Involving older people with multimorbidity in decision-making about their primary healthcare: A Cochrane systematic review of interventions (abridged).

OBJECTIVE: To assess the effects of interventions aimed at involving older people with multimorbidity in decision-making about their healthcare during primary care consultations. METHODS: Cochrane methodological procedures were applied. Searches covered all relevant trial registries and databases. Randomised controlled trials were identified where interventions had been compared with usual care/ control/ another intervention. A narrative synthesis is presented; meta-analysis was not appropriate. RESULTS: 8160 abstracts and 54 full-text articles were screened. Three studies were included, involving 1879 patient participants. Interventions utilised behaviour change theory; cognitive-behavioural therapy and motivational interviewing; multidisciplinary, holistic patient review and organisational changes. No studies reported the primary outcome 'patient involvement in decision-making about their healthcare'. Patient involvement was evident in the theory underpinning interventions. Certainty of evidence (assessed using GRADE) was limited by small studies and inconsistency in secondary outcomes measured. CONCLUSION: The evidence base is currently too limited to interpret with certainty. Transparency in design and consistency in evaluation, using validated measures, is required for future interventions involving older patients with multimorbidity in decisions about their healthcare. PRACTICE IMPLICATIONS: There is a large gap between clinical guidelines for multimorbidity and an evidence base for implementation of their recommendations during primary care consultations with older people.

Patient characteristics predicting failure to receive indicated care for type 2 diabetes.

AIMS: To determine which patient characteristics were associated with failure to receive indicated care for diabetes over time. METHODS: English Longitudinal Study of Ageing participants aged 50 or older with diabetes reported receipt of care described by four diabetes quality indicators (QIs) in 2008-9 and 2010-11. Annual checks for glycated haemoglobin (HbA1c), proteinuria and foot examination were assessed as a care bundle (n=907). A further QI (n=759) assessed whether participants with cardiac risk factors were offered ACE inhibitors or angiotensin II receptor blockers (ARBs). Logistic regression modelled associations between failure to receive indicated care in 2010-11 and participants' socio-demographic, lifestyle and health characteristics, diabetes self-management knowledge, health literacy, and previous QI achievement in 2008-9. RESULTS: A third of participants (2008-9=32.8%; 2010-11=32.2%) did not receive all annual checks in the care bundle. Nearly half of those eligible were not offered ACE inhibitors/ARBs (2008-9=44.6%; 2010-11=44.5%). Failure to receive a complete care bundle was associated with lower diabetes self-management knowledge (odds ratio (OR) 2.05), poorer cognitive performance (1.78), or having previously received incomplete care (3.32). Participants who were single (OR=2.16), had low health literacy (1.50) or had received incomplete care previously (6.94) were more likely to not be offered ACE inhibitors/ARBs. Increasing age (OR=0.76) or body mass index (OR=0.70) was associated with lower odds of failing to receive this aspect of care. CONCLUSIONS: Quality improvement initiatives for diabetes might usefully target patients with previous receipt of incomplete care, poor knowledge of annual diabetes care processes, and poorer cognition and health literacy.

Economic inequalities in burden of illness, diagnosis and treatment of five long-term conditions in England: panel study.

OBJECTIVE: We compared the distribution by wealth of self-reported illness burden (estimated from validated scales, biomarker and reported symptoms) for angina, cataract, depression, diabetes and osteoarthritis, with the distribution of self-reported medical diagnosis and treatment. We aimed to determine if the greater illness burden borne by poorer participants was matched by appropriately higher levels of diagnosis and treatment. DESIGN: The English Longitudinal Study of Ageing, a panel study of 12,765 participants aged 50 years and older in four waves from 2004 to 2011, selected using a stratified random sample of households in England. Distribution of illness burden, diagnosis and treatment by wealth was estimated using regression analysis. OUTCOME MEASURES: The main outcome measures were ORs for the illness burden, diagnosis and treatment, respectively, adjusted for age, sex and wealth. We estimated the illness burden for angina with the Rose Angina scale, diabetes with fasting glycosylated haemoglobin, depression with the Centre for Epidemiologic Studies Depression Scale, osteoarthritis with self-reported pain and disability and cataract with self-reported poor vision. Medical diagnoses were self-reported for all conditions. Treatment was defined as ß-blocker prescription for angina, surgery for osteoarthritis and cataract, and receipt of predefined effective interventions for diabetes and depression. RESULTS: Compared with the wealthiest, the least wealthy participant had substantially higher odds for illness burden from any of the five conditions at all four time points, with ORs ranging from 4.2 (95% CI 2.6 to 6.8) for diabetes to 15.1 (11.4 to 20.0) for osteoarthritis. The ORs for diagnosis and treatment were smaller in all five conditions, and ranged from 0.9 (0.5 to 1.4) for diabetes treatment to 4.5 (3.3 to 6.0) for angina diagnosis. CONCLUSIONS: The substantially higher illness burden in less wealthy participants was not matched by appropriately higher levels of diagnosis and treatment.

