Evaluation of a diabetic foot screening and protection programme.

We set out to evaluate a clinical foot-screening programme in terms of primary outcomes (reductions in the incidence of ulcers and lower limb amputation) and process outcomes (compliance with screening, the number of patients not completing the programme and the use of chiropody services and prescribed footwear and cost). All but 4 of 2001 patients attending a general diabetic out-patient clinic were allocated randomly to index and control groups. The exceptions were patients who presented with active ulcers and were placed in the index group. Primary and secondary screening programmes identified 128 high risk patients in the index group and these were admitted to the foot protection programme. At 2-year follow-up, 11 fewer ulcers were reported from the index group. There were 7 amputations (1 major, 6 minor) in the index group and 23 (12 major and 13 minor) in the control group. The differences were not statistically significant for ulceration or minor amputations but significant for major amputations (p < 0.01). The total cost of the 2-year programme was pounds sterling 100,372 (1991-92 costs), with a mean cost per patient of approximately pounds sterling 100. Taking pounds sterling 12,000 as a conservative estimate of the cost of a major amputation, the foot clinic was cost-effective in terms of amputations averted. The process outcomes were much less satisfactory. Cost-effectiveness could have been improved if it had been possible to improve patient compliance.

Differential effects of preterm birth and small gestational age on cognitive and motor development.

AIMS: To determine the differential effects of preterm birth and being small for gestational age on the cognitive and motor ability of the child. METHODS: A longitudinal cohort of all infants of gestational age < or = 32 weeks born to mothers resident in the counties of Cheshire and Merseyside in 1980-1 was studied. The children were assessed at the age of 8 to 9 years using the Wechsler Intelligence Scale for Children, the Neale analysis of reading ability, and the Stott-Moyes-Henderson test of motor impairment. Adequacy of fetal growth was determined by the birthweight ratio--that is, the ratio of the observed birthweight to the expected birthweight for a given gestational age. Children with clinically diagnosed motor, learning or sensory disabilities were excluded. Information on social variables was obtained by a questionnaire completed by the parents. Of the 182 children, 158 were assessed. RESULTS: IQ was positively correlated with birthweight ratio but not with birthweight or gestational age. Motor ability was associated with birthweight, gestational age, and birthweight ratio. Reading comprehension was associated with birthweight ratio, but reading rate and accuracy were best explained by social variables and sex. IQ remained associated with birthweight ratio, after adjusting for maternal education, housing status, and number of social service benefits received. Reading ability was related to these social variables but motor ability was not. CONCLUSIONS: The effects of SGA and preterm birth differed: SGA was associated with cognitive ability, as measured by IQ and reading comprehension; motor ability was additionally associated with preterm birth. Reading rate and accuracy were not associated with SGA or preterm birth but were socially determined.

Cost of care for a geographically determined population of low birthweight infants to age 8-9 years. I. Children without disability.

AIM: To determine the extra cost of healthcare associated with low birthweight, in a cohort study of a geographically defined population in five health districts that comprise Merseyside. METHODS: The study comprised all children of birthweight < or = 1500 g and a 10% random sample of those weighing 1501-2000 g, without clinical disability, born in 1980 and 1981 to mothers resident in Merseyside, and their controls, matched by age, sex, and school class, followed up to age 8-9 years. RESULTS: The cost of care associated with the initial admission to the neonatal special/intensive care unit and subsequent use of hospital and family practitioner services was assessed. There were 641 survivors without disability and 227 non-survivors who weighed < or = 2000 g at birth. The mean cost of neonatal care per low birthweight child was 13 times greater than for a control child. For children weighing < or = 1000 g at birth, neonatal costs were 55 times greater than for the control children. Low birthweight children continue to use hospital and family practitioner services more intensively than controls to age 8-9 years. CONCLUSION: Low birthweight children used hospital and family practitioner services more intensively throughout the follow up period. Whether the increased use of health services persists into adolescence and adulthood is yet to be determined.

Cost of care for a geographically determined population of low birthweight infants to age 8-9 years. II. Children with disability.

