The impact of a general practice co-operative on accident and emergency services, patient satisfaction and GP satisfaction.

BACKGROUND: The advent of general practice co-operatives represented a fundamental change in the delivery and organization of out-of-hours services. Concerns have been voiced that co-operatives might impact adversely on workload in accident and emergency (A&E) departments. OBJECTIVE: The purpose of this study was to assess the impact of establishing a general practice co-operative on use of A&E services, patient satisfaction and GP satisfaction. METHODS: A controlled before and after study of a GP co-operative in Sheffield, UK was carried out. A postal questionnaire was sent to 26 911 people, 13 442 before and 13 469 after the opening of the co-operative, to determine service use, in particular A&E attendance, in the previous 4 weeks. Patient satisfaction was assessed through structured interviews with 653 patients. GP satisfaction was assessed using a postal survey of all 98 Sheffield practices 2 years after the opening of the co-operative. RESULTS: There was no change in the use of A&E services, odds ratio = 1.08 (95% confidence interval 0.60-1.94). There was no change in patient satisfaction overall, mean difference 0.02 (-0.32 to 0.36). Sixty-seven per cent of doctors in member practices were much more satisfied with out-of-hours duty compared with 10% in non-member practices (P < 0.001). CONCLUSIONS: General practice co-operatives have been successful in achieving their policy objectives, improving GP morale without jeopardizing patient satisfaction or impacting adversely on A&E services.

Effectiveness and cost-effectiveness of prognostic markers in prostate cancer.

This paper demonstrates how economic modelling can be used to derive estimates of the cost-effectiveness of prognostic markers in the management of clinically localised and moderately graded prostate cancer. The model uses a Markov process and is populated using published evidence and local data. The robustness of the results has been tested using sensitivity analysis. Three treatment policies of 'monitoring' (observation), radical prostatectomy, or a selection-based management policy using DNA-ploidy as an experimental marker, have been evaluated. Modelling indicates that a policy of managing these tumours utilising experimental markers has an estimated cost per quality-adjusted life year (QALY) of pound 12 068. Sensitivity analysis shows the results to be relatively sensitive to quality-of-life variables. If novel and experimental markers can achieve specificity in excess of 80%, then a policy of radical surgery for those identified as being at high risk and conservative treatment for the remainder would be both better for patients and cost-effective. The analysis suggests that a radical prostatectomy treatment policy for the moderately graded tumours (Gleason grades -7) modelled in this paper may be inferior to a conservative approach in the absence of reliable prognostic markers, being both more costly and yielding fewer QALYs.

A meta-analytic review of the relation between antisocial behavior and neuropsychological measures of executive function.

Previous narrative reviews of the relation between antisocial behavior (ASB) and neuropsychological tests of executive functioning (EF) have raised numerous methodological concerns and produced equivocal conclusions. By using meta-analytic procedures, this study attempts to remedy many of these concerns and quantifies the relation between ASB and performance on six reasonably well validated measures of EF. Thirty-nine studies yielding a total of 4,589 participants were included in the analysis. Overall, antisocial groups performed .62 standard deviations worse on EF tests than comparison groups; this effect size is in the medium to large range. Significant variation within this effect size estimate was found, some of which was accounted for by differences in the operationalizations of ASB (e.g., psychopathy vs. criminality) and measures of EF. Evidence for the specificity of EF deficits relative to deficits on other neuropsychological tasks was inconsistent. Unresolved conceptual problems regarding the association between ASB and EF tests, including the problem of localizing EF tests to specific brain regions, are discussed.