Assessing workload in general practice in England before and after the introduction of the pay-for-performance contract.

Aim: This paper is a report of a study conducted to describe changes in practice team size and composition, and the workload of doctors and nursing staff, before (2003) and after (2005) the introduction of the pay-for-performance contract for general practice.

Background: In 2004, a new pay-for-performance contract for general practice was introduced in England. This improved the quality but may also have altered practice workload, including the workload of nursing staff.

Small vessel remodeling and impaired endothelial-dependent dilatation in subcutaneous resistance arteries from patients with acromegaly.

Context: Patients with acromegaly have increased morbidity and mortality, predominantly from cardiovascular disease. Hypertension and diabetes are more prevalent, and both cause small vessel remodeling and endothelial dysfunction.

Objective: To understand the structure and function of small arteries in acromegaly, sc blood vessels from gluteal fat biopsies were harvested from 18 patients with active disease (AD; age, 56 +/- 15 yr; 14 males), 23 patients in remission (CD; age, 55 +/- 12 yr; 15 males), and 20 healthy controls (age, 55 +/- 11 yr; 10 males) and examined in vitro using pressure myography.

Moving specialist care into the community: an initial evaluation.

Objectives: To assess the likely impact on patients and local health economies of shifting specialist care from hospitals to the community in 30 demonstration sites in England.

Methods: The evaluation comprised: interviews with service providers at 30 sites, supplemented by interviews with commissioners, GPs and hospital doctors at 12 sites; economic case studies in six sites; and patient surveys at 30 sites plus at nine conventional outpatient services. Outcomes comprised: staff views of service organization and development, impact on primary and secondary care, and benefits for patients; cost per consultation and cost per patient in new services compared to estimates of the price of services if undertaken by hospitals; patients' views of waiting time, access, quality (technical and interpersonal), coordination and satisfaction.

General practice factors and MMR vaccine uptake: structure, process and demography.

Background: Despite the fall in MMR uptake between 1998 and 2004, some general practices managed to sustain remarkably high MMR coverage.

Methods: The aim of the study was to identify general practice factors associated with high MMR vaccine coverage. The study population included 257 general practices in Cumbria and Lancashire in 2005.

Effects of early growth on blood pressure of infants of British European and South Asian origin at one year of age: the Manchester children's growth and vascular health study.

Objective: The objective of this study was to investigate early influences of postnatal growth on blood pressure (BP) in healthy, British-born South Asian and European origin infants. We tested the hypotheses that South Asian infants would be smaller in all body dimensions (length and weight) with higher relative truncal skinfold thickness at birth, and that increased (central) adiposity and accelerated growth up to 1 year would be associated with higher BP in both ethnic groups.

Patients And Methods: Five hundred and sixty infants were followed prospectively from birth to 3 and/or 12 months with measures of anthropometry and resting BP, compared against a UK 1990 growth reference, and analysed using regression methods.

Critical appraisal for public health: a new checklist.

Objectives: There have been a number of attempts to develop critical appraisal tools, but few have had a public health focus. This paper describes a new checklist with public health aspects.

Study Design: Review of previous appraisal instruments and pilot test of new checklist.

Should we encourage over-the-counter statins? A population perspective for coronary heart disease prevention.

Background: Prescribed statin therapy has contributed to a dramatic reduction in primary and secondary coronary heart disease (CHD). In the UK, simvastatin is currently available without prescription; however, the US FDA rejected an application for nonprescription lovastatin in 2005.

Objective And Methods: We used population impact measures for three hypothetical levels of CHD risk to estimate the number of CHD events that would be prevented in the US over 5 years under three scenarios: (i) prescription-only regulations; (ii) approval of over-the-counter (OTC) statins; and (iii) implementation of lifestyle interventions.

The population effect of crime and neighbourhood on physical activity: an analysis of 15,461 adults.

Area-based interventions offer the potential to increase physical activity for many sedentary people in countries such as the UK. Evidence on the effect of individual and area/neighbourhood influences on physical activity is in its infancy, and despite its value to policy makers a population focus is rarely used. Data from a population-based health and lifestyle survey of adults in northwest England were used to analyse associations between individual and neighbourhood perceptions and physical activity.

Prioritising between direct observation of therapy and case-finding interventions for tuberculosis: use of population impact measures.

