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Tom Fahey

Publications and source records attributed to Tom Fahey.

At least 37 records · Page 2Linked to original sources
PubMed2004

Coronary risk scores.

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Anticholesteremic Agents↗
PubMed2004

Decision analysis for newly diagnosed hypertensive patients: a qualitative investigation.

This study adopted a qualitative approach to explore patients' views on the usefulness of a decision analytic decision aid (DA). Semi-structured interviews were conducted with 15 newly diagnosed hypertensive patients who had been recruited for a factorial randomised controlled trial of two decision aids. Issues investigated included respondents' attitudes to information, their views on the nature of their relationship with their general practitioner (GP) (paternalistic, shared or consumerist), the ease of use and potential wider application of the computerised decision aid and its influence upon their decision-making about whether or not to begin anti-hypertensive treatment. Views on the decision aid were favourable. For the majority, the decision aid appeared to confirm and/or clarify their stated preferences towards medicine-taking. Occasionally it could provoke a major shift in a respondent's attitude to medicine-taking, while in a few it had no discernible effect. While views on the decision aid were favourable, it was difficult to determine whether this was due to the individualised cardiovascular risk information it provided or the decision analytic process itself.

Aged↗
PubMed2004

Predicting complications from acute cough in pre-school children in primary care: a prospective cohort study.

BACKGROUND: There is uncertainty about which children with cough are most and least likely to experience complications. AIM: To derive a clinical prediction rule for complications in pre-school children presenting to primary care with acute cough. DESIGN OF STUDY: Prospective cohort study. SETTING: Eight general practices in Leicestershire, United Kingdom. METHOD: Pre-school children with cough for < or =28 days and without asthma were recruited. Sociodemographic, clinical history, and examination data were collected and univariable logistic regression used to explore the associations with complications. These were defined as any new symptom, sign or diagnosis identified by a primary care clinician at a parent initiated reconsultation, or hospital admission, before cough resolution. Those factors with stronger relationships (P< 0.2) were then modelled using multivariable logistic regression to identify the factors independently associated with complications. RESULTS: The pre-test probability of complications was 10%. On univariable analysis, fever (odds ratio [OR] = 4.86; 95% confidence interval [CI] = 1.74 to 13.6), chest signs (OR = 2.72; CI = 1.06 to 6.96), and tachypnoea (OR = 3.80; CI = 1.22 to 11.8) were associated with complications. On multivariable analysis, only fever (OR = 5.56; CI = 1.75 to 17.6) and chest signs (OR = 2.88; CI = 1.02 to 8.05) were independently associated with complications. These ORs translate into post-test probabilities of complications of 6% for children with neither fever nor chest signs, 18% for children with chest signs, 28% for children with fever, and 40% for children with fever and chest signs. CONCLUSIONS: If validated, this clinical prediction rule could be used to individualise the management of acute cough in pre-school children.

Acute Disease↗
PubMed2004

The use of infrared thermometry for the detection of fever.

The use of tympanic thermometry is attractive in primary care, but a recent systematic review highlighted the paucity of data comparing tympanic thermometry with conventional methods. We report a study of 94 preschool children presenting to primary care in the United Kingdom (UK) with acute cough in whom tympanic infrared and axillary mercury thermometry are compared. Infrared thermometry showed poor agreement, poor sensitivity and high specificity. Infrared thermometry is too insensitive to be used as a screening test for fever, but when fever is already suspected, for example by touch, it may be useful as a 'rule in' test.

Axilla↗
PubMed2004

Cardiology.

This article describes recent developments in cardiology and cardiovascular disease that are likely to be relevant to primary healthcare professionals and their patients. The following subject areas are covered: Primary prevention: recent developments in pharmaco-logical interventions, drug interactions, and drugs that are likely to cause harm; cardiovascular risk estimation and shared decision making with patients; and new developments in 24-hour ambulatory blood pressure monitoring. Secondary prevention: new models of care, including nurse-led care for the provision of hypertension and secondary prevention clinics; new drugs for the treatment of angina and myocardial infarction; ambulatory electrocardiography for the diagnosis of arrhythmias in primary care; and new developments in the treatment of atrial fibrillation - direct thrombin inhibitors and implantable devices. Tertiary prevention: recent developments in cardiac rehabilitation; recent evidence concerning revascularisation procedures and appropriateness criteria for referral; and implantable defibrillators.

