderly. Approximately one-fifth of the winter excess in admissions is attributable to respiratory disease. Extra vigilance in patients with HF is advisable in winter, as is immunization against pneumococcus and influenza.

Age Distribution↗

PubMed2002

The current cost of heart failure to the National Health Service in the UK.

We have recently shown that heart failure admission rates continue to increase in the UK -- particularly in older age groups. As hospital activity represents the major cost component of health care expenditure related to heart failure, this study evaluated the current cost of this syndrome to the National Health Service (NHS) in the UK. We applied contemporary estimates of health care activity associated with heart failure to the whole UK population on an age and sex-specific basis to calculate its cost to the NHS for the year 1995. Direct components of health care included in these estimates were hospital admissions associated with a principal diagnosis of heart failure, associated outpatient consultations, general practice consultations and prescribed drug therapy. We also calculated the cost of nursing-home care following a primary heart failure admission and the cost of hospitalisations associated with a secondary diagnosis of heart failure. Adjusting for probable increases in hospital activity and the progressive ageing of the UK population, we have also projected the cost of heart failure to the NHS for the year 2000. We estimated that there were 988000 individuals requiring treatment for heart failure in the UK during 1995. The 'direct' cost of health care for these patients was estimated to be pound 716 million, or 1.83% of total NHS expenditure. Hospitalisations and drug prescriptions accounted for 69 and 18% of this expenditure, respectively. The additional costs associated with long-term nursing home care and secondary heart failure admissions accounted for a further pound 751 million (2.0% of total NHS expenditure). By the year 2000, we estimated that the combined total direct cost of heart failure would have risen to pound 905 million -- equivalent to 1.91% of total NHS expenditure. Using well-validated sets of data, these findings re-confirm the importance of heart failure as a major public health problem in the UK. The annual direct cost of heart failure to the NHS in 2000 is likely to be of the order of 1.9% of total expenditure -- the predominant cost component being hospitalisation.

Aged↗