Examining area-level variation in service organisation and delivery across the breadth of primary healthcare. Usefulness of measures constructed from routine data.

BACKGROUND: Australia has a universal healthcare system, yet organisation and delivery of primary healthcare (PHC) services varies across local areas. Understanding the nature and extent of this variation is essential to improve quality of care and health equity, but this has been hampered by a lack of suitable measures across the breadth of effective PHC systems. Using a suite of measures constructed at the area-level, this study explored their application in assessing area-level variation in PHC organisation and delivery. METHODS: Routinely collected data from New South Wales, Australia were used to construct 13 small area-level measures of PHC service organisation and delivery that best approximated access (availability, affordability, accommodation) comprehensiveness and coordination. Regression analyses and pairwise Pearson's correlations were used to examine variation by area, and by remoteness and area disadvantage. RESULTS: PHC service delivery varied geographically at the small-area level-within cities and more remote locations. Areas in major cities were more accessible (all measures), while in remote areas, services were more comprehensive and coordinated. In disadvantaged areas of major cities, there were fewer GPs (most disadvantaged quintile 0.9[SD 0.1] vs least 1.0[SD 0.2]), services were more affordable (97.4%[1.6] bulk-billed vs 75.7[11.3]), a greater proportion were after-hours (10.3%[3.0] vs 6.2[2.9]) and for chronic disease care (28%[3.4] vs 17.6[8.0]) but fewer for preventive care (50.7%[3.8] had cervical screening vs 62.5[4.9]). Patterns were similar in regional locations, other than disadvantaged areas had less after-hours care (1.3%[0.7] vs 6.1%[3.9]). Measures were positively correlated, except GP supply and affordability in major cities (-0.41, p < .01). IMPLICATIONS: Application of constructed measures revealed inequity in PHC service delivery amenable to policy intervention. Initiatives should consider the maldistribution of GPs not only by remoteness but also by area disadvantage. Avenues for improvement in disadvantaged areas include preventative care across all regions and after-hours care in regional locations.

Exploring what patients think when answering the Interpersonal Skills Questionnaire (ISQ): A 'think aloud' study.

BACKGROUND: The Interpersonal Skills Questionnaire (ISQ) was developed to collect patient feedback on consultation skills of practitioners. However, it has not yet been evaluated with pharmacists. OBJECTIVE: To explore the thinking process of patients as they completed the ISQ following a consultation with a pharmacist. METHODS: A qualitative think aloud (TA) methodology was used to explore patients' thinking while completing the ISQ following a consultation with a pharmacist. The study was conducted in secondary care with outpatients ≥18 years old. Interviews were carried out in rounds and were informally analysed (i.e., by writing notes while listening to recordings) to identify any associated major problem(s). Discussions were held between researchers to determine whether changes were needed based on patients' comments. RESULTS: Eight patients in total (50% females) participated in this study (mean age: 48 years). Three rounds of TA were conducted. Most items of the ISQ were interpreted similarly by all participants with no major problems necessitating refining the ISQ. CONCLUSIONS: Modification of the ISQ was unnecessary as interviews demonstrated no major problems with its use. The ISQ is thus a potentially suitable tool to collect patient feedback on pharmacists' consultations.

The effects of general anaesthesia on memory recall following day-case knee arthroscopy

Declaration: The authors would like to declare that this study has not been published or being reviewed by other journals. Retention of new information may be impaired during recovery from general anaesthesia. Patients are likely to be anxious if they cannot recall information conveyed at the surgeons’ postoperative visit. Previous studies have shown evidence of short-term memory impairment after GA. Patients undergoing day case knee arthroscopy under general anaesthesia were told five random words and three diagnostic findings from their operation, by the surgeon prior to discharge. The patients were telephoned the following day to test their recall of words and diagnostic findings, with a maximum possible score of eight. 96 patients were available for the telephone follow-up. The patients were grouped according to the interval between the end of anaesthesia and the time the information was given to them. For knee arthroscopy day cases it appears that, allowing as much time as possible after anaesthesia, at least two hours if possible, before reviewing a patient in the recovery area will likely enhance his/her later recall of the clinical information, potentially setting patient expectations at the appropriate level and improving compliance with postoperative rehabilitation. For the surgeons’ post-operative visit to be valuable to the patient, it should take place at least two hours following cessation of anaesthesia. It is advisable to endorse verbal communication with written information (AU)

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One lithium level >1.0 mmol/L causes an acute decline in eGFR: findings from a retrospective analysis of a monitoring database.