Cardiology↗
PubMed2003

Predictive accuracy of the Framingham coronary risk score in British men: prospective cohort study.

OBJECTIVE: To establish the predictive accuracy of the Framingham risk score for coronary heart disease in a representative British population. DESIGN: Prospective cohort study. SETTING: 24 towns in the United Kingdom. PARTICIPANTS: 6643 British men aged 40-59 years and free from cardiovascular disease at entry into the British regional heart study. MAIN OUTCOME MEASURES: Comparison of observed 10 year coronary heart disease mortality and event rates with predicted rates for each individual, using the relevant Framingham risk equation. RESULTS: Of 6643 men, 2.8% (95% confidence interval 2.4% to 3.2%) died from coronary heart disease compared with 4.1% predicted (relative overestimation 47%, P < 0.0001). A fatal or non-fatal coronary heart disease event occurred in 10.2% (9.5% to 10.9%) of the men compared with 16.0% predicted (relative overestimation 57%, P < 0.0001). These relative degrees of overestimation were similar at all levels of coronary heart disease risk, so that overestimation of absolute risk was greatest for those at highest risk. A simple adjustment provided an improved level of accuracy. In a "high risk score" approach, most cases occur in the low risk group. In this case, 84% of the deaths from coronary heart disease and non-fatal events occurred in the 93% of men classified at low risk (< 30% in 10 years) by the Framingham score. CONCLUSION: Guidelines for the primary prevention of coronary heart disease advocate offering preventive measures to individuals at high risk. Currently recommended risk scoring methods derived from the Framingham study significantly overestimate the absolute coronary risk assigned to individuals in the United Kingdom.

Adult↗
PubMed2003

Quality of care for elderly residents in nursing homes and elderly people living at home: controlled observational study.

OBJECTIVES: To assess the quality of care given to elderly people and compare the care given to residents in nursing homes with those living in their own homes. DESIGN: Controlled observational study. SETTING: Primary care, Bristol. SUBJECTS: Elderly individuals (aged > or =65 years) registered with three general practices, of whom 172 were residents in nursing homes (cases) and 526 lived at home (matched controls). MAIN OUTCOME MEASURES: The quality of clinical care given to patients was measured against explicit standards. Quality indicators were derived from national sources and agreed with participating general practitioners. RESULTS: The overall standard of care was inadequate when judged against the quality indicators, irrespective of where patients lived. The overall prescribing of beneficial drugs for some conditions was deficient--for example, only 38% (11/29) (95% confidence interval 20% to 58%) of patients were prescribed beta blockers after myocardial infarction. The proportion of patients with heart disease or diabetes who had had their blood pressure measured in the past two years (heart disease) or past year (diabetes) was lower among those living in nursing homes: for heart disease, 74% (17/23) v 96% (122/127) (adjusted odds ratio 0.18, 0.04 to 0.75); for diabetes, 62% (8/13) v 96% (50/52) (adjusted odds ratio 0.05, 0.01 to 0.38). In terms of potentially harmful prescribing, significantly more patients in nursing homes were prescribed neuroleptic medication (28% (49/172) v 11% (56/526) (3.82, 2.37 to 6.17)) and laxatives (39% (67/172) v 16% (85/526) (2.79, 1.79 to 4.36)). Nursing home residents were less likely to have the appropriate diagnostic Read code linked to their prescribed neuroleptic drug (0.22, 0.07 to 0.71). CONCLUSIONS: The quality of medical care that elderly patients receive in one UK city, particularly those in nursing homes, is inadequate. We suggest that better coordinated care for these patients would avoid the problems of overuse of unnecessary or harmful drugs, underuse of beneficial drugs, and poor monitoring of chronic disease.

Aged↗
PubMed2003

Clinical management of urinary tract infection in women: a prospective cohort study.

