Analysis of renal service provision in south and mid Wales.

OBJECTIVES: This paper estimates point prevalence of renal replacement therapy (RRT) utilization within population strata defined by geography and deprivation in south and mid Wales. It investigates spatial accessibility of main and satellite renal units by comparing population and patient numbers within bands of travel time. STUDY DESIGN: Prevalence study based on patient registers. METHODS: From a list of patient and renal unit locations, geocoded at the level of unit postcodes, and electoral division-level denominator population data, we calculated RRT point prevalence for the 16 unitary authorities in the study area, fifths of small area deprivation, and three bands of travel time from the nearest main renal unit and any (main or satellite) unit. RESULTS: Overall point prevalence was 633 per million population (pmp) and this varied from 256 to 780 pmp across unitary authorities. RRT prevalence was lower in more deprived areas. Sixty-nine percent of the population and 73% of patients lived within 30 min of a main renal unit. Eighty-four percent of the population and 88% of patients lived within 30 min of a main or satellite renal unit. CONCLUSIONS: The provision of satellite renal units has significantly improved spatial accessibility of RRT services. However, a substantial proportion of the population remains geographically distant from renal units. This has important implications for planning of future provision of RRT, given the inverse relationship between RRT acceptance and travel time, and the impact on quality of life of patients who travel frequently to renal units.

A community outbreak of food-borne small round-structured virus gastroenteritis caused by a contaminated water supply.

In August 1994, 30 of 135 (23%) bakery plant employees and over 100 people from South Wales and Bristol in the United Kingdom, were affected by an outbreak of gastroenteritis. Epidemiological studies of employees and three community clusters found illness in employees to be associated with drinking cold water at the bakery (relative risk 3.3, 95%, CI 1.6-7.0), and in community cases with eating custard slices (relative risk 19.8, 95%, CI 2.9-135.1) from a variety of stores supplied by one particular bakery. Small round-structured viruses (SRSV) were identified in stool specimens from 4 employees and 7 community cases. Analysis of the polymerase and capsid regions of the SRSV genome by reverse transcription-polymerase chain reaction (RT-PCR) demonstrated viruses of both genogroups (1 and 2) each with several different nucleotide sequences. The heterogeneity of the viruses identified in the outbreak suggests that dried custard mix may have been inadvertently reconstituted with contaminated water. The incident shows how secondary food contamination can cause wide-scale community gastroenteritis outbreaks, and demonstrates the ability of molecular techniques to support classical epidemiological methods in outbreak investigations.

Managing care.

The terms 'managed care' and 'disease management' are gaining common usage in the health service but their meaning is not widely understood. Managed care is a generic term describing any health care system that integrates the financing and delivery of medical care. Its growth in the United States has been driven by pressure to control costs, and there is circumstantial evidence that costs are slowing as a result of better management of resources. However, it is not clear how much of this is due to managed care, the selection of more favourable enrollees to health plans or other factors. Research evidence is limited, and that available is constrained by the rapidly changing nature of managed care. In the United States a bewildering variety of managed care arrangements have emerged, although several common characteristics can be identified: limited choice of physician providers; controlled access to secondary care; selective contracting; financial incentives; quality management; and utilization management. All are present in the National Health Service (NHS), which exemplifies a nationalized managed care system. Disease management is an extension of managed care that takes a global approach to patient care by attempting to co-ordinate resources across the entire health care delivery system throughout the life cycle of the disease. This is poorly developed in the NHS, so that the attention of commercial organizations has been attracted. However, concern has been expressed about the implications of commercial involvement: the fragmentation of general medical services; effect of for-profit status; and use of patient-based data. Recent policy developments could allow disease management to develop within the NHS.

Evaluation of a journal club as a forum to practise critical appraisal skills.

Critical appraisal skills are important if clinicians are to practise evidence-based medicine. This is an evaluation of the first six months of a journal club in a department of public health medicine. We analysed attendance, types of paper reviewed, impact on commissioning policy and publication of letters to editors and conclude that journal clubs can be an effective learning environment and further the Clinical Effectiveness Initiative.

Reasons for non-uptake of measles, mumps, and rubella catch up immunisation in a measles epidemic and side effects of the vaccine.

OBJECTIVE: To investigate the reasons for poor uptake of immunisation (non-immunisation) and the possible side effects of measles, mumps, and rubella vaccine in a catch up immunisation campaign during a community outbreak of measles. DESIGN: Descriptive study of reasons for non-immunisation and retrospective cohort study of side effects of the vaccine. SETTING: Secondary schools in South Glamorgan. SUBJECTS: Random cluster sample of the parents of 500 children targeted but not immunised and a randomised sample of 2866 of the children targeted. MAIN OUTCOME MEASURES: Reasons for non-immunisation; symptoms among immunised and non-immunised children. RESULTS: Immunisation coverage of the campaign was only 43.4% (7633/17,595). The practical problems experienced included non-return of consent forms (6698/17,595), refusal of immunisation (2061/10,897 forms returned), and absence from school on day of immunisation (1203/8836 children with consent for immunisation). The most common reasons cited for non-immunisation were previous measles infection (145/232), previous immunisation against measles (78/232), and concern about side effects (55/232). Symptoms were equally common among immunised and non-immunised subjects. However, significantly more immunised boys than non-immunised boys reported fever (relative risk 2.31 (95% confidence interval 1.36 to 3.93)), rash (2.00 (1.10 to 3.64), joint symptoms (1.58; 1.05 to 2.38), and headache (1.31 (1.04 to 1.65)). CONCLUSIONS: Many of the objections raised by parents could be overcome by emphasising that primary immunisation does not necessarily confer immunity and that diagnosis of measles is unreliable. Measles, mumps, and rubella vaccine is safe in children aged 11-15.