OBJECTIVES: Lithium is a mainstay of bipolar disorder treatment, however, there are still differences in opinion on the effects of lithium use on renal function. The aim of this analysis was to determine if there is an association between short-term exposure to various elevated lithium levels and estimated-glomerular filtration rate (eGFR) at ≤3 months, 6 months (±3 months) and 1 year (±3 months) follow-up. SETTING: Norfolk-wide (UK) lithium register and database. PARTICIPANTS: 699 patients from the Norfolk database. PRIMARY OUTCOME MEASURES: eGFR change from baseline at ≤3 months, 6 months (±3 months) and 1 year (±3 months) after exposure to a lithium level within these ranges: 0.81-1.0 mmol/L (group 2), 1.01-1.2 mmol/L (group 3) and 1.21-2.0 mmol/L (group 4). The reference group was patients whose lithium levels never exceeded 0.8 mmol/L. RESULTS: Compared to the reference group, groups 3 and 4 showed a significant decrease in eGFR in the first 3 months after exposure (p=0.047 and p=0.040). At 6 months (±3 months) postexposure group 4 still showed a decline in eGFR, however, this result was not significant (p=0.298). CONCLUSIONS: These results show for the first time that a single incident of a lithium level >1.0 mmol/L is associated with a significant decrease in eGFR in the following 3 months when compared to patients whose lithium levels never exceeded 0.8 mmol/L. It is still not known whether the kidneys can recover this lost function and the impact that more than a single exposure to a level within these ranges can have on renal function. These results suggest that lithium level monitoring should be undertaken at least every 3 months, in line with current UK guidelines and not be reduced further until the impact of more than one exposure to these lithium levels has been fully established.

Epidural analgesia and arterial reconstructive surgery to the leg: effects on fibrinolysis and platelet degranulation.

It has been suggested that the incidence of early graft occlusion after arterial reconstructive surgery to the leg may be decreased by epidural analgesia. This effect may be mediated by the suppression of the usual cortisol response to surgery, which results in increased circulating plasminogen activator inhibitor-1 with consequent adverse effects on fibrinolysis. To investigate this and other potential mechanisms, 30 patients undergoing arterial reconstructive surgery to the leg were randomized to receive either general anaesthesia or general anaesthesia plus epidural analgesia. Post-operative analgesia was provided by morphine infusion or epidural analgesia, respectively. Blood samples were collected at 0, 2, 4, 6, 12 and 24 h, and 2, 3 and 5 days and analysed for cortisol, plasminogen activator inhibitor-1 antigen, interleukin-6 and beta thromboglobulin. The incidence of graft-related and systemic complications was recorded for 30 days. Only one patient developed early graft occlusion that required embolectomy and eventually amputation. There were no significant changes from control values in either group of patients in circulating cortisol, plasminogen activator inhibitor-1 and beta thrombogobulin (a marker for platelet degranulation). Interleukin-6 values increased significantly in both groups after 4 h and remained elevated until day 3. There were no significant differences between the groups in any variable measured. We conclude that any effect of epidural analgesia on early graft patency is unlikely to be mediated by fibrinolysis or platetlet degranulation.

Effects of isoflurane-nitrous oxide anaesthesia on insulin secretion in female patients.

In vitro studies suggest that volatile anaesthetic agents may directly inhibit insulin secretion. It is unclear if supplementation of anaesthesia with isoflurane impairs insulin secretion. We performed a 5-g i.v. glucose tolerance test in 21 patients before and during anaesthesia which was maintained with either 1 or 2 MAC of isoflurane in nitrous oxide, or no volatile agent. The study was carried out before surgery to avoid the influence of hormonal responses to trauma. A significant glycaemic response occurred during both i.v. glucose tolerance tests in all three groups of patients. Serum insulin concentrations were measured and the acute increase in insulin concentration at 3 min and area under the curve for 15 min were calculated. Both variables decreased significantly in all three groups during the tests performed under anaesthesia compared with tests carried out before anaesthesia.

