Comparing measures of variation.
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Humans↗
Biomedical subjects
V Seagroatt
Publications and source records attributed to V Seagroatt.
Mortality after prostatectomy: selection and surgical approach.
Observational studies have found higher long-term mortality after transurethral prostatectomy (TURP) than after open prostatectomy (OP) and that this difference remained after statistical adjustment for comorbidity. This higher mortality has been attributed to the transurethral procedure itself. This association is reassessed here. Time-sequenced hospital and death records were analysed for 13,815 men undergoing prostatectomy (not for cancer) during the years 1963-85. TURP had a lower 30-day case-fatality rate than had OP, a similar 90-day rate, but TURP had a higher one-year rate. By inference, any excess mortality after TURP must begin shortly after the first postoperative month. However, plotting mortality expressed as SMRs, for the three years after operation showed no increase in long-term mortality after TURP, nor was there any concomitant increase in one-year death rates after prostatectomy as TURP replaced OP. Long-term mortality after TURP was close to that expected from background population rates: after SMR for TURP, for the second and third postoperative years, was 100 (95% CI 93-107). In contrast, long-term mortality after OP was lower than expected from population rates with a corresponding SMR of 79 (95% CI 71-88). The apparent excess in long-term mortality after TURP is unlikely to be caused by the operation itself. It is more likely to reflect relatively low long-term mortality in OP patients as a consequence of OP patients having been relatively fitter than those having TURP.
Aged↗
Measures of early postoperative mortality: beyond hospital fatality rates.
OBJECTIVE: To quantify the short term risk of postoperative mortality in ways which take account of deaths after discharge and the background risks of death in patients who come to operation. DESIGN: Analysis of linked abstracts of hospital admission records and death certificates for common operations. SETTING: Six health districts in the Oxford region. SUBJECTS: Records of 223,529 operations performed in 1980-6. MAIN OUTCOME MEASURES: In hospital fatality rates, case fatality rates, and standardised mortality ratios at selected time periods during the year after operation and the ratio of early (< 30 days) to late (90-364 days after operation) fatality rates. RESULTS: Fatality rates throughout the year after operations performed after emergency admissions were generally higher than those for similar operations performed after elective admissions and higher than expected from population rates. Examples were prostatectomy, hip arthroplasty, inguinal herniorrhaphy, and cholecystectomy. Common elective operations such as inguinal herniorrhaphy and cataract operations showed no early peak in mortality, but others did. These included transurethral prostatectomy (ratio of early to late mortality 2.0; 95% confidence interval 1.3 to 2.6), hysterectomy (3.2; 1.5 to 6.6), hip arthroplasty (3.8; 2.5 to 5.4), and cholecystectomy (6.9; 4.3 to 11.1). CONCLUSIONS: Temporal profiles of death rates in the year after operation show which operations have early peaks in mortality and which do not. Emergency and elective operations have very different profiles and should be analysed separately. For elective operations for conditions which pose no immediate threat to life the ratio of early to later fatality rates provides a measure of increase in mortality after operation while allowing for the background risk of death in the patient groups.
Chi-Square Distribution↗
Antiplatelet prophylaxis. Combination treatment may cause bleeding.
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Aspirin↗
Chest illness in infancy and chronic respiratory disease in later life: an analysis by month of birth.
BACKGROUND: Cohorts born at different times of year differ in their risk of exposure to seasonal respiratory infections in early life, but are likely to have similar socioeconomic status and lifestyle thereafter. METHODS: We investigated the long-term consequences of acute chest illness in infancy for later development of chronic respiratory disease by analysing variations by month of birth in hospital admissions for respiratory illness (total n = 49,866), chronic respiratory symptoms and ventilatory function among British school children (n = 11,482) and middle-aged adults (total n = 55,829). RESULTS: Admission for bronchiolitis in the first year of life was three times more common for infants born September to November (autumn) than those born March to May, yet people born in the autumn experienced fewer respiratory symptoms and had better ventilatory function. In two surveys of middle-aged men, forced expiratory volume in one second/forced ventilatory capacity (FEV1/FVC) was significantly (P = 0.025) higher among autumn births. Hospital admissions for chronic bronchitis/emphysema and pneumonia varied little with season of birth. Admissions for asthma were significantly (P < 0.05) more common among children and young adults born in the autumn. CONCLUSIONS: These findings do not support the hypothesis of a causal link between chest illness in infancy and the later development of chronic bronchitis and emphysema. The variation in asthma admissions with month of birth deserves further investigation.
Adult↗
Changing patterns in the epidemiology and hospital care of peptic ulcer.