Does the method of administration influence the UK GMC patient questionnaire ratings?

AIM: To examine whether different methods of administration of a patient questionnaire (PQ) assessing a doctor's professional performance can influence the quality of data collected. BACKGROUND: Patient surveys are important information sources regarding a doctor's professional performance. Previous research across a range of patient outcomes suggests that the method of administration can influence response rates and ratings, although no data that explore how this might influence patients' assessments of a doctor's professional performance are available. METHODS: A volunteer sample of 13 UK doctors from primary care settings undertook a cross-sectional patient survey. Seven doctors distributed patient surveys using exit and touch-tone telephone administration, and six doctors used exit and postal administration. A consecutive sample of up to 40 patients per doctor completed each method of administration; postal and touch-tone surveys were administered retrospectively, whereas the exit surveys were administered prospectively. The GMC (General Medical Council) PQ included nine performance evaluation questions. We examined the response rates, item completion rates and response profiles of exit survey responses with those obtained from either postal or touch-tone telephone methods. RESULTS: The administration methods influence the quality and comparability of data obtained. The exit survey response rate was higher than touch-tone (82.1% versus 37.5%; P < 0.0001) or postal survey (no reminder) (76.7% versus 60.8%; P < 0.0001) administration, but comparable to the postal survey after one reminder (78.3% versus 75.0%; P = 0.39). Item completion rates were comparable for exit and touch-tone surveys (highest rates of missing data 4.1% and 4.6%, respectively), but exit surveys resulted in more missing values than postal surveys (10.3 to 11.7% versus 1.1 to 3.9%). Response profiles varied. Both touch-tone and postal surveys yielded significantly more critical ratings than the exit survey (three of nine items). CONCLUSION: Mixing administration methods requires caution when the data are used to create benchmarks against which a doctor's performance is assessed.

Assessing the professional performance of UK doctors: an evaluation of the utility of the General Medical Council patient and colleague questionnaires.

OBJECTIVE: To investigate the utility of the GMC patient and colleague questionnaires in assessing the professional performance of a large sample of UK doctors. DESIGN: Cross-sectional questionnaire surveys. SETTING: Range of UK clinical practice settings. PARTICIPANTS: 541 doctors gave preliminary agreement to take part in the study. Responses were received from 13 754 patients attending one of 380 participant doctors, and from 4269 colleagues of 309 participant doctors. MAIN OUTCOME MEASURES: Questionnaire performance and standardised scores for each doctor derived from patient and colleague responses. RESULTS: Participant doctors were similar to non-participants in respect of age and gender. The patient and colleague questionnaires were acceptable to participants as evidenced by low levels of missing data. One patient questionnaire item seemed to cause confusion for respondents and requires rewording. Both patient and colleague responses were highly skewed towards favourable impressions of doctor performance, with high internal consistency. To achieve acceptable levels of reliability, a minimum of 8 colleague questionnaires and 22 patient questionnaires are required. G coefficients for both questionnaires were comparable with internationally recognised survey instruments of broadly similar intent. Patient and colleague assessments provided complementary perspectives of doctors' performance. Older doctors had lower patient-derived and colleague-derived scores than younger doctors. Doctors from a mental health trust and doctors providing care in a variety of non-NHS settings had lower patient scores compared with doctors providing care in acute or primary care trust settings. CONCLUSIONS: The GMC patient and colleague questionnaires offer a reliable basis for the assessment of professionalism among UK doctors. If used in the revalidation of doctors' registration, they would be capable of discriminating a range of professional performance among doctors, and potentially identifying a minority whose practice should to subjected to further scrutiny.