The effect of cortisol suppression on interleukin-6 and white blood cell responses to surgery.

BACKGROUND: The endocrine and immune changes associated with surgery are well documented, but the interaction between them has not been fully evaluated. Cortisol production during surgery can be suppressed by etomidate and we have used this to investigate the relationship between the cortisol response and immune changes in the perioperative period. METHODS: We have measured the cortisol, interleukin-6 and white cell responses to elective abdominal hysterectomy in 8 healthy female patients, who received etomidate 0.3 mg kg-1 for induction of anaesthesia. A control group of 8 subjects received thiopentone. Both groups of patients received vecuronium and fentanyl 2 micrograms kg-1 and anaesthesia was maintained with nitrous oxide in oxygen and isoflurane 0.5-1.0%. Venous blood samples were collected before and during surgery and up to 24 h in the postoperative period. RESULTS: Serum interleukin-6 values were significantly greater at 6 and 12 h (P < 0.05) in those patients who received etomidate. Inhibition of the serum cortisol response to surgery in the etomidate group was also associated with less marked lymphopenia at 4 h (P < 0.05). There was no significant difference in neutrophil granulocyte counts between the two groups. CONCLUSION: In conclusion, endogenous corticosteroids modulate the interleukin-6 response to surgery.

Hormonal effects of thoracic extradural analgesia for cardiac surgery.

We have investigated the hormonal and metabolic effects of thoracic extradural analgesia with bupivacaine in addition to sufentanil 20 micrograms kg-1 in nine patients undergoing coronary artery bypass surgery. A control group received general anaesthesia alone. The catecholamine response was inhibited for 24 h after surgery in patients who had received extradural analgesia, and the cortisol response was suppressed during cardiopulmonary bypass. Blood glucose values were unchanged until 24 h after surgery in the extradural group. There were no significant differences in cardiac index between the two groups of patients, although heart rate and mean arterial pressure decreased before surgery in patients who received extradural analgesia. The benefits of this technique in terms of a reduction in postoperative morbidity remain to be determined.

Growth hormone suppression and glutamine flux associated with cardiac surgery.

Pharmacological doses of growth hormone (GH) in humans and rats increase plasma and muscle glutamine values. As major surgery results in a physiological rise in serum GH concentration, we investigated whether this physiological increase in GH altered glutamine metabolism. Eighteen patients undergoing coronary artery bypass graft (CABG) surgery were randomly assigned to receive somatostatin, 100 micrograms subcutaneously at induction of anaesthesia and 8 hourly for 48 h, or placebo. Somatostatin effectively blocked the physiological surge of GH following injury but did not affect plasma or muscle glutamine concentrations, which fell significantly in both groups. Plasma glutamine decreased by 31% (P < 0.01) and 28% (P < 0.01) in the control and somatostatin groups respectively. Muscle glutamine was reduced 45% (P < 0.001) in the control group and 50% (P < 0.001) in the somatostatin group. There was no difference in muscle or circulating glutamate, alanine or branched chain amino acid concentrations or in metabolite values between the somatostatin-treated patients and the control group. There was no relationship between the GH response to surgery and glutamine metabolism following major surgery.

Effects of extradural anaesthesia on interleukin-6 and acute phase response to surgery.

Serum concentrations of the cytokine, interleukin-6 (IL-6), increase after surgical trauma. IL-6 mediates the synthesis of acute phase proteins and stimulates secretion of pituitary hormones. We have examined the time course of circulating IL-6, and cortisol and growth hormone responses in patients undergoing hysterectomy to determine if IL-6 contributes to the early pituitary hormone changes found during surgery. One group (n = 8) received a standardized general anaesthetic while the remaining patients (n = 8) received extradural analgesia to T4-S5 in addition to a similar general anaesthetic. In the general anaesthesia group, there was a significant increase in serum cortisol and growth hormone concentrations before any changes in IL-6 were detected. Furthermore, in the extradural group, in whom these hormonal responses were attenuated, circulating IL-6 concentrations did not differ significantly from the general anaesthesia group. There were no significant differences between the groups in the acute phase response, as measured by circulating concentrations of C-reactive protein and zinc, but the expected effects of extradural block on circulating metabolites and white cell count were demonstrated. We conclude that IL-6 is unlikely to contribute to the initial increases in secretion of pituitary hormones found during surgery, but a later effect of the cytokine on endocrine responses cannot be excluded.