BACKGROUND: Our aim was to study trends in hospital admission rates for peptic ulcer in a geographically defined population, and to distinguish the effects of period, age and birth cohort on the rates. METHODS: Analysis of linked, routinely collected abstracts of hospital inpatient care held by the Oxford record linkage study for the period 1970-1986. Age- and sex-specific and age-standardized hospitalization, readmission and operation rates were calculated for patients with peptic ulcer. Age, cohort and period effects were examined using log-linear models. RESULTS: Records for a total of 5462 people with gastric ulcer and 10,186 with duodenal ulcer were identified. Overall, the age-standardized admission rates for both gastric and duodenal ulcer declined over the study period. The decrease was confined to people < 65 years of age. Among elderly patients admission rates for peptic ulcer increased over time, more so in females than in males. Admission rates were higher in the elderly than in young people for both gastric and duodenal ulcer. The apparent age effect was, in fact, mainly attributable to a birth cohort effect: age-specific admission rates were lower in people born after 1925 than in people born at the beginning of the century. This was more marked for males than females. There was a considerable decline in major operations undertaken on peptic ulcer; admission rates for endoscopy increased; and readmission rates did not show significant changes. CONCLUSIONS: The overall decline found for hospital care of peptic ulcer during the study period is consistent with that found in England for mortality rates ascribed to peptic ulcer. The cohort effect found in the data for hospitalized morbidity supports that reported by others for mortality. The cohort effect indicates that the decline was related more to changes in risk factors in the cohorts born in different periods than to the introduction of new pharmacological treatments since the 1970s.
Adolescent↗
Adolescent onset psychosis. A clinical and outcome study.
58 psychotic adolescents between the ages of 12 and 17 diagnosed according to RDC criteria were matched with psychiatric comparisons and followed-up using a two stage design. Information upon the group as a whole was obtained using death records, criminal records and data from the Oxford Record Linkage System. A sub-sample of 21 matched pairs were interviewed using the Schedule for Affective Disorders and Schizophrenia--Life time version (SADS-L) and the Adult Personality Functioning Assessment (APFA). The outcome of adolescent schizophrenia was poor with 78% continuously ill and socially handicapped. Outcome was better for bipolar disorders and schizo-affective disorders and similar to psychiatric comparisons.
Adolescent↗
Geographical variation in hospital admission rates: an analysis of workload in the Oxford region, England.
OBJECTIVE: To measure variation in hospital admission rates between health districts in part of the English NHS, comparing a wide range of medical and surgical conditions. DESIGN: Retrospective analysis of interdistrict variation using linked routine hospital admission data. Comparisons were also made with levels of variation reported from the USA. SETTING: Oxford Regional Health Authority, 1979-86. SUBJECTS: Six district health authorities--total study population 2.1 million people, 1.6 million hospital admissions. MAIN MEASURES: Age and sex standardised hospital admission rates for resident populations for individual operations and diagnoses; systematic components of variation (SCV). RESULTS: Of 118 standard operation groups, 38 (26% of surgical workload) showed high variation (SCV 16 or more) and 40 (36% of surgical workload) showed low variation (SCV < 4). Operations (SCV) with very low levels of variation included prostatectomy (0.1), inguinal herniorraphy (0.9), and cholecystectomy (1.3). Rates were more variable for myringotomy (3.7), hysterectomy (4.3), dilatation and curettage (5.6), and tonsillectomy (6.2). The SCV was high for only four of the 40 commonest medical causes of admission, and was low for 18 of them. CONCLUSIONS: Most admissions in the Oxford region were for conditions that did not show a great deal of variation in admission rates. The level of variation for many surgical procedures was less than that reported in studies from the USA. Variation was no greater for medical causes of admission than for surgical conditions. Large scale variation may not be an inevitable consequence of autonomous clinical practice.
Age Factors↗
Depressive disorders in long-term survivors of stroke. Associations with demographic and social factors, functional status, and brain lesion volume.
Sixty surviving patients from a community-based stroke register who had computerised tomography (CT) scan evidence of a single brain lesion were interviewed three to five years after their first ever stroke. Depression (DSM-III-R major depression, partially resolved major depression, and dysthymia) was present in 11 (18%) of the patients and was associated with impaired physical and cognitive functioning, greater age, residence in an institution, absence of a close personal relationship, and larger original brain lesion. Of these variables, only functional dependence (odds ratio 16.4; confidence interval 1.6-170), larger lesion volume (6.6; 1-50), and female sex (8; 1.1-56) remained significantly associated with depression after controlling for all other variables. We conclude that depression in long-term survivors of stroke has many of the same associations as depression in non-stroke elderly populations. Depression in long-term stroke survivors may also be associated with larger original brain lesions, although this requires confirmation in a prospective study.
