GP supply, deprivation and emergency admission to hospital for COPD and diabetes complications in counties across Ireland: an exploratory analysis.

INTRODUCTION: Geographical variation in rates of emergency inpatient admission for chronic disease may be due to variation in health need. However, it may also reflect differences in the provision of services which reduce the risk of inpatient admission for chronic disease, such as primary care. AIMS: The aim of this paper was to examine the effect of primary care provision [general practitioner (GP) supply] and deprivation on county-specific rates of emergency admission to hospital for diabetes complications and chronic obstructive pulmonary disease (COPD) in Ireland. METHODS: Data on emergency inpatient discharges were obtained from the hospital inpatient enquiry (HIPE) system. Secondary data on GP supply were obtained from a recently published study, while secondary data on deprivation were obtained from the Small Area Health Research Unit. The effect of county-level GP supply and deprivation on age-standardised rates of discharge for diabetes complications and COPD were examined, adjusting for population density and the proportion of the population who were eligible for free primary care. RESULTS: Greater deprivation and lower GP supply are associated with increased rates of discharge from hospital for COPD and diabetes complications. However, these associations are stronger in counties where a lower proportion of the population are eligible for free primary care. CONCLUSION: Geographical variation in rates of admission to hospital for chronic disease is associated with both population need and health system factors. These findings suggest that primary care resourcing must be a key consideration in any efforts to tackle acute hospital capacity problems.

CASP-19 special section: how does chronic disease status affect CASP quality of life at older ages? Examining the WHO ICF disability domains as mediators of this relationship.

OBJECTIVES: The effect of chronic disease status on quality of life (QoL) has been well established. However, less is known about how chronic diseases affect QoL. This article examines impairment in three domains of the WHO International Classification of Functioning, Health and Disability (ICF) - body function, activity and participation, as well as affective well-being, - as potential mediators of the relationship between chronic disease and QoL. METHOD: A cross-sectional sample (n = 4961) of the general Irish community-dwelling population aged 50+ years was obtained from the Irish Longitudinal Study of Ageing (TILDA). The CASP measure of QoL was examined as two dimensions - control/autonomy and self-realisation/pleasure. Structural equation modelling was used to test the direct and indirect effects of chronic disease on QoL, via variables capturing body function, activity, participation and positive affect. RESULTS: A factor analysis showed that indicators of body function and activity loaded onto a single overall physical impairment factor. This physical impairment factor fully mediated the effect of chronic disease on positive affect and QoL. The total effect of chronic disease on control/autonomy (-0.160) was primarily composed of an indirect effect via physical impairment (-0.86), and via physical impairment and positive affect (-0.45). The decomposition of effects on self-realisation/pleasure was similar, although the direct effect of physical impairment was weaker. The model fitted the data well (RMSEA = 0.02, TLI = 0.96, CFI = 0.96). CONCLUSION: Chronic disease affects QoL through increased deficits in physical body function and activity. This overall physical impairment affects QoL both directly and indirectly via reduced positive affect.

Place DMTS water-escape with direct placement or response information runs.

A two-choice, spatial delayed matching-to-sample (DMTS) water-escape task has proved to be a valuable of assay of trial-dependent memory. The task involves giving rats trials consisting of a forced-choice information run and a free-choice test run that are separated by a 5-m retention interval. Two experiments were conducted to determine the importance of making a complete response (R), partial response (P), or no response (NR; direct placement on escape platform) during the information "run" on acquisition and the subsequent performance of the task. Most of the naive, male, Sprague-Dawley rats were capable of attaining a 90% correct choice criterion when trained with P or NR information runs, but rats trained with R information runs required fewer trials to attain criterion and had shorter escape latencies during the criterion trials. Rats in all three groups showed significant retention at retention intervals as long as 1 h. Rats overtrained on the task with R information runs were subsequently able to perform the task at above chance level, regardless of the type information run given on the trial, but performed more accurately on trials where they made P or R information runs. Thus, rats use and perform better on place DMTS when allocentric environmental and egocentric response-associated cues are both available.

Usefulness of clinical factors in predicting outcomes of passive tilt tests in patients with syncope.

Pretest patient selection affects the outcome of many diagnostic tests; this may be true for tilt-table tests. We assessed the impact of patient age, sex, and symptom burden on the outcome of passive tilt tests. Two hundred one patients with idiopathic syncope (87 men, aged 45 +/- 20 years, median 5 fainting spells each) underwent passive, drug-free tilt tests for 45 minutes. Positive tests were defined as those ending in clinically reminiscent presyncope or syncope. Seventy-eight patients (39%) had a positive tilt test. Patients had a wide range of symptom burden, having a median 5 syncopal spells (interquartile range [IQR] 2.5 to 17.5) over a median 52.5 months (IQR 12 to 180) with a median frequency of 0.17 spells/month (IQR 0.042 to 0.67). None of these measures of symptom burden predicted tilt-test outcome (p = 0.33 to 0.46). In contrast, the age of the patient strongly predicted tilt-test outcome. The likelihood of a positive test was 75% in 36 patients < 25 years old and 31% in 165 patients > or = 25 years of age (p < 0.0001, chi-square for 2 x 5 table). Younger patients also fainted more quickly: patients < 25 years old fainted within 22 minutes of tilt and reached a clearly asymptotic value, whereas the likelihood of a positive tilt in patients > or = 25 years old increased linearly with time, and did not reach an asymptote. Measures of symptom burden do not predict test outcome, and younger patients are more likely to faint during passive tilt testing.

A comparison of iatrogenic injury studies in Australia and the USA. I: Context, methods, casemix, population, patient and hospital characteristics.