Isoflurane inhibits insulin secretion from isolated rat pancreatic islets of Langerhans.

We have investigated the effects of isoflurane on insulin secretion in vitro from rat isolated islets of Langerhans and found a significant, dose-related and reversible inhibition of insulin secretion. Isoflurane 2% decreased insulin secretion stimulated by glucose 20 mmol litre-1 to basal, nonstimulated values. In other studies to identify the stage in the stimulus secretion pathway for insulin at which the anaesthetic may exert an inhibitory action, we have stimulated insulin release using glyceraldehyde and a phorbol ester. Insulin secretion induced by these secretagogues was also blocked by isoflurane. This suggests that the inhibitory effect of the anaesthetic agent may be at a site distal to stimulation of insulin secretion by glyceraldehyde and phorbol esters.

Growth hormone secretion in response to surgery. Effects of cholinergic blockade and octreotide.

Cholinergic blockade markedly reduces the growth hormone (GH) response to most stimuli, with the exception of insulin induced hypoglycaemia. We have administered the cholinergic antagonist, atropine, known to cross the blood brain barrier, to eight healthy female patients prior to elective surgery in order to investigate the role of cholinergic pathways in the GH response to surgery. Additionally, eight patients received the octapeptide analogue of somatostatin, octreotide, known to suppress GH secretion. A control group matched for age and weight received no injection. The GH response to surgery was assessed by peak values and areas under curves. Octreotide resulted in a significant inhibition of GH secretion compared with the control group (p < 0.01 for both parameters). In contrast, atropine did not significantly inhibit the GH response to surgery. In conclusion, octreotide completely suppressed GH secretion during surgery, whereas cholinergic blockade was ineffective. Thus surgery is similar to insulin induced hypoglycaemia poglycaemia in that the GH response is not decreased by cholinergic blockade.

Effects of midazolam on insulin secretion from isolated rat pancreatic islets of Langerhans.

Isolated, cultured rat pancreatic islets of Langerhans were incubated in medium containing glucose 2 or 20 mmol litre-1 and with glucose supplemented with midazolam 10, 100 or 1000 ng ml-1. Glucose 20 mmol litre-1 with the addition of noradrenaline 10 mumol litre-1 was used as a control. In contrast with noradrenaline, midazolam did not inhibit glucose-induced insulin secretion. Noradrenaline 10 mumol litre-1 inhibited secretion to basal values in response to glucose 20 mmol litre-1 (P < 0.001).

Midazolam modifies pancreatic and anterior pituitary hormone secretion during upper abdominal surgery.

We have investigated the effects of midazolam on circulating concentrations of pituitary and pancreatic hormones in eight healthy patients during cholecystectomy and compared the changes with those in a control group of eight patients. Anaesthesia was induced either with midazolam 0.42 mg kg-1 i.v. followed by an infusion of midazolam 0.125 mg kg-1 for 1 h, or with a sleep dose of thiopentone. All patients received vecuronium, and the lungs were ventilated with 0.5-1.0% halothane and 70% nitrous oxide in oxygen. The use of midazolam was associated with a significant decrease (P less than 0.05) in secretion of cortisol and insulin during surgery. Serum growth hormone secretion was augmented, but this did not reach statistical significance. There was little difference in the concentrations of circulating metabolites between the two groups, except for a significant decrease in blood glucose (P less than 0.05) in the midazolam group after 60 min. There were no marked differences in cardiovascular variables between the two groups of patients.

Massive histamine release in a patient with systemic mastocytosis.

We have measured plasma histamine concentrations, systemic vascular resistance, cardiac output and arterial pressure during laparotomy in a patient with systemic mastocytosis. The patient developed vasodilation and hypotension during surgery, associated with a massive increase in plasma histamine concentration.