BACKGROUND: It is unclear how symptoms of urinary tract infection (UTI) influence clinical management in terms of diagnostic testing and treatment with antibiotics. OBJECTIVES: Our aim was to assess how 11 symptoms associated with UTI related to the probability of being tested (near patient test or urine culture) or treated with antibiotics by their GP, and to see if the same 11 symptoms were associated with (i) confirmed infection from urine culture and (ii) re-consultation complaining of the same symptoms within 1 month. METHODS: A prospective cohort study of 160 patients consulting their GP with symptoms of UTI in eight general practices in Avon, UK was carried out. Association between symptoms and the probability of being (i) tested by the near patient test, (ii) tested by urine culture or (iii) treated empirically with antibiotics were examined. The association between symptoms and the probability of being treated empirically or tested (near patient test or mid-stream urine) was examined. Likelihood ratios for symptoms and near patient test results compared with two 'gold standards' for diagnosis of UTI were calculated and their impact on post-test probability of UTI determined. RESULTS: GPs were far more likely to treat empirically patients with symptoms of dysuria and frequency [odds ratio (OR) 6.50, 95% confidence interval (CI) 2.02-20.89] or dysuria alone (OR 5.24, 95% CI 1.62-16.95). They were far less likely to perform diagnostic tests in patients with dysuria and frequency (OR for near patient testing 0.34, 95% CI 0.14-0.83; OR for urine culture 0.15, 95% CI 0.04-0.56). The prior probabilities of UTI were 25% (positive urine culture) and 29% (re-consultation within 1 month), respectively, for each of the 'gold standards' used. Individual symptoms and near patient tests did not raise the posterior probability of UTI irrespective of which 'gold standard' was used. The most useful symptom was a history of vomiting (likelihood ratio 2.96, 95% CI 0.3-31.2), but this occurred in only three patients. CONCLUSIONS: Current clinical practice results in a large proportion of patients receiving unnecessary antibiotic treatment. Individual symptoms of UTI are an inadequate guide on which to base diagnostic testing and antibiotic treatment decisions in primary care. Either this diagnostic inaccuracy should be acknowledged as an inevitable part of clinical practice or more accurate clinical prediction rules that incorporate symptoms, signs and near patient test results that are applicable in everyday clinical practice are required.

Adult↗
PubMed2003

The duration of acute cough in pre-school children presenting to primary care: a prospective cohort study.

BACKGROUND: Professional and parental uncertainty about the natural history of cough in pre-school children may in part be responsible for the high consultation and reconsultation rates and widespread antibiotic use in primary care. A recent systematic review of the natural history of cough included studies of unrepresentative, selected patients with heterogeneous measures and definitions of cough duration. OBJECTIVES: The aim of the present study was to describe the post-consultation duration of cough, compare this with clinician and parental prediction of cough duration, and to determine the clinical factors associated with prolonged cough. METHODS: A prospective cohort study of children aged 0-4 years with cough < or =28 days without asthma presenting to eight general practices in Leicestershire, UK was carried out. Socio-demographic and clinical data were collected, and parents and clinicians were asked to predict the proportion recovering within 7, 14, 21 and 28 days. Parents used a symptom diary to record cough and five other symptoms. Survival analysis was used to describe cough duration, and multivariable Cox regression was used to identify the factors independently associated with prolonged cough. RESULTS: Fifty percent of the children had recovered at 10 days and 90% at 25 days. Cough was associated with fever, breathlessness, disrupted sleep and reduced activity in a high proportion of children. Longer post-consultation cough was associated with longer pre-consultation cough and use of day care facilities. Clinicians overestimated how quickly children recovered from acute cough. Parents' predictions were accurate within 2 weeks, but they underestimated the proportion recovering in weeks 3 and 4. CONCLUSIONS: Clinicians should be aware that from the parental perspective, acute cough is not a trivial illness and that some children remain unwell at 3-4 weeks. For health professionals negotiating the use of antibiotics, this information may enable parental self-care, reduce medicalization and displace the need to prescribe.