Background: Population impact measures (PIMs) have been developed as tools to help policy-makers with locally relevant decisions over health risks and benefits. This involves estimating and prioritizing potential benefits of interventions in specific populations. Using tuberculosis (TB) in India as an example, we examined the population impact of two interventions: direct observation of therapy and increasing case-finding.

The assessment of autonomic function in chronic atrial fibrillation: description of a non-invasive technique based on circadian rhythm of atrioventricular nodal functional refractory periods.

Aims: Heart rate variability (HRV) parameters can be used to assess autonomic function and to predict outcome, but this has been done exclusively in patients with sinus rhythm. Atrial fibrillation (AF) is the commonest sustained arrhythmia and is particularly prevalent in heart failure. We have developed a simple index to assess autonomic function in patients with chronic AF.

Impact of specialist care on clinical outcomes for medical emergencies.

General hospitals have commonly involved a wide range of medical specialists in the care of unselected medical emergency admissions. In 1999, the Royal Liverpool University Hospital, a 915-bed hospital with a busy emergency service, changed its system of care for medical emergencies to allow early placement of admitted patients under the care of the most appropriate specialist team, with interim care provided by specialist acute physicians on an acute medicine unit - a system we have termed 'specialty triage'. Here we describe a retrospective study in which all 133,509 emergency medical admissions from February 1995 to January 2003 were analysed by time-series analysis with correction for the underlying downward trend from 1995 to 2003.

Using economic analyses for local priority setting : the population cost-impact approach.

Introduction: Standard methods of economic analysis may not be suitable for local decision making that is specific to a particular population.

Background: We describe a new three-step methodology, termed 'population cost-impact analysis', which provides a population perspective to the costs and benefits of alternative interventions. The first two steps involve calculating the population impact and the costs of the proposed interventions relevant to local conditions.

Helping to prioritise interventions for depression and schizophrenia: use of Population Impact Measures.

Background: To demonstrate the potential of Population Impact Measures in helping to prioritise alternative interventions for psychiatry, this paper estimates the number of relapses and hospital readmissions prevented for depression and schizophrenia by adopting best practice recommendations. The results are designed to relate to particular local populations.

Methods: Literature-based estimates of disease prevalence, relapse and re-admission rates, current and best practice treatment rates, levels of adherence with interventions and relative risk reduction associated with different interventions were obtained and calculations made of the Number of Events Prevented in your Population (NEPP).

Factors influencing emergency medical readmission risk in a UK district general hospital: A prospective study.

BACKGROUND: Over recent years increased emphasis has been given to performance monitoring of NHS hospitals, including overall number of hospital readmissions, which however are often sub-optimally adjusted for case-mix. We therefore conducted a study to examine the effect of various patient and disease factors on the risk of emergency medical readmission. METHODS: The study setting was a District General Hospital in Greater Manchester and the study period was 4.

Capture-recapture estimates of problem drug use and the use of simulation based confidence intervals in a stratified analysis.

Study Objective: To establish the prevalence of problem drug use in the 10 local authorities within the Metropolitan County of Greater Manchester between April 2000 and March 2001.

Setting And Participants: Problem drug users aged 16-54 resident within Greater Manchester who attended community based statutory drug treatment agencies, were in contact with general practitioners, were assessed by arrest referral workers, were in contact with the probation service, or arrested under the Misuse of Drugs Act for offences involving possession of opioids, cocaine, or benzodiazepines.

Design: Multi-sample stratified capture-recapture analysis.

Carvedilol alone or in combination with digoxin for the management of atrial fibrillation in patients with heart failure?

Objectives: This study examined the relative merits of digoxin, carvedilol, and their combination for the management of patients with atrial fibrillation (AF) and heart failure (HF).

Background: In patients with AF and HF, both digoxin and beta-blockers reduce the ventricular rate, and both may improve symptoms, but only beta-blockers have been shown to improve prognosis. If combined therapy is not superior to beta-blockers alone, treatment of patients with HF and AF could be simplified by stopping digoxin.

Hierarchical statistical modelling of influenza epidemic dynamics in space and time.

An infectious disease typically spreads via contact between infected and susceptible individuals. Since the small-scale movements and contacts between people are generally not recorded, available data regarding infectious disease are often aggregations in space and time, yielding small-area counts of the number infected during successive, regular time intervals. In this paper, we develop a spatially descriptive, temporally dynamic hierarchical model to be fitted to such data.