AIM: To determine the cost of health and educational service provision for low birthweight children with a clinical disability. METHODS: Cohort study of a geographically defined population in five health districts that comprise the County of Merseyside was undertaken. All children with a clinical disability born in 1980 and 1981 to mothers resident in the County of Merseyside were followed up to age 8-9 years. The cost of care associated with the initial admission to the neonatal special/intensive care unit and subsequent use of hospital, family practitioner, and special education services was assessed. RESULTS: There were 52 children with a disability; the disability rate in children of birthweight < or = 2000 g was estimated at 7.7%. Of the total expenditure to age 8-9 years, special education was the largest category (52%) and neonatal care accounted for 35%. The disabled children accounted for 38% of the cost of the whole cohort of 693 disabled and non-disabled children who weighed < or = 2000 g at birth. CONCLUSION: In a cohort of low birthweight children, those who are disabled account for a disproportionate amount of the total expenditure to age 8-9. The cost of long term care for disabled young persons and adults will increasingly dominate the cost of care for the whole cohort of low birthweight children.

An economic evaluation of a clinical trial to compare automated percutaneous lumbar discectomy with microdiscectomy in the treatment of contained lumbar disc herniation.

STUDY DESIGN: A cost-effectiveness study of automated percutaneous lumbar discectomy (APLD) vs. microdiscectomy in the treatment of contained lumbar herniation in a randomized controlled trial. OBJECTIVES: To quantify hospital costs and other public sector expenditure; to collect socioeconomic data that might bear on the recovery rate of patients and their private costs; and to relate costs to clinical outcomes. SUMMARY OF BACKGROUND DATA: The authors are aware of no similar economic evaluation in this field. METHODS: The surgical procedures were costed from detailed lists of the time spent and resources used. Socioeconomic patient data were collected by questionnaires administered around the time of the operation and on follow-up at 6 months. Statistical analysis was by the chi-square method. RESULTS: There was no evidence that either procedure imposed significantly greater costs on patients or nonhospital medical services. CONCLUSION: It was demonstrated that, within the restrictions imposed by the data set, automated percutaneous lumbar discectomy was less cost-effective than microdiscectomy.

Clinical and subclinical deficits at 8 years in a geographically defined cohort of low birthweight infants.

OBJECTIVE: To determine the prevalence of subclinical deficits in cognitive and motor function in low birthweight infants. DESIGN: Children of birth weight < or = 2000 g born to mothers resident in Merseyside in 1980-1 assessed using the Wechsler Intelligence Scale for Children (WISC), the Neale analysis of reading ability, and the Stott-Moyes-Henderson test of motor impairment (TOMI). Children attending normal schools assessed with controls matched for age, sex, and class in school. Children attending special schools were assessed unmatched. SUBJECTS: 233 matched index case-control pairs attending normal primary schools and 46 unmatched children attending special schools. SETTING: Primary and special schools. MAIN OUTCOME MEASURES: IQ score, reading age in months, and TOMI score. RESULTS: Index cases when compared with controls had a lower WISC score (mean IQ difference 8.8; 95% confidence interval (CI) 6.8 to 10.7), a lower reading age (mean difference 6.5 months; 95% CI 4.0 to 9.0), and poorer motor performance as shown by the TOMI score (mean difference 1.4; 95% CI 1.1 to 1.8). Of the children attending special schools, 23/46 (50%) had a WISC score < or = 50. CONCLUSIONS: Low birthweight children have significant subclinical deficits of cognitive and motor function and extra resources, especially in education, may be required to meet their needs.

Prevalence of behaviour disorders in low birthweight infants.

OBJECTIVE: To determine the prevalence of behaviour disorders in low birthweight infants. DESIGN: Children of birth weight < or = 2000 g born to mothers resident in Merseyside in 1980-1 assessed using the Rutter parent and teacher behaviour questionnaires and the Conner modification of the Rutter teacher questionnaire. Children attending normal schools were assessed with controls matched for age, sex, and class in school. Children attending special schools were assessed unmatched. SUBJECTS: 233 matched case-control pairs attending normal primary schools and 46 unmatched children attending special schools. SETTING: Primary and special schools. MAIN OUTCOME MEASURES: Emotional, conduct, and undifferentiated behaviour disorders and hyperactivity. RESULTS: On the parental questionnaire screen, 36% of the cases and 22% of the controls had a behaviour disorder and on the teacher questionnaire the proportions were 27% and 12% respectively. Hyperactivity was significantly more common among male cases than their controls (21% v 5.0%) but differed little among female cases and controls (9% v 7%). CONCLUSIONS: Improving neonatal survival of low birthweight infants is accompanied by a higher prevalence of behaviour disorders. The long term implications for psychiatric morbidity and other adult disease must be monitored.

Predicting costs and outcomes of neonatal intensive care for very low birthweight infants.