Capturing users' experience of UK out-of-hours primary medical care: piloting and psychometric properties of the Out-of-hours Patient Questionnaire.

BACKGROUND AND OBJECTIVE: Provision of out-of-hours care in the UK National Health Service (NHS) has changed in recent years with new models of provision and the introduction of national quality requirements. Existing survey instruments tend to focus on users' satisfaction with service provision; most were developed without undertaking supporting qualitative fieldwork. In this study, a survey instrument was developed taking account of these changes in service provision and undertaking supporting qualitative fieldwork. This paper reports on the development and psychometric properties of the new survey instrument, the Out-of-hours Patient Questionnaire (OPQ), which aims to capture information on the entirety of users' experiences of out-of-hours care, from the decision to make contact through to completion of their care management. METHODS: An iterative approach was undertaken to develop the new instrument which was then tested in users of out-of-hours services in three geographically distributed UK settings. For the purposes of this study, "service users" were defined as "individuals about whom contact was made with an out-of-hours primary care medical service", whether that contact was made by the user themselves, or via a third party. Analysis was undertaken of the acceptability, reliability and validity of the survey instrument. RESULTS: The OPQ tested is a 56-item questionnaire, which was distributed to 1250 service users. Respondents were similar in respect of gender, but were older and more affluent (using a proxy measure) than non-respondents. Item completion rates were acceptable. Respondents sometimes completed sections of the questionnaire which did not equate to their principal mode of management as recorded in the record of the contact. Preliminary evidence suggests the OPQ is a valid and reliable instrument which contains within it two discrete scales--a consultation satisfaction scale (nine items) and an "entry-access" scale (four items). Further work is required to determine the generalisability of findings obtained following use of the OPQ, especially to non-white user populations. CONCLUSION: The OPQ is an acceptable instrument for capturing information on users' experiences of out-of-hours care. Preliminary evidence suggests it is both valid and reliable in use. Further work will report on its utility in informing out-of-hours service planning and configuration and standard-setting in relation to UK national quality requirements.

Exploring users' experiences of accessing out-of-hours primary medical care services.

BACKGROUND: Since 2000, out-of-hours primary medical care services in the UK have undergone major changes in the organisation and delivery of services in response to recommendations by the Carson Review and more recently, through the new General Medical Services Contract (GMS2). People calling their general practice in the evening or at weekends are redirected to the out-of-hours service which may offer telephone advice, a home visit or a visit to a treatment centre. Little is known about users' experiences under the new arrangements. AIM: To explore users' experiences of out-of-hours primary medical care. DESIGN OF STUDY: A qualitative study employing focus groups and telephone interviews. SETTING: Three out-of-hours primary medical care service providers in England. METHODS: Focus groups and telephone interviews were conducted with 27 recent users of out-of-hours services. RESULTS: Key areas of concern included the urgency with which cases are handled, and delays when waiting for a call back or home visit. Users felt that providers were reluctant to do home visits. The service was regarded as under-resourced and frequently misused. Many expressed anxiety about calling, feeling unsure about how appropriate their call was and many were uncertain about how the service operated. CONCLUSIONS: Service users need clear information on how current out-of-hours services operate and how it should be used. Problems with triaging need to be addressed, users should be kept informed of any delays, and care needs to be taken to ensure that the new arrangements do not alienate older people or individuals with complex health needs.

Development and testing of a questionnaire to measure patient satisfaction with intermediate care.