Age Factors↗
Why do doctors find some patients difficult to help?
Almost all doctors encounter difficulties in managing some patients. Previous studies have examined the characteristics of such patients: we have additionally studied the reasons why hospital doctors find these patients 'difficult to help'. Three clinics (two medical and one surgical) were studied. The consultants rated 60 (22%) of 293 attenders s severely or extremely difficult to help. Difficulty was associated with greater patient distress (odds ratio 3.9; 95% CI 2.0-7.7), less patient satisfaction (2.6; 1.3-5.0) and chronic attendance (5.0; 1.4-17.3). An interview study of 40 'difficult' patients indicated that doctors considered psycho-social factors more important in difficult patients (3.2; 1.3-7.7). Objective differences between the doctor's and the patient's aims for care also occurred more frequently for difficult patients (2.8; 1.1-7.2). Three common types of difficulty were identified; medically unexplained symptoms; co-existing social problems; and severe untreatable illness. A review of the management aims for patients whom doctors find 'difficult to help', combined with improved access to psycho-social care, could improve both the quality and the cost-effectiveness of hospital out-patient services.
Adolescent↗
Suicide after discharge from psychiatric inpatient care.
People with a history of psychiatric disorder are at higher risk of suicide than people without such a history. The policy of reducing inpatient care in psychiatry has probably meant that some of the risk of suicide has shifted from the hospital to the community setting. We have quantified the risk of suicide within a year of psychiatric discharge in a population-based study in the Oxford health region, UK. We calculated suicide rates per 1000 person-years at risk (time from discharge to death, subsequent readmission, or the end of the study) and the standardised mortality ratio (SMR) for suicide, taking the value among the general population as 1. Among male patients the SMR for suicide (defined by coroner's verdict of suicide) in the first 28 days after discharge from inpatient care was 213 (95% CI 137-317); the equivalent SMR for female patients was 134 (67-240). The result was similar when we defined suicide more broadly as a suicide, open, or misadventure verdict. The suicide rate in the first 28 days after discharge was 7.1 (4.1-12) times higher for male patients and 3.0 (1.5-6.0) times higher for female patients than the rate during the remaining 48 weeks of the first year after discharge. Most of the patients studied (both those who committed suicide and those who did not) had been psychiatric inpatients for only a short time. The findings confirm that there is significant clustering of suicide soon after discharge from psychiatric care. Skilled support after discharge for high-risk patients in the community is essential. Audit of suicides that occur soon after discharge may help identify the patients at highest risk and thereby reduce the number of avoidable deaths.
Adolescent↗
Why is osteoarthritis of the hip more common on the right?
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Adult↗
Population-based trends in treatment rates in psychiatry in Oxfordshire, 1975-1986.
Routinely collected abstracts of medical records for patients in Oxfordshire were used to identify each individual's first contact with specialist psychiatric in-patient, out-patient or community care services over a 12-year period (1975-1986). During this period first-contact rates for people under 65 years of age declined by 3.3 per cent. The decline was observed for contacts with specialist care outside hospital as well as for in-patient care. It is therefore not attributable simply to a shift away from in-patient care. The decline was seen in most major diagnostic groups including schizophrenia, affective psychosis and the neuroses, and it is therefore not attributable to changing diagnostic practices between these groups. Increases in first-contact rates in this age group were found for alcohol-related disorders in women and self-harm in men. First-contact rates for people aged 65 years and over increased by 3 per cent per year. The condition that mainly accounted for the increase over time was dementia, which was by far the commonest recorded psychiatric diagnosis in this age group. Although the increase was seen in all modes of care, it was the domiciliary visiting service that contributed most to the upward trend. The implications of these trends for service planning and their limitations as measures of changes in morbidity are discussed.
Adolescent↗
Peptic ulcer, cimetidine, and motor neurone disease--a record linkage study.
A previous cohort study suggested that there might be an association between use of cimetidine and motor neurone disease. The Oxford Record Linkage Study was used to explore this hypothesis. In the analysis the presence of a peptic ulcer in patients after 1976 was taken as a proxy for cimetidine (and ranitidine) use. The past history of 540 patients with motor neurone disease in this period was compared with that of 1370 patients with multiple sclerosis (neurological controls) and over 240,000 control patients with a variety of other conditions. Among those with motor neurone disease, five had been previously admitted to hospital with peptic ulcer in comparison with an expected number of 7.4 (morbidity ratio 0.68, 95% confidence interval: 0.2 to 1.6). The corresponding figures for those with multiple sclerosis were 12 and 9.7 respectively (morbidity ratio 1.24, 95% confidence interval: 0.6 to 2.2). This study provides some evidence against the possibility that cimetidine (and ranitidine) are related to motor neurone disease.