OBJECTIVE: To better understand the differences between two iatrogenic injury studies of hospitalized patients in 1992 which used ostensibly similar methods and similar sample sizes, but had quite different findings. The Quality in Australian Health Care Study (QAHCS) reported that 16.6% of admissions were associated with adverse events (AE), whereas the Utah, Colorado Study (UTCOS) reported a rate of 2.9%. SETTING: Hospitalized patients in Australia and the USA. DESIGN: Investigators from both studies compared methods and characteristics and identified differences. QAHCS data were then analysed using UTCOS methods. MAIN OUTCOME MEASURES: Differences between the studies and the comparative AE rates when these had been accounted for. RESULTS: Both studies used a two-stage chart review process (screening nurse review followed by confirmatory physician review) to detect AEs; five important methodological differences were found: (i) QAHCS nurse reviewers referred records that documented any link to a previous admission, whereas UTCOS imposed age-related time constraints; (ii) QAHCS used a lower confidence threshold for defining medical causation; (iii) QAHCS used two physician reviewers, whereas UTCOS used one; (iv) QAHCS counted all AEs associated with an index admission whereas UTCOS counted only those determining the annual incidence; and (v) QAHCS included some types of events not included in UTCOS. When the QAHCS data were analysed using UTCOS methods, the comparative rates became 10.6% and 3.2%, respectively. CONCLUSIONS: Five methodological differences accounted for some of the discrepancy between the two studies. Two explanations for the remaining three-fold disparity are that quality of care was worse in Australia and that medical record content and/or reviewer behaviour was different.

A comparison of iatrogenic injury studies in Australia and the USA. II: Reviewer behaviour and quality of care.

OBJECTIVE: To better understand the remaining three-fold disparity between adverse event (AE) rates in the Quality in Australia Health Care Study (QAHCS) and the Utah-Colorado Study (UTCOS) after methodological differences had been accounted for. SETTING: Iatrogenic injury in hospitalized patients in Australia and America. DESIGN: Using a previously developed classification, all AEs were assigned to 98 exclusive descriptive categories and the relative rates compared between studies; they were also compared with respect to severity and death. MAIN OUTCOME MEASURES: The distribution of AEs amongst the descriptive and outcome categories. RESULTS: For 38 categories, representing 67% of UTCOS and 28% of QAHCS AEs, there were no statistically significant differences. For 33, representing 31% and 69% respectively, there was seven times more AEs in QAHCS than in UTCOS. Rates for major disability and death were very similar (1.7% and 0.3% of admissions for both studies) but the minor disability rate was six times greater in QAHCS (8.4% versus 1.3%). CONCLUSIONS: A similar 2% core of serious AEs was found in both studies, but for the remaining categories six to seven times more AEs were reported in QAHCS than in UTCOS. We hypothesize that this disparity is due to different thresholds for admission and discharge and to a greater degree of under-reporting of certain types of problems as AEs by UTCOS than QAHCS reviewers. The biases identified were consistent with, and appropriate for, the quite different aims of each study. No definitive difference in quality of care was identified by these analyses or a literature review.

A classification for adverse drug events.

There is considerable evidence that a large number of patients suffer adverse events arising from their health-care management. A significant proportion of these iatrogenic injuries occur as a result of medication errors. Before prevention strategies can be developed, it is necessary to understand the types of errors that are occurring. In order to set priorities, it is necessary to identify the frequency and impact of the various types of medication errors. To fully investigate medication incidents, it is necessary to classify the information in a way that allows the frequencies, causes and contributing factors to be analysed. The development of a sub-branch of the 'Generic Occurrence Classification', specific to medication incidents, allows this analysis to occur.

Gender differences in manifestation of cardiac arrhythmias.

It is now appreciated that a patient's sex has a significant impact on presentation of cardiac diseases. This has been well described in patients with coronary artery disease but is less well appreciated in the setting of arrhythmia management. In Cardiology in Review in 1998, Tracy outlined some of the major differences between the sexes with regard to the electrocardiogram and the presentation of arrhythmias. Arrhythmia management also can be considerably different, and in this review, we address some additional aspects of differences between the sexes in this area.

A classification for incidents and accidents in the health-care system.

Problems that arise from health-care management, rather than from a disease process, are now recognized as making a substantial contribution to patient morbidity and mortality and to the cost of health care. However, most classifications of these problems do not provide sufficient detail to allow comparisons or to develop better strategies for the prevention, detection and management of these problems. A 'Generic Occurrence Classification' was developed to record their salient features, place them in context and elicit any system or human error-based contributing factors. This was done by an iterative process in which 'natural categories', identified from over 2000 incidents and 800 adverse events, were placed in a hierarchical structure created using software written in Microsoft Visual Basic; data were stored in a Microsoft Access database. This was shown to be a valid and reliable way to compare incidents and accidents from different sources and to allow sufficient detail to be retrieved to develop preventive strategies.

The nutritional response to home enteral nutrition in childhood.

The nutritional response to home enteral nutrition (HEN) was evaluated in a prospective study of 44 consecutive children (median age 48 months) who received HEN for more than 1 month (median duration 6 months). Three groups were studied: 17 children were stunted, 14 were wasted and 13 were adequately nourished but unlikely to maintain oral intake during anticipated nutritional stress. In the stunted group (median duration of HEN 15 months) there was a significant correlation between improvements in height-for-age z scores and duration of feeds (r = 0.63; p = 0.006). In the wasted group (median duration of HEN 4 months) all anthropometric indices improved significantly (p < 0.05). HEN was also successful in maintaining nutritional status in the third group. Thus, supplementary HEN is an effective method of nutritional support for a variety of indications, provided concurrent advice from a nutritional care team is available.