BACKGROUND: Individual trials have suggested high levels of general patient satisfaction with intermediate care, but this topic has not been examined in detail. AIMS: To identify the key elements of patient satisfaction with intermediate care, and to see whether these can be validly measured using a questionnaire. METHOD: A questionnaire was developed on the basis of a literature review and piloting with patients and staff on participating schemes (phase I). In phase II, the questionnaire was tested for validity and reliability in a group of patients recently discharged from two "hospital-at-home" intermediate-care schemes. In phase III, a shortened version of the questionnaire was psychometrically tested in five sites taking part in a national evaluation of intermediate care. RESULTS: 96 patients with an average age of 76.5 years took part in phase II. Test-retest reliability was evaluated by repeating the questionnaire 2 weeks later in a subsample of 42 patients. This was "moderate" (kappa 0.4-0.6) for 12 questions, "fair" (kappa 0.2-0.4) for 6 questions and "poor" (kappa 0.1-0.2) for 5 questions. Scores correlated well with the Client Satisfaction Questionnaire (Spearman's r = 0.75, p<0.001). 843 patients (57% of those eligible) from five intermediate-care schemes took part in phase III. Principal components analysis suggested six factors or subscales: general satisfaction, affective response, cognitive response, timing of discharge, coordination after discharge, and access to pain relief, although the last three factors comprised only one question each. The intraclass correlation coefficients in the first three subscales varied from 0.82 to 0.89. Scores for all subscales differed by scheme, suggesting construct validity. Only one question (on general satisfaction) was found to be redundant. CONCLUSION: The questionnaire, with some minor amendments to improve performance, could be used as a validated tool for audit and research in intermediate care. An amended version and scoring programme is available from us on request.

A Bayesian approach to analysing the cost-effectiveness of two primary care interventions aimed at improving attendance for breast screening.

AIMS: To assess the cost-effectiveness of two primary care interventions, a letter and a flag, aimed at improving attendance for breast screening among (i) all women invited for breast screening and (ii) non-attenders. METHODS: A probabilistic decision analytic model was developed using Markov chain Monte Carlo simulation implemented in WinBUGS. The model was populated using economic and effectiveness data collected alongside two randomised controlled trials. RESULTS: For all women invited, the incremental cost-effectiveness ratio (ICER) for the letter compared with no intervention is 27 pounds per additional attendance, and the ICER for the combined letter and flag intervention compared to the letter alone is 171 pounds. The corresponding ICERs for non-attenders are 41 pounds and 90 pounds. The flag intervention is an inefficient option in both settings. A large proportion of the costs fall on the practices (25-67%), depending on the intervention and target population. The total costs incurred do not, however, seem prohibitive. Expected value of perfect information suggests that there is greater value in carrying out further research on the intervention implemented among all women invited for breast screening rather than on non-attenders. CONCLUSIONS: The flag intervention alone does not appear to be an efficient option. The choice between the letter and both interventions combined is subjective, depending on the willingness to pay for an additional screening attendance.

Comparison of methods for analysing cluster randomized trials: an example involving a factorial design.

BACKGROUND: Studies involving clustering effects are common, but there is little consistency in their analysis. Various analytical methods were compared for a factorial cluster randomized trial (CRT) of two primary care-based interventions designed to increase breast screening attendance. METHODS: Three cluster-level and five individual-level options were compared in respect of log odds ratios of attendance and their standard errors (SE), for the two intervention effects and their interaction. Cluster-level analyses comprised: (C1) unweighted regression of practice log odds; (C2) regression of log odds weighted by their inverse variance; (C3) random-effects meta-regression of log odds with practice as a random effect. Individual-level analyses comprised: (I1) standard logistic regression ignoring clustering; (I2) robust SE; (I3) generalized estimating equations; (I4) random-effects logistic regression; (I5) Bayesian random-effects logistic regression. Adjustments for stratification and baseline variables were investigated. RESULTS: As expected, method I1 was highly anti-conservative. The other, valid, methods exhibited considerable differences in parameter estimates and standard errors, even between the various random-effects methods based on the same statistical model. Method I4 was particularly sensitive to between-cluster variation and was computationally stable only after controlling for baseline uptake. CONCLUSIONS: Commonly used methods for the analysis of CRT can give divergent results. Simulation studies are needed to compare results from different methods in situations typical of cluster trials but when the true model parameters are known.

Cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of two primary care interventions aimed at improving attendance for breast screening.

OBJECTIVES: To examine the effectiveness and cost-effectiveness of two interventions based in primary care aimed at increasing uptake of breast screening. SETTING: 24 General practices with low uptake in the second round of screening (below 60%) in north west London and the West Midlands, UK. Participants were all women registered with these practices and eligible for screening in the third round. METHODS: Pragmatic factorial cluster randomised controlled trial, with practices randomised to a systematic intervention (general practitioner letter), an opportunistic intervention (flag in women's notes prompting discussion by health professionals), neither intervention, or both. Outcome measures were attendance for screening 6 months after the practices had been screened and cost-effectiveness of the interventions. RESULTS: 6,133 Women were included: 1,721 control; 1,818 letter; 1,232 flag; 1,362 both interventions. Attendance data were obtained for 5,732 (93%) women. The two interventions independently increased breast screening uptake in a logistic regression model adjusted for clustering, with the flag (odds ratio (OR) 1.43, 95% confidence interval (95% CI) 1.14 to 1.79; p=0.0019) marginally more effective than the letter (OR 1.31, 95% CI 1.05 to 1.64; p=0.015). Health service costs per additional attendance were 26 pounds (letter) and 41 pounds (flag). CONCLUSIONS: Although both interventions increased attendance for breast screening, the letter was the more cost-effective. Any decision to implement both interventions rather than just the letter will depend on whether the additional (41 pounds) costs are judged worthwhile in terms of the gains in breast screening uptake.

Improving attendance for breast screening among recent non-attenders: a randomised controlled trial of two interventions in primary care.

OBJECTIVES: To examine the effectiveness and cost-effectiveness of two primary care based interventions aimed at increasing breast screening uptake for women who had recently failed to attend. SETTING: 13 General practices with low uptake in the second round of breast screening (below 60%) in north west London and the West Midlands, United Kingdom. Participants were women in these practices who were recent non-attenders for breast screening in the third round. METHODS: Pragmatic factorial randomised controlled trial, with people randomised to a systematic intervention (general practitioner letter), an opportunistic intervention (flag in women's notes prompting discussion by health professionals), neither intervention, or both. Outcome measures were attendance for screening 6 months after randomisation and cost-effectiveness of the interventions. RESULTS: 1,158 Women were individually randomised as follows: 289 control; 291 letter; 290 flag; 288 both interventions. Attendance was ascertained for 1,148 (99%) of the 1,158 women. Logistic regression adjusting for the other intervention and practice produced an odds ratio (OR) for attendance of 1.51 (95% confidence interval (95% CI 1.02 to 2.26; p=0.04) for the letter, and 1.39 (95% CI 0.93 to 2.07; p=0.10) for the flag. Health service costs/ additional attendance were 35 pounds (letter) and 65 pounds (flag). CONCLUSIONS: Among recent non-attenders, the letter was effective in increasing breast screening attendance. The flag was of equivocal effectiveness and was considerably less cost-effective than the letter.

How great a burden does early discharge to hospital-at-home impose on carers? A randomized controlled trial.

OBJECTIVE: to assess the effects of an early discharge hospital-at-home scheme on self-reported carer strain and quality of life. DESIGN: a randomized controlled trial SETTING: Bristol, UK. SUBJECTS: 133 carers of patients receiving either early discharge from hospital to hospital-at-home (n = 93) care or usual hospital care and discharge (n = 40). OUTCOME MEASURES: modified 12-item Carer Strain Index, COOP-WONCA charts and EuroQol EQ-5D at 4 weeks and 3 months post-randomization. RESULTS: the mean age of carers was 65 years; 56% were women. There were no marked differences between the groups in any of the outcomes used at either 4-week or 3-month follow-up. CONCLUSION: there was no evidence of increased self-reported burden imposed on carers of patients discharged early from hospital. Decisions on the implementation of hospital-at-home schemes should be influenced by considerations of cost and effectiveness rather than effects on carers. The effects on carers may, however, differ for other forms of home-based care.