Cimetidine↗
Ovarian cancer and ABO blood groups.
OBJECTIVE: To determine whether the distribution of ABO blood groups in women with ovarian cancer differs from that in the general population in a large, defined English region. DESIGN: Analysis of record abstracts of hospital care held in the Oxford record linkage study supplemented with data from the Oxford cancer registry. SETTING: Oxford Regional Health Authority area. SUBJECTS: A total of 1261 women who had ovarian cancer between 1968 and 1986 with ABO blood groups recorded on the Oxford Record Linkage Study and cross checked against the cancer registry comprised the study group. MEASUREMENTS AND MAIN RESULTS: The relative incidence of A:O and B:O blood groups in women with ovarian cancer were compared with the general population in the same region. Ovarian cancer was more common in women of blood group A than in others, with a relative incidence of 1.17. In particular, adenocarcinomas were the most common type of tumour and were associated with blood group A. The association was more striking in married women than in single women probably reflecting differences associated with parity. CONCLUSION: The association between ABO blood groups and ovarian cancer found in this English population is similar in size to that reported from several other populations. Childbearing is known to reduce the risk of ovarian cancer and our findings suggest that the blood group association may be most apparent in married, parous (that is, relatively low risk) women.
ABO Blood-Group System↗
Follow up of patients presenting with fatigue to an infectious diseases clinic.
OBJECTIVES: To determine the symptomatic and functional status during follow up of patients referred to hospital with unexplained fatigue and to identify patient variables associated with persistent functional impairment. DESIGN: Follow up by postal questionnaire six weeks to four years (median 1 year) after initial clinical assessment of patients referred to hospital during 1984-8. SETTING: Infectious diseases outpatient clinic in a teaching hospital. PATIENTS: 200 consecutive patients with fatigue of uncertain cause for at least six weeks; 177 fulfilled the inclusion criteria. MAIN OUTCOME MEASURES: Findings at initial assessment; current symptoms, beliefs about the cause of illness, coping behaviours emotional disorder, social variables including membership of self help organizations, and degrees of recovery and functional impairment from questionnaire responses. RESULTS: 144 (81%) patients returned completed questionnaires. Initial assessment did not indicate the cause of fatigue, other than preceding infection. The proportion of patients with functional impairment was significantly smaller with longer follow up (33% (11/33) at two to four years, 73% (29/40) at six weeks to six months; chi 2 for trend = 12.5, df = 1; p less than 0.05). Functional impairment was significantly associated with belief in a viral cause of the illness (odds ratio = 3.9; 95% confidence interval 1.5 to 9.9), limiting exercise (3.2; 1.5 to 6.6), avoiding alcohol (4.5; 1.8 to 11.3), changing or leaving employment (3.1; 1.4 to 6.9), belonging to a self help organization (7.8; 2.5 to 23.9), and current emotional disorder (4.4; 2.0 to 9.3). CONCLUSIONS: Short term prognosis for recovery of function was poor but improved with time. Most patients had made a functional recovery by two years after initial clinic attendance. Impaired functioning was more likely with certain patient characteristics. Prospective studies are required to clarify whether these associations are the consequences of a more disabling illness or indicate factors contributing to impaired function.
Adaptation, Psychological↗
Incidence of disease after vasectomy: a record linkage retrospective cohort study.
OBJECTIVE: To determine whether vasectomy is associated with an increased risk of several diseases, and in particular testicular cancer, after operation. DESIGN: Retrospective cohort study using linked medical record abstracts. SETTING: Six health districts in Oxford region. SUBJECTS: 13,246 men aged 25-49 years who had undergone vasectomy between 1970 and 1986, and 22,196 comparison subjects who had been admitted during the same period for one of three specified elective operations, appendicitis, or injuries. MAIN OUTCOME MEASURES: Hospital admission and death after vasectomy or comparison event. RESULTS: The mean durations of follow up were 6.6 years for men with a vasectomy and 7.5 years for men with a comparison condition. The relative risk of cancer of the testis in the vasectomy cohort (4 cases) compared with that in the other cohorts (17 cases) was 0.46 (95% confidence interval 0.1 to 1.4), that of cancer of the prostate (1 v 5 cases) 0.44 (0.1 to 4.0), and that of myocardial infarction (97 v 226 cases) 1.00 (0.8 to 1.3). There was no evidence of an increase associated with vasectomy in the incidence of a range of other diseases. CONCLUSIONS: Vasectomy was not associated with an increased risk of testicular cancer or the other diseases studied. With respect to prostatic cancer, while we found no cause for concern, longer periods of observation on large numbers of men are required.
Adult↗