Child, Preschool↗
PubMed2003

The influence of absolute cardiovascular risk, patient utilities, and costs on the decision to treat hypertension: a Markov decision analysis.

OBJECTIVE: To estimate the effectiveness and cost-effectiveness of blood pressure-lowering treatment over a lifetime. DESIGN: Markov decision analysis model comparing treatment and non-treatment of hypertension. PARTICIPANTS: Hypothetical cohorts for 20 different strata of sex, age (30-79 years, in 10-year age bands), and cardiovascular risk (low and high risk). MAIN OUTCOME MEASURES: Life expectancy, and incremental cost : effectiveness ratios for treatment and non-treatment strategies. RESULTS: In terms of life expectancy, blood pressure treatment increased life expectancy in all age, sex, and risk strata, by between 1.6 and 10.3%, compared with a policy of non-treatment. In terms of cost-effectiveness, treatment was more effective, but also cost more than non-treatment for all age, sex, and risk strata except the oldest high-risk men and women. Incremental cost per quality-adjusted life year (QALY) among low-risk groups ranged from pound 1030 to pound 3304. Cost-effectiveness results for low-risk individuals were sensitive to the utility of receiving antihypertensive treatment. Treatment of high-risk individuals was highly cost-effective, such that it was the dominant strategy in the oldest age group, and resulted in incremental costs per QALY ranging from pound 34 to pound 265 in younger age groups. CONCLUSIONS: Policy decisions about which patients to treat depend on whether a life-expectancy or cost-effectiveness perspective is taken. Treatment increases life expectancy in all strata of age, sex, and cardiovascular risk. However, younger individuals stand to gain proportionately more from blood pressure treatment than do the elderly. In terms of cost-effectiveness, patients at high risk of cardiovascular disease are a highly cost-effective group to treat. In patients at lower risk of cardiovascular disease, consideration should be given to issues of patient preference and cost.

Adult↗
PubMed2003

A factorial randomised controlled trial of decision analysis and an information video plus leaflet for newly diagnosed hypertensive patients.

BACKGROUND: There is a lack of evidence regarding the value of tools designed to aid decision making in patients with newly diagnosed hypertension. AIM: To evaluate two interventions for assisting newly diagnosed hypertensive patients in the decision whether to start drug therapy for reducing blood pressure. DESIGN OF STUDY: Factorial randomised controlled trial. SETTING: Twenty-one general practices in south-west England, UK. METHOD: Adults aged 32 to 80 years with newly diagnosed hypertension were randomised to receive either: (a) computerised utility assessment interview with individualized risk assessment and decision analysis; or (b) information video and leaflet about high blood pressure; or (c) both interventions; or (d) neither intervention. Outcome measures were decisional conflict, knowledge, state anxiety, intentions regarding starting treatment, and actual treatment decision. RESULTS: Of 217 patients randomised, 212 (98%) were analysed at the primary follow-up (mean age = 59 years, 49% female). Decision analysis patients had lower decisional conflict than those who did not receive this intervention (27.6 versus 38.9, 95% confidence interval [CI] for adjusted difference = -13.0 to -5.8, P < 0.001), greater knowledge about hypertension (73% versus 67%, adjusted 95% CI = 2% to 9%, P = 0.003) and no evidence of increased state anxiety (34.8 versus 36.8, adjusted 95% CI = -5.6 to 0.1, P = 0.055). Video/leaflet patients had lower decisional conflict than corresponding controls (30.3 versus 36.8, adjusted 95% CI = -7.4 to -0.6, P = 0.021), greater knowledge (75% versus 65%, adjusted 95% CI = 6% to 13%, P < 0.001) and no evidence of increased state anxiety (35.7 versus 36.1, adjusted 95% CI = -3.9 to 1.7, P = 0.46). There were no differences between either of the interventions and their respective controls in the proportion of patients prescribed antihypertensive medication (67%). CONCLUSIONS: This trial demonstrates that, among patients facing a real treatment decision, interventions to inform patients about hypertension and to clarify patients' values concerning outcomes of treatment are effective in reducing decisional conflict and increasing patient knowledge, while not resulting in any increases in state anxiety.

Adult↗