Inter-rater reliability of the Barthel ADL index: how does a researcher compare to a nurse?

OBJECTIVES: To investigate whether a nonclinical research assistant, using standardized scoring criteria, can reliably administer the Barthel Activities of Daily Living (ADL) Index in a sample of elderly inpatients. DESIGN: Paired comparison of nurse and nonclinical research assistant Barthel Index assessments. SETTING: Acute hospital wards from two hospitals in a UK Healthcare Trust, with a catchment population of approximately 224,000 people. METHODS: A consecutive sample of 94 elderly patients with a variety of medical problems. MAIN OUTCOME MEASURES: Barthel ADL Index, Folstein Mini-Mental Status Examination. RESULTS: Whilst the inter-rater reliability of the Barthel Index was within acceptable boundaries, two items out of ten had only fair agreement and low crude agreement (transfer and dressing) on Cohen's kappa scores. CONCLUSIONS: Depending on the differences observed in any particular context, the Barthel Index can be applied with reasonable reliability by nonclinical staff applying the standardized scoring criteria. It should be noted, however, that the kappa coefficients between clinical and nonclinical assessors tend to be lower than those found when comparing two clinically trained assessors in previous research.

Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care.

OBJECTIVE: To compare effectiveness and acceptability of early discharge to a hospital at home scheme with that of routine discharge from acute hospital. DESIGN: Pragmatic randomised controlled trial. SETTING: Acute hospital wards and community in north of Bristol, with a catchment population of about 224 000 people. SUBJECTS: 241 hospitalised but medically stable elderly patients who fulfilled criteria for early discharge to hospital at home scheme and who consented to participate. INTERVENTIONS: Patients' received hospital at home care or routine hospital care. MAIN OUTCOME MEASURES: Patients' quality of life, satisfaction, and physical functioning assessed at 4 weeks and 3 months after randomisation to treatment; length of stay in hospital and in hospital at home scheme after randomisation; mortality at 3 months. RESULTS: There were no significant differences in patient mortality, quality of life, and physical functioning between the two arms of the trial at 4 weeks or 3 months. Only one of 11 measures of patient satisfaction was significantly different: hospital at home patients perceived higher levels of involvement in decisions. Length of stay for those receiving routine hospital care was 62% (95% confidence interval 51% to 75%) of length of stay in hospital at home scheme. CONCLUSIONS: The early discharge hospital at home scheme was similar to routine hospital discharge in terms of effectiveness and acceptability. Increased length of stay associated with the scheme must be interpreted with caution because of different organisational characteristics of the services.

Hospital at home or acute hospital care? A cost minimisation analysis.

OBJECTIVE: To compare, from the viewpoints of the NHS and social services and of patients, the costs associated with early discharge to a hospital at home scheme and those associated with continued care in an acute hospital. DESIGN: Cost minimisation analysis. SETTING: Acute hospital wards and the community in the north of Bristol (population about 224 000). SUBJECTS: 241 hospitalised but medically stable elderly patients who fulfilled the criteria for early discharge to a hospital at home scheme and who consented to participate. MAIN OUTCOME MEASURES: Costs to the NHS, social services, and patients over the 3 months after randomisation. RESULTS: The mean cost for hospital at home patients over the 3 months was 2516 pounds, whereas that for hospital patients was 3292 pounds. Under all the assumptions used in the sensitivity analysis, the cost of hospital at home care was less than that of hospital care. Only when hospital costs were assumed to be less than 50% of those used in the initial analysis was the difference equivocal. CONCLUSIONS: The hospital at home scheme is less costly than care in the acute hospital. These results may be generalisable to schemes of similar size and scope, operating in a similar context of rising acute admissions.

Effect of varying the time frame for COOP-WONCA functional health status charts: a nested randomised controlled trial in Bristol, UK.