A geographically determined cohort of all infants of less than 1,500 g born in 1980 and 1981 were clinically followed up to age four to determine their disabilities which were classified as mild, moderate or severe. A quality adjustment coefficient, determined by the severity of the disability, was used to calculate the number of quality adjusted lives produced. The total cost of care for these children was assessed as the sum of hospital costs to age four (which were specifically determined) and an estimate of the life-time costs of care of disabled children from information provided by the Education and Social Service departments. A very poor predictive power of birthweight with cost was obtained with the ungrouped birthweight data, whereas clinical factors explained up to 60% of the variance of the initial hospital costs for survivors and up to 30% of the variance of life-time costs and the cost of quality adjusted lives produced. Rules for the allocation of resources based on discrimination by birthweight are flawed but the application of clinical discretion is important.

Costs and benefits of neonatal intensive care.

A cohort of very low birthweight infants (less than 1500 g) born in 1979-81 from a geographically defined area was followed up, and a costing of the initial admission to the neonatal intensive care unit was made. A four point scale for the severity of disability was used and estimation of the costs of education and full time residential care was made and discounted at 5% over the appropriate period. During the three years a progressively increasing proportion of infants survived, and this was associated with an increasing proportion of disabilities among the survivors. If costs are related to outcome up to the age of 4 they get progressively less over the three year study period. After the age of 4 the costs of special education and residential care dominate, and the cost trend is reversed.

Measuring the saving attributable to an antibiotic prescribing policy.

An analytical framework is suggested for the economic evaluation of policies to improve the management of hospital infection. Consideration of the costs and benefits to be expected from improved policies implies the existence of an optimal infection rate which is higher than the minimum attainable. It follows that hospitals can and probably do spend too much on infection control in, at least, some areas. This optimal approach is not operational at present but its data requirements might be thought of as an agenda for future research. In the meantime, progress in infection control economics depends on a piecemeal approach. An example is given in the estimation of the cost savings attributable to an improved antibiotic prescribing policy at the Royal Liverpool Hospital.

Cost of neonatal intensive care for very-low-birthweight infants.

A detailed costing of the Mersey regional neonatal intensive care unit was made for 1983 (at 1984 prices) for three levels of care; costs per inpatient day were 297 pounds, 138 pounds, and 71 pounds for intensive, special, and nursery care, respectively. Regression of ungrouped patient-specific costs against birthweight showed the explanatory power of birthweight to be negligible. The average cost per very-low-birthweight (less than 1500 g) infant was 4490 pounds for a survivor and 3446 pounds for a non-survivor. A similar study elsewhere showed an almost six-fold difference in cost between survivors and non-survivors. It is postulated that medical management policy largely determines this difference and is crucial to any investigation of cost-efficiency.

Studies on the spin-spin interaction between flavin and iron-sulfur cluster in an iron-sulfur flavoprotein.

When the di- or trimethylamine dehydrogenases (trimethylamine:(acceptor) oxidoreductase (demethylating), EC 1.5.99.7) of certain methylotrophic bacteria are reduced by two electrons with substrate unusual EPR signals arise at g = 2 and g = 4 (Steenkamp, D.J. and Beinert, H. (1982) Biochem. J. 207, 233-239; 241-252) indicative of spin-spin interaction between the FMN and iron-sulfur compounds of these enzymes. An attempt is made to understand, describe and simulate these spectra in terms of a triplet state with possible contributions from both dipolar and anisotropic exchange (J) interactions. No direct measurement of J is available, but various approaches to setting limits to J are outlined. According to these, J approximately 0.4 to 3 cm-1 or 15 to 50 cm-1. The spectra show, in the g = 2 region, a pair of rather sharp inner and a pair of broad outer lines; the latter broaden as well as move out from the center with increasing time (after substrate addition) and substrate concentration, while there is little change of g = 4. The best fits to such spectra were obtained by assuming distribution of D and E values, depending on substrate effects and arriving presumably from 'g-strain'. The fact that both shapes and intensities at g = 2 and g = 4 could be reproduced simultaneously at two frequencies indicates that the assumptions underlying our approaches and interpretations are permissible and reasonable, although we cannot claim their uniqueness. The distance between the centers of the spin densities of the flavin radical and the Fe-S cluster is thought to lie between the limits 3 to 5 A if the asymmetries in the spin-spin interaction are magnetic dipole-dipole in origin. Because there is an indication that the interaction is anisotropic exchange, the upper limit is less stringent.