STUDY OBJECTIVES: To investigate whether changing the stated time frame for COOP-WONCA charts has any effect on responses. Specifically, to assess the effect of attempting to avoid the situation where the time frame crosses the onset of an acute episode. DESIGN: A randomised controlled trial of two time frames, nested within a main trial comparing early discharge with a hospital at home scheme against routine discharge policy. The time frames compared were the standard two weeks (four for the pain chart) and a shorter period of 48 hours for all seven charts. SETTING: Acute hospital wards in Frenchay Healthcare Trust and the Avon Orthopaedic Centre in Bristol. PARTICIPANTS: Patients entered into the main trial, who were medically stable, in need of continued rehabilitative care but suitable for discharge to hospital at home. MAIN RESULTS: A total of 200 patients were randomised, 106 to the shorter time frame, 94 to the standard charts. No clear differences were observed between the two groups for the proportion failing to self complete the charts. For the (seven) chart scores, only pain was statistically significantly different between the time frames (Mann-Whitney p = 0.0085; proportion reporting moderate or severe pain 19% higher in the standard group, 95% confidence intervals 5% to 33%). For both this chart and that for change in health, however, there was evidence of greater differences between the versions of the chart among those admitted more recently (p values for relevant interactions 0.004 and < or = 0.001 respectively). CONCLUSIONS: While the present findings give some support for the wide applicability of the standard version, there is sufficient evidence here to indicate that the time frame may influence the results, particularly for patients with a recent acute episode. In the absence of further data, then, it would seem prudent to consider a shorter time frame for such patients, especially if the aim is to assess current health status or to measure changes over a comparatively short period of time, or both.

Use of the EuroQoL among elderly acute care patients.

The assessment of the validity and reliability of generic quality of life (QoL) instruments among elderly patient groups has tended to lag behind such assessments in general populations, yet it is an important methodological issue. This paper presents the findings from a study of the use of the EuroQoL among an elderly acute care patient group, focusing particularly on the ability to self-complete, construct validity and sensitivity to change. Two hundred and fourteen UK patients aged 65 years and over, participating in a randomized controlled trial comparing hospital at home and routine hospital care were asked to complete the EuroQoL and a number of other instruments at randomization and at 4 week and 3 month follow-ups. The inability to self-complete the EuroQol was found to be strongly related to both increased age and reduced cognitive function (p < 0.0001). From logistic regression, the expected probability of an acute care patient requiring interview administration at age 65 years is 11%, at age 75 years is 37% and at age 85 years is 73%. The relationships with age and limiting long-standing illness/disability were weaker than expected, but the results obtained from the EuroQoL were highly correlated with those from both the Barthel Index and the COOP-WONCA charts where this was anticipated. Preliminary evidence of sensitivity to change was found from descriptive statistics of the changes in scores for four specific subgroups of patients, but the small numbers and high variability in each sub-sample means that this should be interpreted with caution. The most important issue arising from the research concerns the impact of age on the ability to self-complete the EuroQoL questionnaire. It is argued that this research points to the need for rigorous studies (such as randomized controlled trials) to assess the impact of the format of administration of the EuroQoL on the scores obtained.

Voice changes in acromegaly.

The fundamental frequency of 14 patients undergoing hypophysectomy was studied. Eight patients had acromegaly, 3 had a prolactinoma, and 3 had nonfunctioning adenomas. The fundamental frequency of 22 normal, healthy volunteers was measured for comparison. In addition, the external size of the larynx of all patients and volunteers was measured and a relationship between external laryngeal size and the mean fundamental frequency was identified in the volunteers. The mean fundamental frequency in patients with acromegaly was significantly lower than the other 6 patients undergoing hypophysectomy and, in addition, was also lower than the 22 normal volunteers. Postoperatively the fundamental frequency of the acromegalic patients increased rapidly to within the expected normal range. Patients with acromegaly have a lowered fundamental frequency which is most likely due to altered vocal cord mass and elasticity, which is a reversible change. Patients with acromegaly can expect a rapid and complete return of normal fundamental frequency within 2 weeks of surgery to remove the pituitary adenoma.

Finding the means to carry on. Suicidal feelings in cancer patients.

People suffering from advanced cancer may question the point of carrying on. It is essential that nurses are sensitive to patients' suicidal feelings at such times, and that a multidisciplinary assessment is made of the patient's key concerns. By bringing such problems into the open, these concerns may begin to be addressed.